Medical Coding for Pressure Ulcers
Alicia: Pressure ulcers these are fun,not quite as much fun as neoplasms, but most people that start out in the medical fieldwhen they're young they end up working in, they used to be called nursing homes now.They are skilled facilities and stuff like that. So most of us have time in there, andpressure ulcers are something that is kind of the bane of the healthcare profession becausethey are very hard to treat and prevent. Q: It was asked by one of the students previously,pressure ulcers, how do we code them? You have to code the site where it's located andyou have to code the stage. So, she wanted to know is it site stage, site stage; or isit site, site, stage, stage?
A: First, let's figure out what a pressureulcer is. Pressure ulcers on the skin reduce blood flowto the area. Without enough blood, the skin can die and an ulcer may form. An ulcer isliterally like how you get a cold sore on your lip or something like that. That's what'shappening. You are more likely to get a pressure ulcerif you are in a wheelchair. It doesn't matter how old you are but you've got constant pressureon your buttocks, in your sacrum and stuff. Usually if you're in a wheelchair you can'tfeel, so you don't know when it's starting to go numb.
If you're an older adult, cannot move certainparts of your body without help because of a spinal injury or multiple sclerosis, havea disease that affects blood flow including diabetes or vascular disease like PVD orneuropathy or stuff like that and you're not able to feel. You have Alzheimer's diseaseor another condition that affects your mental status. In other words, you're sitting fora long period of time and you don't think to get up. You have fragile skin, the older you get,if you've noticed if you look at somebody that's a whole lot older than you, you'llnotice their skin gets papery thin and you
can see the vessels and stuff. You have urinaryincontinence or bowel incontinence. Again, this goes with Alzheimer's disease, if you'resitting in a chair and Alzheimer's isn't like you forgot where your keys are. Alzheimer'sis like when you can't remember what a key is used for. If you can't remember that youhave to go to the bathroom when you feel that discomfort, you have urinary incontinence.You do not get enough nutrition (malnutrition) that's another keyway to have problems. Here are the main places that pressure ulcersoccur: The back of the neck, the head because of the bed, on your elbows. If you've everhad to be bedridden like if you were pregnant
or something, they made you stay in bed fora long time and you're constantly pushing yourself, sliding yourself up in the bed,you'll get pressure ulcers on the elbows. Your sacrum (the tailbone), buttock area,because that's where people like to lay on their back and stuff, or on their sides orsacrums; that's why they say you have to move every two hours or more often. The ankle andthe heel, you don't think about that, but if you're not moving and your foot sits fortwo hours in one position, your foot can go numb. So, that's the most common places. Let's get into the coding aspect of it. Theseare the common codes for pressure ulcers:
You've got 707.00 and they start with a zero.It goes all the way down to different body parts and they mainly list those red bulletedareas that we were talking about. Then, there are stages. Now these are going to be 707.02codes and each one of those is going to indicate a different. I did list all of these becauseI wanted to give you this description so you have a better understanding. Stage 1 is considered a superficial lesionwith discoloration of the skin, but the lesion is not actually an ulcer at this point. Itpresents as a nonblanching reddened area on the skin. Stage 1 indicates a higher riskfor serious pressure ulcer but does not cause
Process of Elimination for ICD9 Medical Coding Part 2
What about Combo codes? When you're dealingwith ICD9, you are going to see combo codes meaning, two codes to explain the one diseaseprocess or what's going on. That's kind of like up here where we had acuteand chronic. Let's say our person had acute cholecystitis with cholelithiasis thatword right now just means they have a stone. I may not repeat that word because I'm justgoing to say stone because that's a hard word to say. So, 574 is the basic category forhaving a stone and that's a stone in the gallbladder, not a stone in the kidneys. Don'tget that confused or anything. That's common to have stones in the gallbladder.
So, you have to break this down, you can'tjust use 574, it tells you, you need more digits, plus we don't just have stones inthe gallbladder, we have inflammation of the gallbladder with stone. So, 574.00 we gota calculus or a stone of the gallbladder with acute cholecystitis without mention of obstruction.So, see how they've got that broken down? We've got 574, okay we got a stone and weknow it's in the gallbladder. Now, is it acute? Yes, it's acute and our person has inflammation,their gallbladder is inflamed. Okay, well, is that stone pushing and blocking, not allowingthe gallbladder to work properly? If it is, that means it's got an obstruction so thereforeyou're going to use 574.01; and if it didn't,
then it would be (.00). Again, you don't have to have that memorized,but as a coder you need to know the process and this is where your anatomy terminologyand physiology comes in. That you need to know that if a person has an inflamed gallbladder,why they have an inflamed gallbladder? Is it because they have a stone? If it's becausethey have a stone, is it acute? Is that stone blocking anything? Those are the things youneed to know. And so, these codes break down and tell you, my person has an inflamed gallbladder,they have a stone and it does not state in this statement right here that there is anobstruction. If it doesn't state there is
an obstruction, it has to state quot;with obstructionquot;for you to be able to use 574.01; that's a guideline. So you know that your code is goingto be 574.00. I'm just kind of explaining these codes andthen I'm going to show you how you're going to be able to break those down and make quickpicks here just a little bit. So that's a combo code concept. What about dual coding?Again, like the other one, do I have to use more than one code? Now, up here for thislate effect, 438.11 it explains it all. We've got two separate conditions but we got onecode that explains it. Same thing with the respiratory failure, one code explains twoconditions.
Dual Coding really comes more with manifestations,and nothing in ICD10 for education is easier to explain guidelines in diabetic codes soI'm constantly referring back to diabetes codes because just about every ICD9 guidelinesin a way you come back to diabetes. So, our patient has diabetic neuropathy. The codefor diabetic neuropathy is 357.2, but you just can't code 357.2. When you go look up357.2, it tells you code first the underlying disease, and249.6 is a diabetic code meaningsomething happened that made them diabetic for a short time. But 250.6 is a regular diabeticcode that means they're diabetic. The basic diabetic code is 250.00, that's a defaultcode for diabetes. If your doesn't
tell you what type of diabetes that your patienthas, the default is 250.00 because 98% of all diabetics are type 2 diabetics and that'sacceptable to use that, unless you're told that it is type 1 or type 2. So now we know. The 250.61 is diabetes type 1 because thelast digit right here is going to tell whether it's a type 1 or type 2, and if it's controlledor uncontrolled. Now, just jumping ahead real quick it has to state uncontrolled for youto. the word has to be there for you to actually use that code. But right now, we'vegot diabetic neuropathy 357.2 we can't use it by itself because this guideline righthere with that code told us we're not allowed