OASIS Alert

Hint: Always code stage 3 and 4 pressure ulcers.

Pressure ulcers, also known as decubitus ulcers, bed sores, plaster ulcers, or ulcers from shearing, are localized injuries to the skin and/or underlying tissue usually over a bony prominence, usually occurring as a result of pressure, or pressure in combination with shear, according to the National Pressure Ulcer Advisory Panel.

You'll need to list two codes to completely describe a pressure ulcer, says Sharon Molinari, RN, HCS-D, COS-C, a home health consultant based in Henderson, Nev. -- one to identify the site of the pressure ulcer, and a second to identify the stage.

For example: Your patient has a stage 3 pressure ulcer on his right hip. To code for this patient, you would list both:

• 707.04 (Pressure ulcer, hip) and
• 707.23 (Pressure ulcer stage III).

Take note: According to the ICD-9 coding guidelines, only the physician can diagnose the type of ulcer your patient has, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, director of coding with Foundation Management Services in Denton, Texas ."But it's the clinical documentation that guides ulcer staging, so the clinician determines the stage."

However, if it's not a pressure ulcer that came on the referral, in home care and hospice, it is often the clinician who describes the ulcer to the physician and suggests that it meets the definition of pressure ulcer, says 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.

If the documentation shows that your patient had a stage 1 or 2 pressure ulcer that was healed on admission, you don't need to list a code for it, Twombly says. But you should always code for stage 3 and 4 pressure ulcers, even if they are closed. Because there is a strong risk that stage 3 and 4 pressure ulcers will open again, they can be considered closed, but are never considered healed.

When presented with a patient who has bilateral ulcers, you may be hard-pressed to select codes to accurately reflect his condition. Because the ICD-9 coding classification doesn't provide for laterality, you're stuck between listing repetitive codes and seeming to underreport your patient's ulcers. And it's a violation of the guidelines to list a code more than once.

To code for bilateral ulcers, you will list each site only once, Twombly says. If the bilateral ulcers have the same stage, this means you will list only one site and stage code pair to describe both ulcers.

When the bilateral ulcers are of differing stages, you will still list the site only one time, but you should list an ulcer stage code to describe each stage.

And what if your patient has multiple ulcers of varying stages? You will list codes for each ulcer site paired with a code for each pressure ulcer stage, Twombly says.

Coding example: Your patient has a stage 3 pressure ulcer on his right buttock, a stage 2 pressure ulcer on his left buttock, a stage 1 pressure ulcer on his left heel, and a closed stage 4 pressure ulcer on his elbow. How should you code for him?

Code for this patient as follows, suggests Twombly:

• M1020a: 707.05 (Pressure ulcer; buttock);
• M1022b: 707.23 (Pressure ulcer, stage III);
• M1022c: 707.22 (Pressure ulcer, stage II);
• M1022d: 707.07 (Pressure ulcer; heel);
• M1022e: 707.21 (Pressure ulcer; stage I); and
• M1022f: 707.01 (Pressure ulcer elbow).

This patient has bilateral pressure ulcers of differing stages on his buttocks. To code for these, you need only list the site one time. But you'll list a code for each stage following the site code.

Even though your patient's pressure ulcer of the elbow is closed, OASIS-C guidelines hold that stage 3 or 4 pressure ulcers never heal. So, you'll need to report the stage 4 pressure ulcer even though it is closed.

Coding Example: Your new patient was referred to home health with stage 4 pressure ulcers of the hip and sacrum. She also has a stage 1 pressure ulcer of the ear. She just started taking Synthroid for hypothyroidism. To describe this patient, you would list the following codes, says Molinari:

• M1020a: 707.04 (Pressure ulcer, hip);
• M1022b: 707.03 (Pressure ulcer, sacrum);
• M1022c: 707.24 (Pressure ulcer, stage IV);
• M1022d: 244.9 (Unspecified hypothyroidism);
• M1022e: 707.09 (Pressure ulcer, other site);
• M1022f: 707.21 (Pressure ulcer, stage I).

You'll list 707.25 (Pressure ulcer, unstageable) when the stage of your patient's pressure ulcer cannot be clinically determined, says Twombly.

You'll list 707.25 when the pressure ulcer is covered by eschar or when the patient has a documented deep tissue injury that is not due to trauma, Twombly says. And 707.25 is also the right code to list when your patient's pressure ulcer has been treated with a skin or muscle graft.

Conflict: When answering the OASIS-C pressure ulcer items, you shouldn't mark pressure ulcers treated by skin or muscle graft as unstageable. Instead, you'll stage pressure ulcers treated by skin grafts at the stage they were before the graft. Pressure ulcers treated with muscle grafts are no longer considered pressure ulcers in terms of the OASIS integumentary items. Instead, these wounds become surgical wounds. But in M1020/M1022, according to the official coding guidelines, pressure ulcers treated by skin or muscle graft are considered unstageble and should be coded with 707.25.

Coding Example: When the clinician turned the patient over, she saw a dark purplish area on his hip that she suspects is a deep tissue injury that will become a pressure ulcer. To code for this patient, Twombly suggests listing 707.04 (Pressure ulcer; hip) and 707.25 (Pressure ulcer, unstageable).