22 Dec Off
by Angie Hlad, CRN-C
When documenting ulcers, it is important to clarify if the ulcer is a pressure or non-pressure ulcer. When a provider only documents the stage of the ulcer, such as “stage 2 ulcer, left heel”, it is does not provide enough information for the coder to determine the proper code assignment. Once the provider makes the determination of chronic non-pressure or pressure ulcer, it should be documented as such. The documentation for these two types of ulcers is very similar:
- Document the site, including laterality (for both pressure and non-pressure ulcers).
- If it is a pressure ulcer, document the stage; gangrene should be noted if present.
- If it is a chronic, non-pressure ulcer, document the depth of the ulcer (e.g. limited to skin breakdown, with fat layer exposed, etc.). Also, note if gangrene is present.
- With chronic, non-pressure ulcers, document the cause. This is important. Documentation must clearly link the ulcer and the cause. For example, “non-pressure ulcer of the left ankle DUE TO atherosclerosis of lower extremity.”
- If either type of ulcer has any associated diagnosis, they must be clearly linked in the documentation as Coders cannot assume a causal relationship.
It is important to note that “wound” is not an interchangeable term for ulcer. If documentation states “wound of left buttock” – this would be coded S31.829A. Wound codes do not map to HCC’s, therefore, careful consideration must be taken when documenting. Ulcers should not be documented as “wounds” as this term has its own code set in ICD-10. Ulcers do map to an HCC, and thus the more specific the documentation (site, laterality, stage, depth, and associated or casual conditions), the more specific the code assignment and in turn the most appropriate HCC.