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Case 2: A patient is seen for bilateral pressure ulcers to the buttocks and elbows. The pressure ulcers on the elbows are documented as partial thickness skin loss into the dermis . The pressure ulcers on the buttocks are documented as full thickness skin loss with necrosis into the subcutaneous tissue.
ICD-10 Code Assignment for Pressure/Non Pressure Ulcers 1 Stage 1: Skin changes limited to persistent focal edema 2 Stage 2: An abrasion, blister, and partial thickness skin loss involving the dermis and epidermis 3 Stage 3: Full thickness skin loss involving damage and necrosis of subcutaneous tissue 4 Stage 4: Necrosis of soft tissues through the underlying muscle, tendon, or bone 5 Unstageable: Based on clinical documentation the stage cannot be determined clinically (e.g., the wound is covered with eschar) or for ulcers documented as deep tissue injury without evidence of trauma.
The pressure ulcers on the elbows are documented as partial thickness into the dermis, which supports stage 2 (stated to be healing or abrasion, blister, partial thickness skin loss involving epidermis and/or dermis)—which again matches the physician documentation.
Each type of ulcer is coded with reference to the complications associated with it. For example, the code used for Acute gastric ulcer with hemorrhage would be K25.0
Ulcers are broadly classified based on the organ they are present. Each type of ulcer is further classified into acute or chronic.
There are codes ranging from problems in relationship with in-laws (Z63.1) to being pecked by a chicken (W61.33) to being bitten by a sea lion (W56.11)!
F10 is the ICD-10 code for alcohol related disorders which is classified further into alcohol abuse (F10.1), alcohol dependence (F10.2), alcohol use, unspecified (F10.9). The F10 code can be further specified by the use additional codes. For example, blood alcohol level measurement is Y90.
Ulcer is one of the most frequently reported diagnosis codes in gastroenterology. However, with the advent of ICD-10, coding for the simple diagnosis has become complicated for even the most experienced doctors. To make your life a little easier, we compiled a list of accurate coding guidelines for ulcers that you could refer to for your next case.
The term “non-pressure ulcer” was coined to designate a primary mechanism other than shear or pressure. If there is poor circulation, such as that caused by venous or arterial insufficiency or excessive moisture or trauma, a patient may develop a non-pressure ulcer.
Pressure ulcers are deemed patient safety indicators and hospital acquired conditions because a concerted program for prevention and treatment can prevent them and protect our patients from iatrogenic harm. The diagnosis of a “pressure ulcer” may trigger prevalence and incident reporting.
A “diabetic foot ulcer,” which is caused exclusively by hyperglycemia, in the absence of neuropathy or ischemia, is a rarity. That term almost always refers to an ulcer on the foot of a diabetic that derives from neuro/ischemic etiology, as opposed to being strictly and principally due to pressure injury.
The American Podiatric Medical Association adds that “ (diabetic foot) ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation (such as friction or pressure), and trauma, as well as duration of diabetes.” They go on to note that “vascular disease can complicate a foot ulcer, reducing the body’s ability to heal and increasing the risk for an infection.”
Neuropathy results in malum perforans pedis (a.k.a. bad perforating foot) ulcers. These are painless, non-necrotic, circular lesions circumscribed by hyperkeratosis. They often overlie a metatarsal head. Ischemic wounds manifest local signs of ischemia such as thin, shiny, hairless skin with pallor and coldness. These are often found at areas of friction and may be painful.
Why should we specifically carve out pressure ulcers? Pressure ulcers are deemed patient safety indicators and hospital acquired conditions because a concerted program for prevention and treatment can prevent them and protect our patients from iatrogenic harm. The diagnosis of a “pressure ulcer” may trigger prevalence and incident reporting.
Pressure ulcers form in sites that experience shear or pressure, typically in tissue overlying bony prominences such as elbows, the sacrum, hips, or heels. After sacral, heel ulcers are the second most common type of pressure injury. The etymology of the term “decubitus ulcer” is from the Latin, decumbere, which means “to lie down,” ...
Yes we can't assume the cause effect relationship between diabetes and foot ulcer, the relationship should be documented by the provider. stages also need to clearly mention by the provider and you can go with other part of foot because as you said no heel or midfoot is mentioned....
You may not code this as a diabetic foot ulcer since the provider does not link the conditions. The diabetes is not even referenced on the exam part. The provider also needs to document the severity as a breakdown of skin or fat layer exposed etc. not stages.