Primary Care Coding Alert

Question: An established elderly patient reports to the family physician (FP) for inspection of sores on her back. The FP diagnoses a stage I pressure ulcer on her lower back. The FP refers the patient to a dermatologist for treatment of the ulcer after a level-three E/M. How should I report this diagnosis?

Indiana Subscriber

Answer: You should submit a pair of codes; one to represent the stage of the pressure ulcer, and another 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; and medical decision making of low complexity ...) for the E/M;

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

• 707.21 (Pressure ulcer stage I) appended to 99213 to represent the pressure ulcer's stage.

Explanation: Use the "stage" codes (707.2x) to describe the status of the patient's wound -- but code the ulcer location first using 707.00-707.09.