The Spinning World of Coding Updates

  • Gretchen Dixon
  • Volume 09 - Issue 1

Have you reviewed the added wound severity codes effective October 1, 2017? Do you sometimes second guess the diagnosis codes selected? Do the codes accurately reflect the patient’s medical condition? Are you comfortable the claim will not hit any edits and reimbursement will be timely? You may answer yes, no, maybe or doubt sets in with a big question mark of “am I sure?”. Here are some updates and changes to wound care diagnosis ICD-10 diagnosis codes.

For the fiscal year of 2018 starting October 1, 2017, the Cooperating Parties [the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Centers for Medicare and Medicaid Services (CMS), and National /Center for Health Statistics (NCHS)] for the ICD-10-CM approved expanding the category for non-pressure chronic ulcers is a positive change. Notice the new options of choosing a code with or without necrosis of muscle or bone. This article will focus on the added new codes (63) with descriptions stating “without evidence of necrosis . . .” providing a more accurate acuity level, complexity of care and intensity of services provide in wound care. The category of L97 titled Non-Pressure Chronic Ulcer of Lower Limb, not elsewhere classified, includes the following descriptions:

  • Chronic ulcer of skin of lower limb NOS (not otherwise specified)

  • Non-healing ulcer of skin

  • Non-infected sinus of skin

  • Trophic ulcer NOS

  • Tropical ulcer NOS

  • Ulcer of skin lower limb NOS

Within the ICD-10 coding manual for this code family L97, there are specific coding directions involving underlying medical conditions and the hierarchy of code reporting these diagnoses. Under this family, the anatomy hierarchy includes laterality (unspecified, right or left respectively) and begins with the L97.1 Non-Pressure Chronic Ulcer of Thigh and ending with the last L97.92 Non-Pressure Chronic Ulcer of Unspecified Part of Left Lower Leg. All of these specific codes require a total of 6 characters for completeness. The following charts include samples of the new codes and description changes noted in red which must be supported with clinical documentation. However, due to the numerous codes, refer to your 2018 ICD-10-CM Coding Manual for the complete listing beginning with L97.101 through L97.629.

NOTE: In the wound care setting, there never should be ICD-10 codes selected with the term unspecified severity. The ICD-10 diagnosis codes to watch for end with the number “9” such as code L97.329 Non-Pressure Chronic Ulcer of Left Ankle with Unspecified Severity.

Relative Code ICD-10 Diagnosis Code ICD-10 Code Description

L97.10 –

Non-pressure Chronic Ulcer of Unspecified Thigh

L97.105 Non-pressure chronic ulcer unspecified thigh with muscle involvement without evidence of necrosis
  L97.106 Non-pressure chronic ulcer unspecified thigh with bone involvement without evidence of necrosis
  L97.108 Non-pressure chronic ulcer unspecified thigh with other specified severity

L97.11 –

Non-Pressure Chronic Ulcer of Right Thigh 

L97.115 Non-pressure chronic ulcer right thigh with muscle involvement without evidence of necrosis
  L97.116 Non-pressure chronic ulcer right thigh with bone involvement without evidence of necrosis
  L97.118 Non-pressure chronic ulcer right thigh with other specified severity

L97.12 –

Non-Pressure Chronic Ulcer of Left Thigh

L97.125 Non-pressure ulcer left thigh with muscle involvement without evidence of necrosis
  L97.126 Non-pressure chronic ulcer left thigh with bone involvement without evidence of necrosis
  L97.128 Non-pressure chronic ulcer left thigh with other specified severity
                                                                                                                             

L97.20 –

Non-Pressure Chronic Ulcer of Unspecified Calf

L97.205 Non-pressure chronic ulcer unspecified calf with muscle involvement without evidence of necrosis
  L97.206 Non-pressure chronic ulcer unspecified calf with bone involvement without evidence of necrosis
  L97.208 Non-pressure chronic ulcer unspecified calf with other specific severity

L97.21 –

Non-Pressure Chronic Ulcer of Right Calf

L97.215 Non-pressure chronic ulcer right calf with muscle involvement without evidence of necrosis
  L97.216 Non-pressure chronic ulcer right calf with bone involvement without evidence of necrosis
  L97.218 Non-pressure chronic ulcer right calf with other specific severity

L97.22 –

Non-Pressure Chronic Ulcer of Left Calf

L97.225 Non-pressure chronic ulcer left calf with muscle involvement without evidence of necrosis
  L97.226 Non-pressure chronic ulcer left calf with bone involvement without evidence of necrosis
  L97.228 Non-pressure chronic ulcer left calf with other specified severity
                                                                                                                             

L97.30 –

Non-Pressure Chronic Ulcer of Unspecified Ankle

L97.305 Non-pressure chronic ulcer of unspecified ankle with muscle involvement without evidence of necrosis
  L97.306 Non-pressure chronic ulcer of unspecified ankle with bone involvement without evidence of necrosis
  L97.308 Non-pressure chronic ulcer of unspecified ankle with other specified severity

L97.31 –

Non-Pressure Chronic Ulcer of Right Ankle

L97.315 Non-pressure chronic ulcer of right ankle with muscle involvement without evidence of necrosis
  L97.316 Non-pressure chronic ulcer of right ankle with bone involvement without evidence of necrosis
  L97.318 Non-pressure chronic ulcer of right ankle with other specified severity

L97.32 –

Non-Pressure Chronic Ulcer of Left Ankle

L97.325 Non-pressure chronic ulcer left ankle with muscle involvement without evidence of necrosis
  L97.326 Non-pressure chronic ulcer left ankle with bone involvement without evidence of necrosis
  L97.328 Non-pressure chronic ulcer left ankle with other specified severity
                                                                                                                             

L97.41 –

Non-Pressure Chronic Ulcer of Right Heel and Midfoot

L97.415 Non-pressure chronic ulcer right heel and midfoot with muscle involvement without evidence of necrosis
  L97.416 Non-pressure chronic ulcer right heel and midfoot with bone involvement without evidence of necrosis
  L97.418 Non-pressure chronic ulcer right heel and midfoot with other specified severity

L97.42 

Non-Pressure Chronic Ulcer of Left Heel and Midfoot

L97.425 Non-pressure chronic ulcer left heel and midfoot with muscle involvement without evidence of necrosis
  L97.426 Non-pressure chronic ulcer left heel and midfoot with bone involvement without evidence of necrosis
  L97.428 Non-pressure chronic ulcer left heel and midfoot with other specified severity

Coding Question Related to Radiation Late Effects or Complications

Proctitis:

Radiation proctitis or colitis seems to be an issue for Medicare claim reporting with ICD-10 hierarchy. Based on CMS transmittals and websites for hyperbaric oxygen Therapy (HBOT), there is a coding hierarchy which will need to be followed to prevent claim edits. ICD-10 code L59.8– Other Specified Disorders of the Skin and Subcutaneous Tissues Related to Radiation will need to be listed as the first or principle diagnosis code. The reason for this is CMS has clearly documented this diagnosis as a covered diagnosis.

Adding ICD-10 diagnosis codes K52.0 – Gastroenteritis and Colitis Due to Radiation or K62.7 – Radiation Proctitis as Secondary Diagnoses should provide additional support for the designed treatment plan. In the coding manual, the coder is directed to select an additional code to identify the type of radiation; therefore, clinical documentation history needs to provide details of the past radiation treatment regime.

Unfortunately, even though the code selection may not make sense to us, as coders we must follow the various third-party payers such Medicare for their unique coding and billing requirements to the best of our ability.

Here is the access to the most current Centers of Medicare and Medicaid Services HBO spreadsheet regarding covered diagnosis as of October 30, 2017, for your reference: https://www.cms.gov/Regulations-and-Guidance/ Transmittals/2017Downloads/R1975OTN.pdf

With the above stated, this is an example of how the codes should be reported; however, understand there is no guarantee even this hierarchy would be accepted. Patient history notes history of adenocarcinoma of prostate, treated with radioactive seed implants 24 months ago, presents with diagnosis of proctitis due to radiation therapy and severe pelvic pain. What is missing is the other details on the type, number and length of treatment with radioactive seed implants.

Principle Diagnosis Secondary Diagnoses

L59.8 - Other Specified Disorders of the Skin and Subcutaneous Tissues Related to Radiation

 

 

 

 

K62.7 - Radiation Proctitis

R10.2 - Pelvic and Perineal Pain

Z85.46 - Personal History of Malignant Neoplasm of Prostate

W88.1 - Exposure to Radioactive Isotopes

Y84.2 - Radiological Procedure and Radiotherapy as the Cause of Abnormal Reaction of the Patient, or of Later Complication, without Mention of Misadventure at the Time of the Procedure

 

Skin Grafts Versus Tissue Grafts Clarification

There have been some questions circulating in our industry about the term skin graft being documented on the HBO2 evaluation. However, the clinical documentation references note the patient received a tissue graft and within a few hours of the surgical procedure, the tissue graft was compromised with a change in color from pink to turning dusky. 

This was a sign the tissue graft was compromised and needed immediately post-surgical intervention with hyperbaric medicine therapy.

First review the definition of both skin graft and graft or tissue flap/ graft. A skin graft is a thin sheet of skin harvested from a donor site creating two possible wound care sites.

Skin graft is a surgical procedure involving harvesting a sheet of healthy skin from an area of the body and transplanting it to a different part of the body to provide a protective covering of an area missing normal skin. The skin graft may consist of partial or full thickness to replace damaged layers of the skin.

This may be due to burns, injury or an illness.  A partial or split thickness skin graft contains the epidermis and part of the dermis layer of skin tissue where as a full thickness skin graft contains the epidermis and entire thickness of the dermis.

A tissue flap is tissue transferred with its own blood supply intact from one area of the body to another area of the body. A flap is attached to the body by an artery or vein at its base to be used for reconstructive surgery repairing a large defect deeper than the top layers of the skin. There are two different surgical methods:

  • Pedicle flap means the flap of tissue from the back or belly is moved to the chest without cutting its original blood supply. The tissue is pulled under the skin up to the chest area and attached.
  • Free flap means the tissue and blood vessels are cut. After the flap is in place, the surgeon sews the blood vessels in the flap to blood vessels in the body chest. This requires microscopic surgery to anastomose the blood vessels from the donor tissue to the recipient tissues.

A tissue graft is a transfer of tissue mass without its own blood supply and depends entirely on the blood supply from the recipient site for growth of new blood vessels.

In summarization, a tissue flap has its own blood supply and a graft does not, requiring a good vascular bed at the site to survive.

Complications post-surgical flap or graft present with ischemia, change in skin temperature, skin or fat necrosis, venous congestion or occlusion, arterial occlusion or mechanical meaning there is no overt explanation. Clinical documentation must include details of the situation in the history of present illness (HPI) to support the medical necessity of trying to salvage the flap or graft.

A statement by the provider needs to include the following details in the HPI:

  • Prior surgical interventions: patient response with outcomes
  • Date when hypoxia or decreased perfusion was identified as compromising the viability of the flap or graft
  • Identify any prior adjunctive treatments performed with responses
  • Identify any comorbidities which may need intervention pre-hyperbaric therapy

The following is a sample statement that wraps up the elements noted in the HPI, summarizing the appropriateness of HBO2:

“The viability of the graft’s survival appears threatened due to a mechanical complication. HBOT during this immediate post-operative period may improve the survival of the flap with the increased perfusion of oxygen.”

There are four (4) ICD-10 diagnosis codes CMS lists in their above Excel spreadsheet supporting these complications for both tissue flap or tissue graft located under skin graft or skin terms as follows:

Skin graft (allograft): Rejection T86.820

                                  Failure T86.821

                                  Infection T86.822

                                  Other complications of skin graft (allograft, autograph) T86.828

Compliance Wrap-Up

Wound care is under intense scrutiny today, especially hyperbaric medicine. Therefore, providers need to invest by reviewing their own current clinical documentation and identify weaknesses in the details thus making improvements to support medical necessity through a clear and consistent clinical rationale for hyperbaric therapy. The ICD-10 diagnosis codes listed in this article provide an overview of the level of detail required in history of present illness section of the clinical documentation to support selection of diagnosis codes at their highest level of specificity. Keep in mind the bottom line is all submitted diagnosis codes provide the third-party payer a “picture” of the patient’s medically complex condition(s) for treatment within the wound care setting. If your diagnosis codes are without specificity, then you risk either a claim held for additional information or possibly a denied claim resulting in a negative toward your department’s financial viability.

 

References

  1. CMS dated January 18, 2018, page 5, Section 10318.4, ICD-10 diagnosis codes listed

  2. https://www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/2018Downloads/R2005OTN.pdf

  3. Optum360 2018 ICD-10-CM Professional for Hospital Coding Manual

  4. CMS 1975 dated November 9, 2017Change Request10318

  5. https://www.cms.gov/Regulations-and-Guidance/Guidance/ Transmittals/2017Downloads/R1975OTN.pdf
  6. CMS National Coverage Determination policy for HBO: https://www.cms.gov/medicare-coverage-database/details/ncd- details.aspx?ncdid=12&ver=3

  7. Novitas Solutions HBO policy L35021 dated November 5,2017 http://go.cms.gov/2GcwzIp

  8. First Coast Services Options HBO policy L36504 datedAugust 11, 2017 https://medicare.fcso.com/lcd/active/l36504.pdf

  9. Palmetto GBA Prepayment Service Specific Complex Review Results for Outpatient HBO: https://www. palmettogba.com/palmetto/providers.nsf/vMasterDID/ AQHKNG6518?OpenDocument

  10. Aetna HBOT policy dated July 18, 2017 http://www.aetna.com/cpb/medical/data/100_199/0172.html
  11. WPS Targeted Prove & Educate policy dated February 15, 2018 https://www.wpsgha.com/wps/portal/mac/site/eligibility/news- and-updates/hbo-g0277-99193-per-session

  12. United Healthcare HBO policy H-008 dated April 18, 2017 http://bit.ly/2GKVArF

 

About the Author

Gretchen-Dixon
Gretchen Dixon, MBA, RN, CCS, is the owner of Professional Compliance Strategies (PCS), LLC, and consults on outpatient departments and physician services. She has provided revenue-cycle compliance audits of services with a focus on wound care department operations for more than 10 years. She holds several credentials including an MBA in healthcare management, an RN with a practicing license in New York, and 23 multistate licensure from Virginia, AHIMA Certified Coding Specialist (CCS), AHIMA ICD-10-CM/PCS Approved Trainer, and is an AAPC Certified Professional (Healthcare) Compliance Officer. A longtime internal healthcare auditor, Dixon identifies issues through audits of D, C, B (documentation, coding and billing) of provided services. The outcome of each audit determines the topics of education to be provided to the staff and physicians, as she proactively believes education is the key to having complete, accurate, and consistent documentation supporting reimbursement for billed services. If you are interested in her services, contact Dixon at This email address is being protected from spambots. You need JavaScript enabled to view it. or call 1-615-210-7476
 

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