Wound Care Documentation Case Study: Decubitus Ulcer

  Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the author do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.

  When reviewing this case study, refer to the instructions given in the case study published in the January/February 2015 issue of Today’s Wound Clinic (as well as the series of ICD-10 Diagnosis Coding Documentation Tips that were regularly provided between October 2013 and December 2014) in an effort to evaluate your documentation practices. Remember: We are only working with the diagnosis codes in these particular case studies to reinforce the importance of documentation specificity, as that is a key element for data accuracy. The appropriate diagnosis code is also necessary for determining medical necessity.

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Case Study: Decubitus Ulcer

By Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA

  (Note: Code ICD-10 diagnoses information only.)

  This is the first wound center visit for a 50-year-old male who has been living with C2-3 quadriplegia due to vertebral fractures and spinal cord injuries since a motorcycle accident 26 years ago. He was referred by his primary care physician. He developed a left ischial pressure ulcer after sitting on the toilet for a prolonged period of time while undergoing a bowel prep for a colonoscopy six weeks ago. The cushion in his wheelchair was old. He had an ulcer in the same area years ago, but has had very few skin problems since due to the wonderful care by his family. He has been living with type 2 diabetes for 21 years.

  On exam, he has a small stage III pressure ulcer on the heel of his right foot measuring 1 cm² x 0.8 cm² x 0.1 cm² and a blister on the left heel. He has been under the care of a local podiatrist who, the patient says, performed a debridement in his office last week for the foot ulcer. The foot ulcer is filled with necrotic tissue.

  There is a stage IV left ischial pressure ulcer measuring 2.2 cm² x 2.5 cm² x 0.5 cm² that is filled with necrotic material, and the bone is palpable. The ischial ulcer was sharply debrided of necrotic muscle and tendon down to visible bone. The lateral foot ulcer was debrided of necrotic subcutaneous tissue.

  Using the code table and your ICD-10 codebook, properly code the diagnoses for this case.

  Remember: Encounters for late effects of injuries should have a seventh character of “S” for sequelae.

  When using the seventh character “S,” it is necessary to code the injury code that precipitated the sequelae and the code for the sequelae itself. The “S” is added only to the injury code, not the sequelae code. The seventh character “S” identifies the injury responsible for the sequelae. The specific type of sequelae is sequenced first, followed by the injury code.

  For answers, click here.

  Donna Cartwright, MPA, RHIA, CCS, RAC, FAHIMA is senior director of strategic reimbursement at Integra LifeSciences Corp., Plainsboro, NJ, and an approved ICD-10 trainer by the American Health Information Management Association. She may be reached for questions at 609-936-2265 or at donna.cartwright@integralife.com.