Wound Care Documentation Case Study: Venous Ulcers

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 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: Venous Ulcers
by Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA

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

This is the third wound clinic visit for a 62-year-old male who is being treated for chronic venous hypertension
of the right lower extremity with inflammation of the right ankle. Recently, he developed an ulceration in this same area.
The ulcer appears to be limited to the breakdown of the skin.

An ulcer on the ankle of his right lower extremity measuring 2.0 cm² x 0.9 cm² x 0.1 cm² is seen on exam. The ankle ulcer contains some necrotic tissue. The patient is at the wound clinic today for sharp debridement of the ankle ulcer to remove the necrotic tissue.

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

For answers, click here.