Wiki Non-Pressure Ulcer Severity Coding

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stogsmom3

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I do wound care coding for the professional side. I'm wondering how to code a non-pressure ulcer severity, when the provider documents tendon exposure, but doesn't state that the muscle is exposed with/without necrosis. Also, often times they'll debride the tendon but not the muscle. Would I code the 11042 or 11043 if debrided excisionally?

Thanks
Melissa
 
I am certainly no Wound Care Specialist, but there are new and expanded severity codes for Non-pressure Chronic Ulcers for 2018, in particular in the 6th Characters. The new 6th Character 5 is for "with muscle involvement but without evidence of muscle necrosis." This does not address either Fascia or Tendon, both of which are essentially a part of the muscle. The 6th Character 3 is for "with necrosis of muscle," which also doesn't address Fascia or Tendon. Lastly, there is 6th Character 8 which is for "with other specified severity." Since neither 3 or 5 includes Fascia and/or Tendon, then 8 may be the best option for this dilemma.
As for the CPT codes you bring up, I would consider any debridement of necrotic tendon to be the equivalent of debridement of either or both muscle and fascia, i.e. 11043.
I would like to see what others (the experts) say about this.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com
 
AlanPechacek said:
icd10orthocoder.com
Click to expand...
Dr. Pechacek, we are being told by our medical providers that a pressure ulcer will always be reported at it's initial severity for the duration of the wound, even if consistent care is being performed and wound is healing to a lesser stage. We believe per coding guidelines that the wound staging should be updated according to its current stage at the time of the encounter.

EX 01/01/20xx Pt presents with stage 4 sacral pressure ulcer

After continuous treatment, on 03/01/20xx wound now presents as a stage 2 sacral pressure ulcer.

Providers believe that as of 03/01/20xx they should still code it as stage 4, that the wound will always be a stage 4 ulcer until it fully heals, or worsens.
we as coders believe that at this point in time, for DOS 03/01/20xx it should be coded as stage 2.

What are your thoughts on this scenario? Any guidance on how we can bridge this knowledge gap with our providers and overcome the pushback that we get on this subject? Unless we are in the wrong, I would love to understand more.

Please see attached the guidelines we have found and the email response from our provider.

Thanks a million!
 

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hildapgarciav said:
Dr. Pechacek, we are being told by our medical providers that a pressure ulcer will always be reported at it's initial severity for the duration of the wound, even if consistent care is being performed and wound is healing to a lesser stage. We believe per coding guidelines that the wound staging should be updated according to its current stage at the time of the encounter.

EX 01/01/20xx Pt presents with stage 4 sacral pressure ulcer

After continuous treatment, on 03/01/20xx wound now presents as a stage 2 sacral pressure ulcer.

Providers believe that as of 03/01/20xx they should still code it as stage 4, that the wound will always be a stage 4 ulcer until it fully heals, or worsens.
we as coders believe that at this point in time, for DOS 03/01/20xx it should be coded as stage 2.

What are your thoughts on this scenario? Any guidance on how we can bridge this knowledge gap with our providers and overcome the pushback that we get on this subject? Unless we are in the wrong, I would love to understand more.

Please see attached the guidelines we have found and the email response from our provider.

Thanks a million!
Click to expand...

Hello!

I know this response is late, but I hope it helps you (or someone else) in the future.

I was an inpatient coder turned CDI nurse who worked closely with the Wound Care team at a physical rehabilitation hospital for many years. The below response mentions a stage 4 injury based on the question, but this response applies to a pressure injury (PI) at any specified stage.

The way that it was explained to me by wound care experts is that a healing stage 4 PI is considered a stage 4 injury (and should be coded as a stage 4 (L89.xx4)) until completely healed, because the connective tissue forming above the wound bed is fragile and the wound remains at its original stage and depth until the tissue rebuilding above it has completed the remodelling process and turned into healed epithelial tissue. If not given proper care until completely healed/"reepithelialized", the "healing" stage 4 can open right back up to a stage 4 injury again.

Another way to think of it is like this: a stage 4 PI has necrosis of soft tissues through the muscle and that muscle is not coming back to then be able to stage the wound as a lesser stage. Until healed and no longer meeting the UHDDS definition of a reportable diagnosis, the stage 4 PI would remain a stage 4 PI in various stages of healing. It could never become a stage 2 PI no matter what treatment it received.

Here is a helpful resource for further information: https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Wound_assessment_and_management/.

Cheers to everyone asking questions and looking for answers!

Best Regards,
Amanda Ros, BBA, BSN, RN, CCS, CDIP
Audit Ready Coding
amanda@auditreadycoding.com
 
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