coding stage of foot ulcer

tag60

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Complaint: Pt presents with chronic right foot ulcer that is painful and non-healing.

Exam: Right foot with stage 2-3 non-healing plantar ulcer. Has partial left foot amputation. (No further description provided.)

Assessment: 1. Diabetes. 2. Foot ulcer. Cleaned and dressed wound. Referral to wound clinic.

Questions:

Am I correct to code this as a diabetic ulcer; that is, diabetes with foot ulcer, E11.621. (Provider does not seem to link the two conditions, but they are, right?)

When I code the additional code for foot ulcer, how do I translate his "stage 2-3" to the correct degree of severity under L97.51x? (Does L97.512 mean stage 2, and L97.513 mean stage 3, etc.?) I've been researching as best I can and can't seem to find a definitive answer to this.)

Which is correct for the foot ulcer--
L97.41x for "heel and midfoot" OR
L97.51x for "other part of foot" ? (I'm thinking this one since he does not specifically state heel or midfoot, agree?)

Thank you in advance for bearing with all these questions and for your help!
 

mitchellde

True Blue
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You may not code this as a diabetic foot ulcer since the provider does not link the conditions. The diabetes is not even referenced on the exam part. The provider also needs to document the severity as a breakdown of skin or fat layer exposed etc. not stages. The diabetes can be added as a secondary Diagnosis but as uncomplicated. You can never assume a condition is diabetic.
 
Last edited:
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Yes we can't assume the cause effect relationship between diabetes and foot ulcer, the relationship should be documented by the provider. stages also need to clearly mention by the provider and you can go with other part of foot because as you said no heel or midfoot is mentioned....
 
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