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For other articles and previous issues click here. January 17, 2005 Coding
for Decubitus Ulcer A decubitus ulcer is damage to the skin and underlying tissues resulting from the lack of blood flow and irritation to the skin over bony areas. Also called pressure sores, pressure ulcers, and bedsores, these sores are caused by unrelieved pressure and develop over weight-bearing parts of the body such as hips, shoulder blades, tailbone, and heels. Decubitus ulcers can range from a reddened area on the skin to severe tissue damage that may extend to the muscle and bone. They are difficult to treat and slow to heal. Decubitus ulcers are classified to ICD-9-CM code 707.0x with the fifth-digit subclassification identifying the location of the decubitus ulcer. If the physician documents skin ulcer but does not specify it as a decubitus ulcer, then assign code 707.1x with a fifth digit specifying the site of the skin ulcer. Symptoms • Stage 1: Pressure sores are painful and tender. They may be reddened or darker than normal, but there are no breaks in the skin. When the sore is pressed, it does not turn white (nonblanchable). • Stage 2: The skin breaks open, blisters, or forms an ulcer. The area around the sore may be red and irritated. It may include a partial-thickness skin loss involving the epidermis and dermis. • Stage 3: There is a full-thickness loss of skin with extension into subcutaneous tissue forming a small crater but not through the underlying fascia. Any dead skin and tissue must be removed (debrided). The patient experiences no pain due to the significant tissue damage. There is a high risk of infection or tissue death. • Stage 4: Full-thickness loss of skin and subcutaneous tissue with extension into muscle and bone causing extensive damage. The ulcer may also damage the tendons and joints. If a physician documents and treats a decubitus ulcer, then code 707.0x is assigned regardless of severity and stage. ICD-9-CM does not classify decubitus ulcer by stage. Therefore, code 707.0x is assigned for a stage 1 or 4 ulcer (AHA Coding Clinic for ICD-9-CM, 1999, fourth quarter, page 20). Diagnosis Treatment At stages 2 and 3, treatment may also include keeping the wound clean but moist with gauze dressings moistened with saline. Prescribed ointments or creams may be used. Wound debridement may be done if the skin or underlying tissue dies to reduce risk of infection and promote healing. At stage 4, decubitus ulcers require debridement and some may also require deeper surgery. Conservative debridement of necrotic tissue with forceps and scissors should be instituted. More advanced ulcers with fat and muscle involvement require surgical debridement and closure. Affected bone tissue requires surgical removal. In addition, disarticulation of a joint may be needed. A sliding full-thickness skin flap graft is the closure of choice, especially over large bony prominences such as the trochanters, ischia, and sacrum. Debridement • Wet-to-dry dressings. Apply wet dressings to the wound and allow them to dry. When the dry dressing is removed, it pulls off the dead tissue. • Apply medications that contain enzymes to dissolve dead tissue. • Apply medicated dressings • Whirlpool baths • Surgical debridement with scalpel or scissors
to remove dead tissue Documentation of the type of debridement performed by the healthcare provider must be descriptive enough to support coding excisional or nonexcisional debridement. Documentation of an excisional debridement should include the following: • Method of debridement. Excisional debridement is the “definite cutting away of tissue” (AHA Coding Clinic for ICD-9-CM, 1991, third quarter, pages 18-19). • Depth of excisional debridement. Did the healthcare provider debride beyond the dead or damaged tissue down to healthy, viable tissue? • Instruments used to perform the debridement. Did the healthcare provider use a scalpel or scissors? The use of scissors may not be indicative of an excisional debridement. Scissors may have been used to cut away the loose fragments, which is not considered an excisional debridement. The use of a scalpel (or blade) is a better indication that an excisional was done. However, a code can not be assigned based on the use of a scalpel alone. Once again, the description of the procedure performed must support the type and method of debridement performed before a code can be assigned. When a patient has multiple layers (skin, muscle, bone) of the same site debrided, assign a code only for the deepest layer debrided. Do not assign two or more codes when the debridement extends past the skin and subcutaneous tissue into the muscle or bone. Only one code for the deepest layer of debridement is assigned (AHA Coding Clinic for ICD-9-CM, 1999, first quarter, pages 8-9). Coding and sequencing for decubitus ulcers are dependent upon the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding. — This information was prepared by Audrey Howard, RHIA, and Vicki Sippel, RHIA, of 3M Health Information Systems (800-367-2447), a leading supplier of coding and classification systems to nearly 4,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information. |
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