Vol. 17 •Issue 13 • Page 6
Pressure Ulcers Under Scrutiny
It is more important than ever to ensure that pressure ulcers and the accompanying procedures are documented and coded appropriately.
In 2006, 322,946 Medicare patients had a pressure ulcer assigned as a secondary diagnosis. These cases had average hospital charges of $40,381. It’s no wonder that the Centers for Medicare and Medicaid Services (CMS) has identified pressure ulcers as a preventable high-volume, high-cost condition. With the implementation of the Deficit Reduction Act (DRA) requirements and the CMS proposal to include pressure ulcers as an initial preventable hospital acquired condition, correct coding and assignment of the Present on Admission (POA) indicator is more important than ever.
Pressure or decubitus ulcers, also referred to as bed or pressure sores, are defined as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. They can range from a reddened area on the skin to severe tissue damage that may extend to the muscle and bone.
The National Pressure Ulcer Advisory Panel redefined the stages of pressure ulcers in February 2007 as follows:
Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Pressure ulcers are difficult to treat and slow to heal. These ulcers often develop over weight-bearing parts of the body such as hips, shoulder blades, tailbone and heels. The hip and buttock regions account for the vast majority of all pressure sores followed by those of the lower extremities. A small percentage of pressure sores may occur in other locations that experience long periods of uninterrupted pressure.
The following are some risk factors for pressure ulcers:
The following codes from category 707.0, Decubitus ulcer, are assigned to identify the different sites on the body where a pressure ulcer may develop.
707.00, Decubitus ulcer, unspecified site
707.01, Decubitus ulcer, elbow
707.02, Decubitus ulcer, upper back
707.03, Decubitus ulcer, lower back
707.04, Decubitus ulcer, hip
707.05, Decubitus ulcer, buttock
707.06, Decubitus ulcer, ankle
707.07, Decubitus ulcer, heel
707.09, Decubitus ulcer, other site
It is important to note here that these codes are classified as complications/comorbidities (CC) under the current CMS DRG system. However, under the proposed MS-DRGs codes 707.00, 707.01 and 707.09 are considered CCs and codes 707.02 through 707.07 are considered major CCs (MCC). This is an important potential change because MCCs will result in even larger reimbursements to hospitals than CCs.
If a physician documents and treats a pressure ulcer, then a code from category 707.0 is assigned regardless of severity and stage. ICD-9-CM does not classify pressure ulcer by stage. Therefore, code 707.0x is assigned for a stage 1 or a stage 4 pressure ulcer. If the physician documents a skin ulcer but does not specify it as a decubitus or pres-sure ulcer, one of the following codes is assigned instead:
707.1X, Ulcer of lower limb, except decubitus
707.8, Chronic ulcer of other specified sites
707.9, Chronic ulcer of unspecified site
Patients can develop more than one ulcer at various sites. Multiple codes from category 707.0, Decubitus ulcer, may be assigned when a patient has multiple pressure ulcers of more than one site.”
Treatment of Pressure Ulcers
The first step in treatment is to reduce or eliminate the cause of the pressure ulcer. Special support surfaces are available for bedding and wheelchairs and include foam devices, air-filled devices, low-airloss beds and air-fluidized beds. Regardless of the choice of support surface, turning and repositioning the patient remain the main mode of prevention and treatment.
Wound debridement may be performed if the skin or underlying tissue dies. Debridement is performed to reduce the risk of infection and to promote healing. For coding purposes, excisional debridement is assigned to code 86.22, Excisions debridement of wound, infection or burn. Nonexcisional debridement is assigned to code 86.28, Nonexcisional debridement of wound, infection or burn.
One of the greatest difficulties in coding debridements is determining the type of debridement performed. According to Coding Clinic, excisional debridement is “the surgical removal or cutting away of devitalized tissue, necrosis or slough.” Nonexcisional debridement includes “brushing, irrigating, scrubbing or washing of devitalized tissue, necrosis or slough.”
Care should be taken to ensure that the medical record supports the assignment of an excisional debridement. The use of a sharp instrument does not always indicate that an excisional debridement was performed. When the record indicates debridement using a sharp instrument and the record does not clearly state that tissue was excised, the provider of service must be queried or the nonexcisional debridement code 86.28 must be assigned.
Often you will find that the only documentation present is simply the word “debridement.” If this is the only information available, procedure code 86.28 for nonexcisional debridement would be assigned.
In most cases, excisional debridements are performed by physicians. According to Coding Clinic, Second Quarter 2000, it is appropriate to assign code 86.22, when a health care provider such as a physical therapist performs an excisional debridement. However, debridements performed by physical therapists are generally nonexcisional in nature. In excisional debridement a scalpel is used to remove devitalized tissue. It involves cutting outside or beyond the wound margin. Scraping away tissue is not considered an excisional debridement.
ICD-9-CM codes 86.22 and 86.28 are assigned when the debridement involves only the skin and subcutaneous tissue. If excisional debridement is performed down to the level of muscle (83.45) or bone (77.60-77.69), assign only a code for the deepest layer of debridement within the same site.
Multiple codes may be required if debridement is performed to different levels at different sites. For example: If a patient has a debridement of the buttock down to the muscle and the skin and subcutaneous tissue of the leg, two codes should be assigned. Code 83.45, Other myectomy, and code 86.22, Excisional debridement of wound, infection or burn.
If the final inpatient prospective payment system (IPPS) rule for FY 2008 includes the changes discussed above, it will be more important than ever to ensure that pressure ulcers and the accompanying procedures are documented and coded appropriately. Reimbursement may be affected in a number of ways. Watch for information on the IPPS final rule, which is expected to be published in August.
Before the certified coding specialist (CCS) exams, the coder may want to review all issues of Coding Clinic related to pressure ulcers and debridement. After reviewing all related coding guidelines, test yourself with the exercises below:
1. A patient is admitted with complaints of continuous bleeding from a chronic ulcer of the left heel. The patient has noninsulin dependent diabetes and peripheral vascular disease due to the diabetes. Because of gangrene and acute osteomyelitis from the heel ulcer, the patient underwent a left below the knee amputation. The physician documents that the ulcer is a decubitus ulcer. The appropriate diagnosis code assignment is:
a. 250.80, 731.8, 730.07, 440.24
b. 250.80, 731.8, 730.07, 440.24, 707.14, 785.4
c. 707.07, 785.4, 730.07, 250.70. 443.81
d. 707.07, 250.80, 731.8, 730.07, 440.24, 785.4
2. A 75-year-old patient who was admitted to the hospital for hip replacement was diagnosed with a decubitus ulcer of the buttock. The physician described the ulcer as a stage one decubitus, 1.5 c.m., without exudates, but with a small white fibrous region. The patient received skin care by nursing. Is it appropriate to code the decubitus ulcer with code 707.05 as an additional diagnosis even though it has not progressed to the third stage?
3. A 56-year-old paraplegic patient is admitted for closure of a recurrent left ischial sinus and residual pressure sore that has been present for many years. Six months prior to admission the patient had excision and closure of the sinus with good healing. The wound, however, eventually broke down and the sinus recurred. The surgeon excised the left ischial sinus and capsule with rotation flap closure. The appropriate diagnosis and procedure code assignment is:
a. 707.04, 344.1, 86.3, 86.74
b. 707.04, 344.1, 86.74
c. 686.9, 707.04, 344.1, 86.3. 86.74
d. 686.9, 344.1, 707.04, 86.3
This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.
Answers to CCS Prep!: 1. c: Assign code 707.07, Decubitus ulcer heel, as the principal diagnosis for the chronic, nonhealing decubitus ulcer. It is important to recognize that not all ulcers in diabetic patients are diabetic ulcers. In this case, the physician documented that the heel ulcer was a decubitus ulcer, which had progressed to osteomyelitis and gangrene. The osteomyelitis would not be coded as a diabetic complication. Assign codes 785.4, Gangrene, 730.07, Acute osteomyelitis, Ankle and foot, 250.70, Diabetes with peripheral circulatory disorders, and 443.81, Peripheral angiopathy in diseases classified elsewhere, as additional diagnoses; 2. a: Yes, assign a code from category 707.0, Decubitus ulcer, for all decubitus ulcers. ICD-9-CM does not classify ulcers by severity or stage. Therefore, decubitus ulcers are assigned to code 707.0X whether superficial or advanced; 3. a: Assign code 707.04, for the residual pressure sore with recurrent ischial sinus. The formation of the ischial sinus in the decubitus ulcer is an integral part of the disease process and no additional code should be assigned. Assign code 86.3, Other local excision or destruction of lesion or tissue of skin and subcutaneous tissue, for the excision of the ischial sinus and code 86.74, Attachment of pedicle or flap graft to other sites, for the rotation flap repair and closure.