All pressure ulcers are wounds, but not all wounds are pressure ulcers. A wound is an injury to living tissue caused by a cut, blow, or other external or internal factor. Wounds usually break or cut the skin.
Inpatient coders may be very familiar with pressure ulcers and their stages, but they also need to understand other types of wounds. “People are sometimes so focused on one area that they forget wounds consist of a lot of different types,” says Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta.
- Surgical incisions, whether closed and intact, purposely left open, dehisced, or infected
- Lacerations and abrasions, such as road burns or any traumatic damage to the skin, including open fractures
- First- to third-degree burns, regardless of the cause
- Draining infections, such as osteomyelitis, pilonidal abscess, perianal abscess, cellulitis with ulceration, and even infected insect bites
- Open areas of skin necrosis from any cause, including open gangrene, venous ulcers, pressure ulcers, diabetic vascular ulcers, and neuropathic ulcers
“Generally when you talk about ICD-9-CM procedure code 86.22 [excisional debridement of skin and subcutaneous tissue], you talk about necrotic tissue, infections, or burns,” Gold says. “But there are some many different types of wounds. We need to be aware of all of the different types of wounds.”
Wounds generally start at the skin and work deeper, Gold says. “On occasion, you can have a contusion of the brain and you are not going to see anything on the outside,” he adds.
- Epidermis: the outermost layer of skin
- Dermis: beneath the epidermis; contains tough basilar tissue, hair follicles, and sweat glands
- Subcutaneous tissue: also known as the hypodermis; made of fat and connective tissue
Wounds that involve only the epidermis are generally stage 1. As the wound progresses toward the dermis, it becomes stage 2. When the subcutaneous tissue is involved, the wound is at stage 3. If the wound goes into deeper tissue, it becomes stage 4, Gold says.
Most of the body also has two layers of fascia. The superficial layer of fascia is within the subcutaneous tissue, Gold says. The deep fascia lies underneath and surrounds the muscles.
A wound that extends to the superficial fascia is still in the skin layer, Gold says. In fact, there is a muscle in this subcutaneous layer in the face called the platysma muscle. This is still skin and subcutaneous tissue. “It’s not until we get to the deep fascia which overlays the rest of the muscles that you are going to get a stage 4 wound.”
When talking about a care plan for a patient with a wound, clinicians need to consider both the ultimate goal of treatment and the etiology of the wound, says Gloria Miller, CPC, CPMA, vice president of reimbursement services for Comprehensive Healthcare Solutions, Inc., in Tacoma, Wash.
Ulcers are generally chronic wounds, while other types of wounds can be acute or chronic, she says.
Ulcers often have comorbidities, such as diabetes, Miller says. Those comorbidities can influence treatment choices.
Coders also need to look for an appropriate diagnosis and appropriate staging for hospital-acquired pressure ulcers. These are ulcers that were not present on admission.
If a clinician cannot stage an ulcer at a given time because the bottom cannot be visualized, coders can report the ulcer as unstageable, Miller says. However, once the clinician is able to document the stage after cleaning or debridement of the ulcer, coders should use that stage going forward. “For example, if it’s a stage 3, then it is considered a healing stage 3 throughout the course of treatment,” Miller says.
In order to document a wound, the physician needs to name the wound and provide a diagnosis; for example, a diabetic foot ulcer of the left foot. The physician also needs to document the:
- Cause of the wound (e.g., diabetes, arterial ulcer, venous stasis ulcer, etc.).
- Length, width, and depth of the wound.
- Plan of care to get to the healing process. This can include surgical intervention, resection of dead tissue (also known as debridement), dressings, patient education, and possibly further testing.
- Order for any procedure(s).
- Plan of care.
Wound care goes far beyond just excisional debridement, Miller says. Part of the reason is because of the variety of surgical procedures that are available.
Treatment options for surgical incisions include primary closure, delayed primary closure, and closure by secondary intention.
Physicians can suture lacerations by preparing the skin edges and debriding necrotic or damaged tissue, then suturing it closed. They can also use primary or secondary grafts, apply dressings, or leave the wound open if it is too dirty to close. The preparation of the wound for closure is integral to the closure, and debridement is not ordinarily codable as excisional debridement.
For burns, physicians can apply dressings, debride necrotic tissue, use a skin graft or flap, and use hyperbaric oxygen therapy.
For an abscess, the physician can open the abscess, debride the necrotic tissue, then drain the abscess or close it over a drain.
Various conditions can result in open areas of skin necrosis. For arterial ulcers or open gangrene, physicians can perform debridement, increase arterial flow if possible, apply a graft, administer topical wound care, or possibly amputate the limb.
Venous ulcers typically require topical wound care, Miller says.
For pressure ulcers, physician can perform excisional or non-excisional debridements, administer topical wound care, and/or create a flap closure.
Physicians can debride diabetic vascular or neuropathic ulcers, or perform topical or non-excisional wound care.
Before a coder can report 86.22, they need to know whether the physician actually performed a true excisional debridement of skin and subcutaneous tissue, Miller says.
A true debridement is defined as an excisional procedure. Cleaning and irrigation are not considered true debridement, Miller says. Physicians use a recognized sharp instrument, such as a cutting curette, laser, scissors, or scalpel, to perform the excisional debridement.
“The excisional debridement itself is not related to the depth of the wound, but to the type of tissue removed from it,” Miller says.
Excisional debridement is always considered surgical, Miller says. It involves removing or cutting away devitalized tissue, necrosis, or slough. Physicians can perform excisional debridement on burns, wounds, or infections, as well as ulcers.
Depending on the circumstances, the physician may perform the debridement in a surgical suite, at the bedside, in the ED, or in an outpatient wound clinic, Miller says.
Documentation for the debridement for proper coding by ICD or by CPT® must include:
- Medical justification for the debridement
- Specific procedure performed and the outcome
- Type of surgical instrument used
- Type of tissue removed, including depth of the procedure
- Pain control used and how tolerated
- Amount of bleeding and how controlled
- Follow-up treatment plan
ICD-9-CM includes several procedure codes for debridement. Report code 86.22 for excisional debridements. Do not report 86.22 for:
- Bone (77.60-77.69)
- Muscle (83.45)
- Hand (72.36)
- Nail bed (86.27)
- Non-excisional debridement (86.28)
- Open fracture site (79.60-79.69)
- Pedicle or flap grafts (86.75)
If the physician uses a VersaJet, coders will report 86.28 (nonexcisional debridement of wound, infection, or burn), because the jet is not a sharp instrument. Non-excisional debridement also includes maggot therapy, brushing, irrigation, washing, and ultrasonic debridement.
For an abdominal wall debridement, coders need to pay careful attention to the depth of the debridement. If it is just a skin incision in the abdominal wall, such as a surgical incision that requires debridement, coders will use the code for skin, Gold says. In the past, coders were instructed to use ICD-9-CM code 54.3 (excision or destruction of lesion or tissue of abdominal wall or umbilicus). If the debridement goes deeper than the skin and subcutaneous layers and through to the peritoneum, report 54.3.
“Only debridement down to the peritoneum justifies code 54.3,” Gold says. AHA’s Coding Clinic, Third Quarter 2014, will state this fact as a change to existing advice.
ICD-10-CM includes additional details in codes for wounds. Wounds are identified by specific anatomical site, including laterality and type of wound (e.g., laceration, puncture, open), Gold says. Some of the codes also require coders to specify whether any foreign body remains in the wound. Wound codes in ICD-10-CM also require a seventh character to denote the encounter.
For the initial visit for a laceration of the right ankle without a foreign body, coders would report ICD-10-CM code S91.011A. If a foreign body remains in the wound, the code becomes S91.021A.
Another change in ICD-10-CM is the inclusion of stages of more types of wounds. In ICD-9-CM, coders are used to coding pressure ulcers by stage. But in ICD-10-CM, they will also need stages to code arterial ulcers, venous ulcers, and ulcers caused by diabetic neuropathic disease, Gold says.
For a patient with a non-pressure chronic ulcer of the right calf, coders will use different codes for the following depths of the ulcer:
- Limited to breakdown of skin (L97.211)
- With fat layer exposed (L97.212)
- With necrosis of muscle (L97.213)
- With necrosis of bone (L97.214)
If the physician fails to document the depth of the ulcer, report L97.219 (non-pressure chronic ulcer of right calf with unspecified severity).
Editor’s Note: This article was originally published in Briefings on Coding Compliance Strategies.Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.