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June 14, 2004

Coding for Psoriasis
Vol. 16 No. 12 p. 46

Psoriasis is a common chronic skin disorder characterized by a rapid buildup of rough, dry, dead skin. It may cause unsightly patches of skin, discomfort, and pain. In psoriasis, skin cells grow too quickly, resulting in thick, white and red patches on the skin. Flare-ups may occur periodically followed by periods of remission. Psoriasis may be an inherited disease influenced by many factors, such as the following:
• certain infections such as strep throat;
• immune system response to disease;
• injury to the skin;
• reaction to a medication or vaccine;
• stress/anxiety;
• alcohol; and
• environmental factors such as cold weather.

It is estimated that psoriasis affects between 3 million and 5 million Americans and may develop at any age.

Signs and Symptoms
The following are common signs and symptoms of psoriasis:
• red patches (plaque) of skin that may be bright, dry, and raised and covered with white, silvery scales;
• pustules on top of the red patches;
• mild scaling to thick, crusted plaque on scalp;
• small scaling dots;
• itching after sudden flare-ups;
• swollen and stiff joints; and
• fingernails or toenails may pit, discolor, separate from the nail bed.

Although psoriasis may occur anywhere on the body, it most commonly appears on the knees, elbows, trunk, lower back, hands, feet, and scalp. Psoriasis may be categorized in the following way:
• Mild — small areas of rash
• Moderate — inflamed skin with raised red areas topped with loose, silvery, scaling skin
• Severe — skin is itchy and tender with large skin patches. The skin may be cracked, causing minor bleeding.

Types
There are several types of severe psoriasis, including the following:
• Plaque psoriasis (696.1) — patches of red, raised skin
• Guttate psoriasis (696.1) — small, red, individual drops or dots on the skin
• Pustular psoriasis (696.1) — large fluid-filled plaque; raised bumps containing pus
• Inverse psoriasis (696.1) — small, dry areas of skin that are red and inflamed but not scaling
• Erythrodermic psoriasis (696.1) — severe inflammation and shedding (sloughing) of skin
• Psoriatic arthritis (696.0) — joint swelling, tenderness, limitation of range of motion, joint warmth or redness
Koebner’s phenomenon occurs when psoriasis appears on the site of a skin injury.

Diagnosis
The physician can diagnose psoriasis based on appearance and location of skin patches. No special tests are necessary. However, the physician may decide to perform a skin biopsy if the condition is hard to diagnose by appearance or if other skin disorders need to be ruled out. An x-ray may be performed to diagnose psoriatic arthritis. In addition, blood work may be done to rule out other forms of arthritis.

Treatment
There is no cure for this noncontagious condition. However, psoriasis may be treated with various medications and phototherapy. The goal of treatment is to suppress the skin cells’ growth and reduce inflammation. The treatment plan will depend on the patient’s response to treatment and difference in type and severity. Some common creams and ointments used to treat psoriasis include the following:
• Calcipotriene (Dovonex) — controls overproduction of skin cells
• Steroid creams/corticosteroids
• Coal tar
• Anthralin
• Topical form of retinoic acid/retinoid (tazarotene)
• Zinc pyrithione (Derma-cap)

Some oral medications used to treat psoriasis include:
• Retinoids — reduces the proliferation of skin cells
• Methotrexate — blocks growth of skin cells
• Cyclosporine (Gengraf, Neoral) — suppresses the immune system

Phototherapy is also used to treat psoriasis. Psoralen plus ultraviolet A suppresses the growth of skin cells. Narrow-band ultraviolet B (UVB) is another type of phototherapy used. Goeckerman treatment utilizes UVB treatment in conjunction with coal tar. When anthralin and UVB light are used together, it is called Ingram treatment.

Finally, biologic drugs may be used to slow down the proliferation of skin cells. Common biologic drugs include alefacept (Amevive) and efalizumab (Raptiva).

Coding and sequencing for psoriasis 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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