Wiki Coding pressure ulcer stages, should ICD stage be updated during healing process?

[hildapgarciav]

For wound care, we are asking our providers to updated their ICD-10 codes when a wound changes stages. Example Sacral pressure ulcer stage 4 at initial assessment, but as services are being rendered, after a few visits, the staging is now at a stage 3. ICD should be updated to reflect Sacral Pressure Ulcer stage 3 for that visit, correct?
We are getting a little bit of push back since someone at some point told them to permanently report the stage that the wound was during the initial assessment.

 

[LisaAlonso23]

For wound care, we are asking our providers to updated their ICD-10 codes when a wound changes stages. Example Sacral pressure ulcer stage 4 at initial assessment, but as services are being rendered, after a few visits, the staging is now at a stage 3. ICD should be updated to reflect Sacral Pressure Ulcer stage 3 for that visit, correct?
We are getting a little bit of push back since someone at some point told them to permanently report the stage that the wound was during the initial assessment.

Your explanation regarding the stage to report appears to be correct. The guidelines are a little vague in the ICD-10 manual. Per the guidelines, if no stage is provided, you are to use the unspecified stage code.

 

[thomas7331]

I agree, coding should always reflect the provider’s assessment of the condition at the current encounter. Codes can never be assigned from information documented at a previous encounter, unless the provider has confirmed, in the record of the encounter you are coding, that the condition still exists. This would apply to any diagnosis, not just pressure ulcer stages.

 

[hildapgarciav]

I agree, coding should always reflect the provider’s assessment of the condition at the current encounter. Codes can never be assigned from information documented at a previous encounter, unless the provider has confirmed, in the record of the encounter you are coding, that the condition still exists. This would apply to any diagnosis, not just pressure ulcer stages.

I appreciate this response, thank you!

 

[siddikpharma]

If physician documenting Mucopurulent Chronic Bronchitis and Emphysema in assessment, how do we report this scenario ? Please someone answer this question.

 

[TThivierge]

Hi Siddikpharma
I would code this as dx J44.00 it describes both dx under this dx code in ICD10 manual. Also add dx R09.3 for purulent sputum. If lab test done on sputum I d code the result. You could use dx B97.89 unspec. bacteria if lab results support this . They do not have any Excludes 1 Ruling.
Well hope helped you somewhat.
Lady T