OASIS Alert

Important: List only one staging code for ulcers of the same size.

Your pressure ulcer coding just got more complex, thanks to the 2009 ICD-9 update effective Oct. 1.

Considering how many patients with pressure ulcers your agency probably sees, you'll soon become a pro at using the new additional codes 707.20-707.25 (Pressure ulcer stages) to show the stage of pressure ulcers. However, don't expect to pick up the new codes without a little homework.

To get up to speed with these new pressure ulcer staging codes, read Chapter 12 in the new Official Coding Guidelines effective Oct. 1 very carefully, advises Judy Adams, RN, BSN, HCSD, with LarsonAllen in Charlotte, N.C. Especially important points include:

1. There's a difference between "stage unspecified" and "unstageable." Code 707.20 (Pressure ulcer, unspecified stage) is not the same as 707.25 (Pressure ulcer, unstageable), Adams says. You should use 707.20 only when there is no documentation in the record of the pressure ulcer's stage.

Good news: You don't have to rely on the physician to provide the pressure ulcer stage, but someone should query the physician if there is no detailed documentation present. The coding guidelines indicate that any clinician can determine the stage based upon guidance available from the Wound, Ostomy, and Continence Nurses Society (WOCN) or the National Pressure Ulcer Advisory Panel (NPUAP), Adams says.

2. No stage (or unstageable) means no points. The biggest challenge in establishing the stage of a healing pressure ulcer is that you can't reverse-stage a pressure ulcer, Adams notes. Say your agency receives a referral for a patient who has a healing pressure ulcer and there is no documentation in the record. In this case, the clinician can't just rely on assessment skills but must try to find out what stage that pressure ulcer was at its worst.

The alternative is to use 707.20 to indicate stage unspecified, but this will result in lost revenue opportunities for your agency. Medi-care PPS will give you points for both case mix and nonroutine supplies (NRS) based on the stage of the most problematic observable pressure ulcer.Another challenge for home health clini-cians occurs when you must stage a pressure ulcer as unstageable (707.25) because it is covered by eschar, a skin or muscle graft, or is a deep tissue injury not due to trauma, Adams says.

Tricky: OASIS guidance doesn't always coincide with coding guidance, points out Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR ��" Coding Done Right in Denton, Texas. Remember that the Centers for Medicare & Medicaid Services says to use OASIS guidance for OASIS and coding guidance to code.

Coding vs. OASIS: An ulcer covered by eschar loses the opportunity for HHRG points but still earns NRS points, Selman-Holman points out. A pressure ulcer covered by a skin graft is still documented on OASIS according to stage but should be coded as unstageable (707.25). A pressure ulcer treated with a muscle graft is no longer a pressure ulcer by OASIS standards but is coded as unstageable (707.25).

Coding example: Your patient has bilateral pressure ulcers of the buttocks. One is a stage 3 and the other a stage 2. He also has a stage 4 pressure ulcer of the sacrum. Code for this patient as follows, Adams says:

• M0230a: 707.03 (Pressure ulcer; sacrum);

• M0240b: 707.24 (Pressure ulcer stage IV);

• M0240c: 707.05 (Pressure ulcer; buttock);

• M0240d: 707.23 (Pressure ulcer stage III); and

• M0240e: 707.22 (Pressure ulcer stage II).

Coding for this patient uses five of the six reportable diagnosis spots on the OASIS, Adams points out. Clinicians will have to think carefully about sequencing these situations, especially for patients who may present with other co-morbidities.

Another example: Your patient was ref-erred to home health with a stage 3 pressure ulcer of the coccyx and hip and a stage 2 pressure ulcer on the ear.

• M0230a: 707.05 (Pressure ulcer;buttock);

• M0240b: 707.04 (Pressure ulcer; hip);

• M0240c: 707.23 (Pressure ulcer stage III);

• M0240d: 707.09 (Pressure ulcer; other site); and

• M0240e: 707.22 (Pressure ulcer stage II).

This situation is coded slightly differently than the first. You'll list a code for each of the three locations, but only two stage codes, Ad-ams says. This is because the ulcers in two locations are the same stage, and coding rules prohibit repeating the same code more than once for a claim.

Avoid this: Use the 707.2x codes only when reporting pressure ulcers, cautions Trish Twombly, RN, BSN, HCS-D, CHCE, director of coding with Foundation Management Services in Denton, Texas. You should avoid the temptation to use a code from the 707.20-707.25 range to report staging for arterial, venous, or diabetic ulcers.