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road map Walk Through Skin and Subcutaneous Tissue Crossovers By Deborah Grider, CPC, CPC-H, CPC-P, CEMC, CPC-I, CCS, CCS-P Our journey using the ICD-10-CM roadmap leads The codes in categories L89 Decubitus ulcer and L97 us to draft guidelines and coding issues focusing on Non-decubitus chronic ulcer of lower limb, not elsewhere clas- “Understanding the ICD-10-CM Draft Guidelines for sified contain a great deal of detail. the Skin and Subcutaneous Tissue.” Consider the codes . The fourth character delineates the anatomy for the Skin and Subcutaneous Tissue located in chap- details (right versus left, upper versus lower). ter 12 of ICD-10-CM. The fifth character identifies the ulcer’s specific site. In ICD-9-CM there are three subchapters in chapter 12: . The sixth character identifies ulcer depth. 680–686 Infections of skin and subcutaneous tissue For example: A physician is called by the nursing home 690–698 Other inflammatory conditions of skin and subcutaneous tissue to treat a patient with bed sores on the left buttock. 700–709 Other diseases of skin and subcutaneous tissue After examining the patient, the physician documents decubitus ulcer, left buttock, stage II. These three subchapters were expanded in ICD-10-CM Compare a pressure ulcer (decubitus ulcer) of the chapter 12 to include blocks L00-L99, as follows: left buttock: L00–L08 Infections of the skin and subcutaneous tissue L10–L14 Bullous disorders ICD-9-CM ICD-10-CM L20–L30 Dermatitis and eczema L40–L45 Papulosquamous disorders 707.0 Chronic ulcer of skin L89 Pressure Ulcer L50–L54 Urticaria and erythema 707.0 Pressure ulcer Includes: L55–L59 Radiation-related disorders of the skin and Bed sore bed sore subcutaneous tissue Decubitus ulcer decubitus ulcer L60–L75 Disorders of skin appendages Plaster ulcer plaster ulcer L76 Intraoperative and postprocedural complications of Use addition code to iden- pressure area dermatologic procedures tify pressure ulcer stage pressure sore L80–L99 Other disorders of the skin and subcutaneous tissue (707.20 -707.25) Code any association Chapter 12 in ICD-10-CM was restructured to bring 707.02 Buttock gangrene (I96) together related disease groups. Nearly all of the catego- 707.2 Pressure ulcer stages L89.3 Pressure ulcer of buttock ries and subcategories in ICD-10-CM were expanded to Code first site of pressure either the fourth- or fifth-character level in this chapter. ulcer (707.00 -707.09) L89.32 Pressure ulcer of left buttock ICD-10-CM includes a number of category and/or sub- 707.20 Pressure ulcer, category title changes to adequately reflect the content. unspecified stage L89.321 Pressure ulcer of left buttock stage I Diseases were grouped in either their own blocks or new 707.21 Pressure ulcer categories to identify specific disease types. stage I L89.322 Pressure ulcer of left buttock, stage II Codes in ICD-9-CM moved to chapter 12 in ICD-10-CM: 707.22 Pressure ulcer stage II L89.323 Pressure ulcer of ICD-9-CM ICD-10-CM left buttock, stage III 707.23 Pressure ulcer stage III L89.324 Pressure ulcer of 704.1 Hirsutism L68 Hypertrichosis left buttock, stage IV 707.24 Pressure ulcer 039.0 Erythrasma L08.1 Erythrasma stage IV L89.329 Pressure ulcer 136.0 Ainhum L94.6 Ainhum of left buttock, 707.25 Pressure ulcer unspecified stage unstageable Decubitus Ulcers and Non-decubitus Chronic Ulcers of Lower Limbs Using ICD-9-CM, two codes are necessary. The first listed diagnosis identifies the decubitus ulcer’s location Decubitus ulcers were also expanded in ICD-10-CM. and the secondary code describes the ulcer’s stage. In In ICD-9-CM, two codes are used to identify the decu- ICD-10-CM, only one code is necessary to describe bitus ulcer and a secondary code is assigned to identify both the pressure ulcer site and the ulcer’s stage. Notice Road Map to ICD-10-CM to Map Road Walk Through Skin and Subcutaneous Tissue Crossovers Tissue Subcutaneous and Skin Through Walk the pressure ulcer stage. In ICD-10-CM, only one code the level of specificity in ICD-10-CM. is needed to adequately describe the condition and the ulcer’s stage. 46 AAPC Coding Edge road map Both decubitus and non-decubitus ulcers may become ICD-9-CM ICD-10-CM so severe that gangrene (necrosis of the tissue) sets in 707.02 Decubitus ulcer L89.322 Pressure ulcer of left at the ulcer’s site. For gangrene cases resulting from a of the buttock buttock stage II skin ulcer, the gangrene should be sequenced first, fol- 707.22 Pressure ulcer lowed by the code for the ulcer. stage II When gangrene is present, the primary focus of treat- ment is to remove the gangrene, usually with debride- When assigning a code for these ulcers using ment or amputation of the affected area. The “code ICD-10-CM, review the record thoroughly to verify first” note at categories L89 and L97 instructs that both the ulcer’s site and severity. For multiple ulcers of gangrene should be sequenced before the ulcer. This the same site, it is only necessary to assign a code for note applies only if gangrene is present. the most severe ulcer. For example: A patient with a gangrenous pressure Any condition reducing blood flow to the legs may ulcer of the right ankle, with necrosis of the muscle cause a lower limb ulcer. The same condition may also and bone is treated for debridement of the area. prevent an ulcer from healing, even with aggressive Review the comparison: treatment. When the underlying condition is known, it should be sequenced before the ulcer. ICD-9-CM ICD-10-CM Atherosclerosis of the lower extremities and diabetes 707.06 Pressure ulcer, ankle I96 Gangrene, not else- mellitus are common underlying conditions. Combina- 707.24 Pressure ulcer, stage IV where classified tion codes for atherosclerosis of the lower extremities 785.4 Gangrene L89.514 Pressure ulcer of and diabetes mellitus include lower extremity ulcers. right ankle, stage IV The sequencing instructions at categories L89 and L97 differ slightly from the standard conventions, however. Using ICD-9-CM, gangrene of the lower extremities A serious decubitus ulcer that does not respond to instructional notes state to code first any associated treatment may be a reason for hospital admission. If condition. In the example above, the pressure ulcer and decubitus ulcer is the reason for admission, it should the ulcer’s stage are coded first and second, with the be the principal, first-listed diagnosis. Secondary codes gangrene as a tertiary diagnosis. In ICD-10-CM, the for the other decubitus ulcer-associated health prob- instructional notes identifies that gangrene is coded lems should also be assigned. Generally, an underlying first, followed by the pressure ulcer. This differs from condition is responsible for a non-decubitus ulcer of the ICD-9-CM instructions. lower limb (L97). A secondary external cause code identifying the expo- An L97 code should be used with the combination sure’s source should be used when reporting categories code for the underlying condition to specify the ulcer’s L56 Other acute skin changes due to ultraviolet radiation site and depth. In some cases, no underlying cause for and L57 Skin changes due to chronic exposure to non-ionizing the ulcer is documented. In such cases, a code from radiation. L97 may be listed first. For example: A female patient who uses a tanning bed The instructional note at L97 indicates the “code first” in her apartment daily is treated by a dermatologist for note is applicable only when an underlying condition is multiple solar keratoses on her face due to overexposure documented. in the tanning bed. For example: A patient is treated in the outpatient hos- Compare ICD-9-CM and ICD-10-CM: pital wound care clinic for a severe non-healing ulcer of the right midfoot and heel with bone necrosis due to ICD-9-CM ICD-10-CM diabetes mellitus. 702.0 Actinic keratoses L57.0 Actinic keratoses Compare ICD-9-CM and ICD-10-CM codes E926.2 Visible and ultraviolet (solar) ICD-9-CM ICD-10-CM light sources W89.1 Exposure to E849.0 Place of occurrence, tanning bed 250.81 Diabetes with other E086.621 Diabetes mellitus due home Y92.039 Place of occur- specified mani- to underlying condi- rence apartment festations, type I tion with foot ulcer [juvenile type], not L97.413 Non-pressure With both ICD-9-CM and ICD-10-CM, the condi- stated as uncon- chronic ulcer of tion followed by the external cause code is reported. trolled right heel and mid- Because the location of the overexposure is known, it 707.14 Ulcer of heel and foot with necrosis midfoot of bone can be reported as well. Notice in ICD-10-CM, the place of occurrence states “apartment.” www.aapc.com March 2009 47 road map To discuss this article or topic, go to http://forums.aapc.com/ The place of occurrence codes for home is sub-divided L76.11 Accidental puncture and laceration of skin and subcu- to include apartment, boarding home, single family taneous tissue during a dermatologic procedure residence, institution, nursing home, prison, reform L76.12 Accidental puncture and laceration of skin and subcu- school dormitory, and mobile home. These catego- taneous tissue during other procedure ries are further divided to include areas of the home L76.2 Postprocedural hemorrhage and hematoma of skin including, bathroom, bedroom, driveway, garden, and subcutaneous tissue following a procedure kitchen, swimming pool, etc.

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