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The Pressure is On!
The Anatomy and Pathophysiology spotlight this month is pressure ulcers. The Integumentary system is the largest organ of the body and is composed of the skin and accessory tissues. There are three layers of skin; the epidermis is the outer layer of skin, which protects the body. The dermis layer contains hair follicles, glands, blood and lymphatic vessels, and nervous tissue found deeper in the dermis. The final layer is the hypodermis, which contains the dermal appendages (nails, hair, sebaceous, and sweat glands). When there is an injury to the skin and underlying tissue, a pressure ulcer may result.
Pressure ulcers, also called decubitus ulcers or bedsores, are often seen in patients with diabetes, vascular disease, urinary or bowel incontinence, malnourishment, or a debilitating disease such as multiple sclerosis. Patients who are bed ridden or confined to a wheelchair are more prone to pressure ulcers in areas such as the back, hip, shoulder, back of head, ankle, and heel. Continual pressure or contact against the skin reduces blood flow and a lack of oxygen in the tissue. Subsequently, the skin begins to break down and eventually will die.
Pressure ulcers are categorized in stages based severity:
- Stage 1 - Begins as a reddened area that does not turn white when pressed.
- Stage 2 - Appears as a blister or open sore and involves the epidermis and dermis.
- Stage 3 - The ulcer appears as an open sore referred to as a crater. Damage is to the subcutaneous and underlying fascia.
- Stage 4 - Has progressed to a deep level with necrosis to the muscle and bone; there may also be involvement of tendons or joints.
- The stage of a pressure ulcer is based on clinical documentation; when it cannot be clinically determined it is coded unstageable.
The Official Coding Guidelines contain instructions to code pressure ulcers. There are changes from the current guidelines in ICD-9-CM; ICD-10-CM contains many combination codes which will reduce the number of codes required to accurately report the condition. An instructional “code first” note for associated gangrene applies to all pressure ulcer codes. Codes are located in L89 (Pressure Ulcer) and in order are categorized by site (elbow, back, hip, buttocks, ankle, heel), laterality, and severity which is identified by stages (I-IV). For example, a stage 2 pressure ulcer on a patient’s right elbow would be reported with L89.012 Pressure ulcer of right elbow, stage 2. Providers should be queried when documentation lacks the stage of the ulcer, location, or laterality.
Stay tuned for more A&P articles in the coming months.
IN THE NEWS
Final month: Version 5010 Enforcement Discretion Period
The Version 5010 enforcement discretion period ends on June 30, 2012. As you recall, the Version 5010 upgrade is necessary as it supports both ICD-9-CM and ICD-10-CM code set structures. In addition to the code set changes, standards for electronic administrative transactions, such as remittance advices and eligibility inquiries, are being updated.
All HIPAA-covered entities were required to upgrade to Version 5010 by January 1, 2012. However, the Centers for Medicare & Medicaid Services (CMS) initiated an enforcement discretion period to give the industry additional time to complete testing and for vendors to complete software installation.
CMS gives the following steps to consider if you are still experiencing Version 5010 issues:
- Reach out to clearinghouses for assistance and take advantage of any free or low cost software that may be available from payers.
- Check with payers now to see what plans they will have in place to handle incoming claims.
CMS is providing resources on the CMS ICD-10 Latest News and Version 5010 web pages to help you understand and manage your upgrade.
S: Janice presents today after being discharged from the hospital. She is complaining of a painful area on her left buttock. It also hurts when she sits down, so she has been shifting her weight to her right side to stop the pain, but this is causing stiffness.
O: There is an oval area of broken skin, with dermal and epidermal skin loss, about 1 cm in diameter and moderate exudate. There is partial thickness skin loss on her buttock with damage to the skin giving the appearance of an abrasion or blister.
A: Grade 2 pressure ulcer, left buttock
P: Order high-specification foam mattress. Closely observe skin for changes. Positioning and re-positioning regimen will be called in to the home health agency. She is to return in 1 week for reassessment.
ICD-10-CM code: L89.322 Pressure ulcer of left buttock, stage 2
Rationale: In ICD-10-CM the codes for pressure ulcers are combination codes that include site, laterality, and stage.
ICD-10 Implementation Strategies
In this section, we share strategies to help your practice successfully implement ICD-10-CM. Please remember to track your progress in your ICD-10 Implementation Tracker on AAPC's website.
Talking With Your Payers
Now might be a good time to get in touch with your major payers to see how they are coming along with the ICD-10-CM transition. Take the time to see what they are currently doing to prepare and what they are planning to do for the rest of the year. Did they have struggles with 5010? Are they foreseeing any issues with ICD-10-CM? Have they started mapping their policies and coverage determinations to see how ICD-10-CM will impact them? How are they handling the “hold time” for a final date from CMS? The more information you have on what your big payers are doing for preparation, the better you will be able to prepare your action items for transition. Open lines of communication will be very important for a smooth transition for everyone. The more you talk with your payers now, the better you can work together in conversion.
ICD-10 Code Translator
The ICD-10 code online translator tool allows you to compare ICD-9 to ICD-10 codes. ICD-9 is being expanded from 17,000 to approximately 141,000 ICD-10 codes, and this online tool can help you map that expansion.