Primary Care Coding Alert

Question: An established 75-year-old Medicare patient reports to the FP for inspection of sores on her back. The FP performs an expanded problem focused history and an expanded problem focused exam, and then diagnoses a stage I pressure ulcer on her lower back. The FP refers the patient to a dermatologist for treatment of the ulcer. Should I be reporting the new pressure ulcer ICD-9 codes for this encounter?

Idaho Subscriber

Answer: Yes, but those codes represent the stage of the pressure ulcer; you will also have to code for the ulcer itself. On the claim, report the following:

" 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the E/M

" 707.03 (Pressure ulcer; lower back) appended to 99213 to represent the pressure ulcer

" 707.21 (Pressure ulcer stage I) appended to 99213 to represent the pressure ulcers stage.

Explanation: Use the new pressure ulcer ICD-9 codes to describe the healing stages of the patients wound -- but first code the site of pressure ulcer using 707.00- 707.09, according to information beneath the 707.2 code in ICD-9-CM 2009.