MDS Alert

Get it right with these key ICD-9 coding principles.

Sometimes you have to think outside the checkbox to communicate the exact type of skin ulcer on the MDS and to Medicare.

And one way to do that is to include an ICD-9-CM code in Section I3 and also on the UB-04.

Example: Suppose the patient has a diabetic ulcer. If the physician or clinician legally accountable for establishing the diagnosis has diagnosed diabetes mellitus with neuropathy, and a diabetic ulcer, use the following codes, suggests Charlotte Lefert, RHIA, coding strategy facilitator for the LTC Community of Practice for the American Health Information Management Association:

- 250.8x, Diabetes with other specified manifestations (x = type 1 or 2 diabetes); and 707.1x, Ulcer of lower limbs, except pressure ulcer, with x for the site of the diabetic ulcer (go to the ICD-9 codebook for that information).

- 250.6x, Diabetes mellitus with neuropathy; and 357.2, Polyneuropathy in diabetes.

Key point: You have to sequence the codes for diabetes mellitus with its related manifestations together as they are 'paired' codes," says Lefert.

Code diabetes mellitus first followed by the related manifestation.

What if the resident has a venous stasis ulcer not related to diabetes?

Code that as 454.0, Varicose veins of lower extremities with ulcer. But if the person had diabetes mellitus as the underlying cause of the venous stasis ulcer, you'd code 250.81 (if it were type 1 diabetes) and then the 707.1x, with x for the site of the ulcer, Lefert advises.

For an arterial or ischemic ulcer, code 707.1x (with x being the site of the ulcer), and then the underlying condition of atherosclerosis of the extremities (440.23) and other underlying conditions.

If the underlying condition causing the arterial ulcer is diabetes, then it's considered to be a diabetic ulcer, says Lefert.

As for including a wound-related ICD-9-CM code on the UB-04: List it first if the wound is the primary reason for the Medicare Part A SNF coverage, advises Darlene Greenhill, a nursing home consultant in Atlanta.

Otherwise, you would sequence the wound code in the order of importance to give a picture of the patient and support billing on the claim, Greenhill advises.