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CODING ALERT

Chapter on diseases of the skin and subcutaneous tissue is a total revamp

By Judy Monestime  bio

ICD-10-CM Chapter 12, “Diseases of the Skin and Subcutaneous Tissue (L00-L99),” represents a complete restructuring to bring together groups of diseases that are related to one another in some way. For example, dermatitis and eczema are separated from urticaria and erythematous conditions. Additionally, greater specificity has been added to many of the codes at either the fourth, fifth or sixth character level. Most of these diagnoses codes will require additional documentation and queries for specificity. For example, laterality, site, and stage of pressure ulcers are now included in one code. Furthermore, a block of codes for radiation-related disorders of the skin and subcutaneous tissue is included in ICD-10-CM that was not contained in previous classification systems.

The chapter includes the following sections:

  • L00-L08, Infections of the skin and subcutaneous tissue
  • L10-L14, Bullous disorders
  • L20-L30, Dermatitis and eczema
  • L40-L45, Papulosquamous disorders
  • L49-L54, Urticaria and erythema
  • L55-L59, Radiation-related disorders of the skin and subcutaneous tissue
  • L60-L75, Disorders of skin appendages
  • L76, Intraoperative and postprocedural complications of skin and subcutaneous tissue
  • L80-L99, Other disorders of the skin and subcutaneous tissue

Several coding guidelines are provided for the ICD-10-CM Official Guidelines for Coding and Reporting including:

Pressure ulcer stages

  • Codes from category L89, pressure ulcer, are combination codes that identify the site of the pressure ulcer as well as the stage of the ulcer.
  • The ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, unspecified stage and unstageable.
  • Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable.

Unstageable pressure ulcers

  • Assignment of the code for unstageable pressure ulcer (L89.–0) should be based on the clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined (as when the ulcer is covered by eschar or has been treated with a skin or muscle graft) and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma. This code should not be confused with the codes for unspecified stage (L89.–9). When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.–9)

Documented pressure ulcer stage

  • Assignment of the pressure ulcer stage code should be guided by clinical documentation of the stage or documentation of the terms found in the Alphabetic Index. For clinical terms describing the stage that are not found in the Alphabetic Index, and there is no documentation of the stage, the provider should be queried.

Patients admitted with pressure ulcers documented as healed

  • No code is assigned if the documentation states that the pressure ulcer is completely healed.

Patients admitted with pressure ulcers documented as healing

  • Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage.
  • If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.

Patient admitted with pressure ulcer evolving into another stage during the admission

  • If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, assign the code for the highest stage reported for that site.

The depth of the ulcer is identified by stages I through IV. According to the National Pressure Ulcer Advisory Panel, the descriptions of the four stages are as follows:

Stage

Description

Stage I

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.

Stage II

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.

Stage III

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location.

Stage IV

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur.

Pressure ulcers may also be described as unstageable. This is specific type of pressure ulcer and should not be used when stages I through IV are not documented.

Let’s practice! How do you code the following encounter?

This 46-year-old woman has a gangrenous pressure ulcer of the left hip with cellulitis and a pressure ulcer of the sacrum documented by Dr. Rogers. The assessment indicates a stage 2 pressure ulcer of the sacrum with a stage 3 decubitus ulcer of the left hip. What is the correct diagnosis code(s)?

  • I96, Gangrene, not elsewhere classified
  • 223, Pressure ulcer of left hip, stage 3
  • 152, Pressure ulcer of sacral region, stage 2
  • 116, Cellulitis of left lower limb

Rationale: Decubitis ulcers are classified to pressure ulcers. The note at the beginning of category L89 indicates the sequencing. Any associated gangrene is listed first. Subcategory L89.2 classifies pressure ulcers of the hip. It is necessary to review the tabular to select the correct stage and laterality. The sacral region includes the tailbone and the coccyx.

Judy Monestime, MBA, CDIP, CPC, is an AHIMA-approved ICD-10-CM/PCS trainer.

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