ICD-10-CM Wound Care Review Part 1

  • Gretchen Dixon, MBA, CCS, CPCO
  • Volume 06 - Issue 2

Bolstering Your Documentation for the Four Most Common Wound Diagnoses in the Clinical Setting

Level of Acuity with Intensity of Services and Complexity of Care

As we draw nearer to the ICD-10-CM go-live date of October 1, 2015, now is the time to identify and address any weaknesses that may affect future reimbursement for provided services. As a provider, your documentation is the key source of information supporting the level of acuity with intensity of services and complexity of care for each of your patients. As we have discussed before, if your documentation is without details, inconsistent, ambiguous, or incomplete, your patient’s level of acuity and provided services may not be supported. It is anticipated that within approximately two years after the implementation of ICD-10-CM, through data mining, unspecified codes will be reimbursed at a lesser value. Why? Unspecified codes only support a low level of acuity with the intensity of services and complexity of care. The use of unspecified codes may affect your profiles, which are monitored by third party payers as well as the public. Third party payers can remove providers from their plans if they feel there is an over-reporting of services based on diagnoses reported.

Focus on ICD-10-CM and Wound Care

Take this time to revisit your use of selected un- specified codes. In the wound care environment, a good start would be to review documentation details required for the four most common types of ulcers/wounds treated in a wound clinic. Of course, this does not exclude the fact these types of wounds are diagnosed in all healthcare settings, thus the documentation information value is for all types of providers. This article breaks out the following wounds/ulcers and outlines their documentation requirements for this specificity:

  1. Diabetic foot ulcer
  2. Pressure ulcer
  3. Trauma wound (will be discussed in a future article)
  4. Arterial ulcer

REMINDER: Don’t forget to sequence diagnoses!

List your first diagnosis (called the principal diagnosis or PDX), which supports the reason for the encounter and services provided. Per ICD-10-CM Coding Manual directions: code first any associated underlying condition. Instruction examples are to code first diagnosis, such as atherosclerosis of lower extremities, diabetic ulcers, or associated gangrene.

List all other diagnoses (called secondary diagnoses), which describe any co-existing conditions which require or affect patient care treatment or management.

  1. First diagnosis: type 2 diabetes mellitus with foot ulcer of right planter foot
  2. Secondary diagnoses that affect the management of the patient's treatment:
  • Right foot plantar surface ulcer involves the necrotic subcutaneous tissue
  • Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (microvascular disease)
  • Hyperglycemia

GENERAL ICD-10-CM DOCUMENTATION GUIDELINES FOR ULCERS OR WOUNDS

When describing ulcers and wounds, it is necessary to include additional details in specific categories:

  • Anatomical location — be as specific as possible
  • Diagnosis — related complications (example: atherosclerosis of specified vessel involving the right lower extremity with ulcer)
  • Secondary diagnoses that affect the patient's treatment and/or management of care
  • Describe the severity (depth) of the non-pressure ulcers (wound descriptions provided later in this article)
  • Pressure ulcers are required to have the stage reported, not the severity of the wound tissue noted above

NOTE: Electronic health records can help the provider include specific information, thus improving clinical documentation. However, the point-and- click process of adding information can result in the use of pre-determined verbiage for general diagnoses rather than objective observations made during the patient visit. Therefore, documentation details may need to be added as free text for clarification. DO NOT rely on the same identical phases used for all patients during visits! The individuality of the patient is frequently eliminated and patient records all read the same.

WOUNDS MOST COMMONLY TREATED IN A WOUND CLINIC

Diabetic Foot Ulcer

Diabetic ulcers (DFUs) require detailed documentation and more than one ICD-10-CM code to accurately describe the patient’s condition. The first diagnosis is always the reason for the encounter, which would be the ulcer.

DFU Case Scenario: The patient’s diagnosis is ulcer on the plantar surface, involving subcutaneous tissue, of the right foot due to diabetes with circulatory complications and hyperglycemia. Patient’s blood glucose is not well controlled and ranges from 180 to 230 mg/dL on a regular basis as reported by the patient. Currently the patient is on the following medications: metformin, glipizide, and NPH insulin injections in the morning and at bedtime.

Documentation details of DFUs are often problematic and can result in the diagnosis being incorrectly coded. This is due to documentation that is ambiguous, inconsistent, vague, or incomplete, which can cause the question of which came first: the ulcer in a diabetic patient or a diabetic patient who developed an ulcer due to complications of the disease? Documentation needs to clearly identify the causative relationship since not all wounds/ ulcers have this relationship with diabetes.

So, what do you document? Looking at the above scenario, we can discuss the ICD-10-CM coding options that would need to be applied.

This is an established patient with an identified DFU of the plantar surface on the right foot. The ulcer involves the necrotic subcutaneous tissue and is due to diabetes microvascular disease. The patient exhibits hyperglycemia with blood sugar ranges from 180 to 230 mg/dL, with today at 190 mg/dL.

The first diagnosis would be type 2 diabetes mellitus with a skin ulcer. The following information relates to specific documented diagnoses of diabetes with complications related to wound care services. Note how the ICD-10-CM code description has been expanded as a combination code different from the broadness of ICD-9-CM diagnosis codes. Table 1 provides the specific coding description of options for type 2 diabetes mellitus with skin complications. Blue highlight represents the applicable code.

 

Table 1
ICD-10-CM Code ICD-10-CM Code Description
E11.620 Type 2 DM with diabetic dermatitis
E11.621 Type 2 DM with diabetic foot ulcer
E11.622 Type 2 DM with diabetic other skin ulcer
E11.628 Type 2 DM with diabetic other skin ulcer complications

DM=diabetes mellitus

Diabetes Mellitus-Related ICD-10-CM Codes

In ICD-10-CM, several changes are noted according to ICD-10-CM Draft Official Guidelines for Coding and Reporting. During the development of ICD- 10-CM, diabetes combination codes were created requiring the following three components to be reported:

  1. Type of diabetes (type 2 is the most common in wound clinics)
  2. Body system affected (nervous, circulatory, nephrology skin)
  3. Complication affecting a body system

NOTE:¹

  • ICD-10-CM coding guidelines: select or assign codes as necessary to describe all of the complications of the disease
  • Sequence diagnoses based on reason for the encounter
  • If the type of diabetes is not documented, the default diagnosis code to be selected is type 2 diabetes mellitus or ICD-10-CM code E11.XX
  • Document when the patient is on insulin versus oral hyperglycemic medications
  • In describing the patient's blood sugar control, the provider needs to avoid the use of terms controlled or uncontrolled and use the terms inadequately, out of control, or poorly controlled, which all code to hyperglycemia. If the patient has periods of low blood sugars then the term hypoglycemic should be documented.

The second diagnosis would be type 2 diabetes mellitus with diabetic foot ulcer located on the plantar ulcer of the right foot. The ICD-10-CM code is a combination code noting the anatomical location and the severity of the ulcer (DFU scenario documents involving subcutaneous tissue), so it is important to include in your documentation the depth of the non-pressure ulcer/wound. Table 2 lists the options available for selection based on the provider’s documentation. Blue highlight represents the applicable code.

Keep in mind the documentation of laterality and code selection changes. There is no selection for bilateral extremity for this category. However, there is a code for unspecified laterality and unspecified severity of the ulcer, which should never be coded in the wound care setting.

Diagnosis: type 2 diabetes mellitus with diabetic foot ulcer located on the plantar surface of right foot.

Severity (depth): fat layer exposed (subcutaneous tissue)

Table 2
Severity (depth) Documentation

ICD-10-CM Codes           

ICD-10-CM Descriptions
Is it limited to breakdown of skin? L97.411 Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface) limited to breakdown of skin
Is the fat layer exposed? L97.412 Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface) with fat layer exposed
Is there necrosis of muscle? L97.413 Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface) with necrosis of muscle
Is there necrosis of bone? L97.414 Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface) with necrosis of bone
No severity specified (should not be used) L97.419 Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface)

The third diagnosis would be type 2 diabetes mellitus with circulatory complications supporting the microvascular disease. Table 3 provides the specific coding description of options for type 2 diabetes mellitus with diabetic circulatory complications.

 

Table 3
ICD-10-CM Code ICD-10-CM Code Description
E11.51 Type 2 DM with diabetic peripheral angiopathy without gangrene
E11.52 Type 2 DM with diabetic peripheral angiopathy with gangrene
E11.59 Type 2 DM with diabetic with other circulatory complications

DM=diabetes mellitus

The diagnosis would be for type 2 diabetes mellitus with either hyperglycemia or hypoglycemia. Tables 4 and 5 illustrate the specific coding options for type 2 diabetes mellitus with management issues commonly occurring in a wound clinic.

Table 4
Hyperglycemia
ICD-10-CM Code ICD-10-CM Code Description
E11.65 Type 2 DM with hyperglycemia

DM=diabetes mellitus

Table 5
Hypoglycemia
ICD-10-CM Code ICD-10-CM Code Description
E11.641 Type 2 DM with hypoglycemia with coma
E11.649 Type 2 DM with hypoglycemia without coma

DM=diabetes mellitus

Possible Codes: If the patient also has peripheral neuropathy, Table 6 provides the specific documentation details and coding options for type 2 diabetes mellitus with diabetic neurological complications.

Table 6
ICD-10-CM Code ICD-10-CM Code Description
E11.40 Type 2 DM with diabetic neuropathy, unspecified (needs to be specific)
E11.41 Type 2 DM with diabetic mononeuropathy
E11.42 Type 2 DM with diabetic polyneuropathy
E11.43 Type 2 DM with diabetic autonomic (poly) neuropathy
E11.49 Type 2 DM with other diabetic neurological complications

DM=diabetes mellitus

Based on the case scenario, the following ICD-10-CM codes should be selected for this patient:

  • E11.621 — Type 2 diabetes mellitus with diabetic foot ulcer
  • L97.412 — Non-pressure chronic ulcer of right heel & midfoot (includes plantar surface) with fat layer exposed (reason for the wound care department encounter)
  • E11.51—  Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
  • E11.65 — Type 2 diabetes mellitus with hyperglycemia

Pressure Ulcer

Pressure ulcers are frequently treated in the wound care setting. Therefore, ICD-10-CM includes in the description the combination of laterality with the anatomical location of the ulcer as well as the stage of the pressure ulcer. The ulcer staging can be documented by either the provider or the clinician. However, the documentation must consistent.

Pressure Ulcer Case Scenario: An established patient with a pressure ulcer of the right heel now presents with necrosis of soft tissue involving the tendon. The tissues of this ulcer continue to  deteriorate due to non-compliance of pressure relief. This pressure ulcer is now at stage 4.

 

Table 7

Anatomical LocationLaterality
Elbow Right
Left
Unspecified—should not be a coding option selected in a wound care setting
Back Right upper or lower
Left upper or lower
Unspecified part of back—should not be a coding option selected in a wound care setting
Hip Right
Left
Sacral region does not have any additional specificity other than to include staging Unspecified—should not be a coding option selected in a wound care setting
Buttock Right
Left
Unspecified—should not be a coding option selected in a wound care setting
Contiguous site of back, buttock, and hip Document ulcer staging
No laterality required with this code
Ankle Right
Left
Unspecified—should not be a coding option selected in a wound care setting
Heel Right
Left
Unspecified—should not be a coding option selected in a wound care setting
Other site –head Document ulcer staging
No laterality required with this code
Other site not listed above Document ulcer staging
No laterality required with this code
Unspecified site Should not be a coding option selected in a wound care setting

NOTE: Pressure ulcer ICD-10-CM code descriptions do not require reporting tissue severity as with non-pressure ulcers. However, laterality and staging of the pressure ulcer are required. The broad ICD-10-CM category for pressure ulcers begins under L89.XXX and is broken down by anatomical locations and staging. Anatomical descriptions for pressure ulcers are listed in Table 7.

Staging descriptions for pressure ulcers are listed in Table 8.

Table 8
Stage 1 ulcers consist of but are not limited to:

Intact skin with non-blanchable redness of localized area

Usually located over bony prominences

Stage 2 ulcers consist of but are not limited to:

Partial thickness loss of dermis

Shallow open ulcer with a red-pink wound bed

No slough in wound bed

May also present as intact or open/ruptured serum-filled blister

Bruising indicates suspected deep tissue injury

Stage 3 ulcers consist of but are not limited to:

Subcutaneous tissue may be visible

No exposed muscle/tendon/bone

Slough may be present

May include undermining & tunneling

Shallow ulcer on nose/ear/occiput/malleolus due to lack of subcutaneous tissue

Stage 4 ulcers consist of but are not limited to:

Full thickness loss with exposed muscle/tendon/bone

Slough/eschar may be present on some parts of wound bed

Often includes undermining and tunneling

May extend into muscle/supporting structures/fascia/tendon/joint capsule

 

NOTE: ICD-10-CM coding requires documentation of laterality (right or left or both) along with the pressure ulcer staging to avoid unspecified codes. Without specifying laterality, the code description includes “unspecified heel.” The codes in Table 9 note the documented location of the right heel along with the applicable stages. The code that applies to the pressure ulcer described in the case scenario, a stage 4 pressure ulcer of the right heel, is highlighted.

Table 9
ICD-10-CM Code ICD-10-CM Code Description
L89.610 Pressure ulcer of right heel, unstageable
L89.611 Pressure ulcer of right heel, stage 1
L89.612 Pressure ulcer of right heel, stage 2
L89.613 Pressure ulcer of right heel, stage 3
L89.614 Pressure ulcer of right heel, stage 4
L89.619 Pressure ulcer of right heel, unspecified stage—should not be a coding option selected in a wound care setting

Arterial Ulcer

Lower extremity arterial disease (LEAD) is most commonly caused by atherosclerosis, particularly in patients with high risk lifestyle factors such as advanced age, diabetes mellitus, hyperlipidemia, hypertension, obesity, and smoking as well as a family history of cardiovascular disease. With ICD-10-CM, a patient with an arterial ulcer will require more than one diagnosis code to accurately reflect the level of acuity with complexity of care and intensity of services. However, these new ICD-10-CM codes for arterial ulcers encompass the following details, which are required in a provider’s clinical documentation:

The disease of atherosclerosis

  • Anatomical specific location
  • Laterality (right or left)
  • Type of arteries involved
    • Native arteries
    • Unspecified type of bypass graft(s)
    • Autologous vein bypass graft(s)
    • Non-autologous biological bypass graft(s)
    • Other type of bypass graft(s)
    • Type of bypass vein

Arterial ulcers have associated common characteristics that include:

  • Wound margins well-demarcated and
    • Wounds are often full-thickness, deep, and painful
    • Wound bed may have nonviable gray-yellow tissue or eschar with a pale coloration due to compromised blood flow
    • Gangrene may be present
  • Typical locations such as the following:
    • Ankles
    • Feet, including toes, tip of toes, or over the phalangeal heads
    • Lateral malleoli
    • Areas of trauma
  • The severity of the ulcer requires an additional code
Arterial Ulcer Case Scenario: A new patient presents with right lower extremity ulcers on the right great and third toes. The physician documents a diagnosis of atherosclerosis of native vessel, which had a non-autologous biological bypass graft inserted during a femoropopliteal bypass performed on the right leg to improve circulation six weeks prior. The right great toe has a gangrenous ulcer with necrotic bone exposed, and the right third toe has eschar present over half of the ulcer with subcutaneous tissue exposed. Both ulcers will require debridement and an aggressive wound care treatment regimen.

The following ICD-10-CM code options listed in Tables 10 through 12 are based on the details contained in the provider’s documentation. The applicable codes are highlighted in blue.

 

Table 10
Diagnosis: Atherosclerosis of native arteries of right leg with ulceration of other part of foot
ICD-10-CM Code ICD-10-CM Code Description
I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg
I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg

 

Table 11
Diagnosis: Atherosclerosis of native arteries of right leg with ulceration of other part of foot
ICD-10-CM Code ICD-10-CM Code Description
I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot (toes)
I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot (toes)

 

Table 12

Diagnosis: Severity of each ulcer is to be coded separately
ICD-10-CM Code ICD-10-CM Code Description
L97.514 Non-pressure chronic ulcer of other part of right foot with necrosis of bone
L97.512 Non-pressure chronic ulcer of other part of right foot with fat layer exposed

Based on the case scenario, the following ICD-10-CM codes should be selected for this patient:

  1. I70.261 — Atherosclerosis of native arteries of extremities with gangrene, right leg
  2. I70.235 — Atherosclerosis of native arteries of right leg with ulceration of other part of foot (toes)
  3. L97.514 — Non-pressure chronic ulcer of other part of right foot with necrosis of bone (reason for the wound care department encounter)
  4. L97.512 — Non-pressure chronic ulcer of other part of right foot with fat layer exposed (reason for the wound care department encounter)

Conclusion

This article has focused specifically on examples related to the most common wounds encountered in the clinical setting, along with the clinical documentation elements necessary to avoid the use of unspecified codes. Keep in mind, when treating wounds it may be necessary to report the wound with a level of severity of tissue destruction code. This L97.XXX code (level of wound severity) supports your level of acuity with intensity of services and complexity of care decisions necessary, such as additional workup evaluations, tests, procedures, and debridements, to provide your patient with the appropriate care. It is the details of your documentation that will tell the most complete and accurate story of your patient’s medical care, so be sure to make the necessary documentation preparations to survive the transition to ICD-10-CM this fall.

References

  1. ICD-10-CM Draft Official Guidelines for Coding and Re- porting 2015. Chapter 4, Sections 1-6

  2. CMS: Billing and Coding with Electronic Health Records, 2013, May 3. (Scanned document)

  3. Optum ICD-10-CM Expert for Hospitals Manual.2015.

  4. Optum ICD-10-CM Mappings Manual.2015.

  5. Wound Management and Healing Manual. 2nd Edition. Western Schools

  6. Optum ICD-10-CM / PCS Coding Readiness Assessment.2015.

  7. Optum ICD-10-CM Clinical Documentation Improvement Desk Reference. 2015. 


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About the Author

Gretchen-Dixon
Gretchen Dixon is the owner of Professional Compliance Strategies LLC and consults on outpatient departments and physician services. She has pro- vided revenue cycle compliance reviews of services with the focus on wound care department operations for over 9 years. She holds several credentials: MBA in Healthcare Management, Registered Nurse with practicing licenses in NY and a multi-state license from Virginia, AHIMA Certified Coding Specialist (CCS), AAPC Certified Professional Compliance Officer (CPCO), and is an AHIMA Approved ICD-10-CM/PCS Trainer/Ambassador. Being a longtime internal health- care compliance auditor, she identifies issues through audits of D, C, Bs (documentation, coding & billing) of provided services. The outcomes of each audit determines the topics of education to be provided to staff and physicians as she believes education is the KEY to having accurate, complete and consistent documentation for accurate reimbursement of billed services. Contact at This email address is being protected from spambots. You need JavaScript enabled to view it. or 615.210.7476.
 

 

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