Podiatry Coding & Billing Alert

Question: The podiatrist documented the admitted patient's non-pressure chronic ulcer as healing. How should we report this?

Ohio Subscriber

Answer: If the podiatrist describes the non-pressure chronic ulcer as healing, report the correct non-pressure chronic ulcer code based upon the information in the documentation, according to the 2018 ICD-10-CM Official Guidelines for Coding and Reporting.

However, if the documentation does not provide information about the severity of the healing non-pressure chronic ulcer, report the appropriate code for unspecified severity.

If the documentation does not make it clear whether the patient has a current (new) non-pressure chronic ulcer or if the podiatrist is treating the patient for a healing non-pressure chronic ulcer, you should query your provider, the guidelines add.

For ulcers that were present on admission but healed at the time of discharge, report the code for the site and severity of the non-pressure chronic ulcer at the time of the patient's admission.