Coding and Documenting Pressure Injuries and Chronic Ulcers. September 21, 2016

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1 Coding and Documenting Pressure Injuries and Chronic Ulcers Laurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS Trainer Director of HIM Consulting Services Panacea Healthcare Solutions, Sandy Brewton, RHIT, CCS, CHCA, CPC AHIMA Approved CD-10-CM/PCS Trainer Senior Healthcare Consultant Panacea Healthcare Solutions, September 21, 2016 Disclaimer Panacea Healthcare Solutions, has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user. Panacea Healthcare Solutions,, its employees, agents and staff make no representation, warranty or guarantee that this information is error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company will bear no responsibility or liability for the results or consequences of the use of this material. The publication is provided as is without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The information presented is based on the experience and interpretation of the publisher. Though all of the information has been carefully researched and checked for accuracy and completeness, the publisher does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation. Current Procedural Terminology (CPT ) is copyright 2015 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Copyright 2016 by Panacea Healthcare Solutions, All rights reserved. No part of this presentation may be reproduced in any form whatsoever without written permission from the publisher Published by Panacea Healthcare Solutions,, 287 East Sixth Street, Suite 400, St. Paul, MN,

2 Goals 1. Review the diagnosis coding for ulcers including chronic and pressure 2. Discuss the ICD-10-PCS coding and current coding guidance 3. Review the CPT coding for ulcers and current coding guidance 4. Analyze inpatient and outpatient coding examples 3 CHRONIC AND PRESSURE ULCERS IT CAN BE A DEEP SUBJECT! 4 2

3 Pressure Ulcer Coding Category L89 Four stages plus unstageable and unspecified stage Combination code which includes anatomic site, laterality (if applicable), and stage Each pressure ulcer should be reported separately There is no limit to the number of ulcers that can be reported Contiguous sites overlapping sites 5 Pressure Ulcer Coding Healed pressure ulcers are not coded Healing pressure ulcers are coded to their documented stage Evolving pressure ulcers are coded to their most severe stage 6 3

4 Pressure Ulcer Coding change-in-terminology-from-pressure-ulcer-to-pressure-injury-and-updates-the- stages-of-pressure-injury/ 7 Pressure Ulcer Coding New terminology of pressure injury suggested by National Pressure Ulcer Advisory Panel in April 2016 A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue 8 4

5 Pressure Ulcer Coding New Staging Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. 9 Pressure Ulcer Coding New Staging Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should Copyright not be used 2016 to ICD10monitor.com, describe moisture a associated skin damage (MASD) division including of Panacea incontinence Healthcare Solutions, associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). 10 5

6 Pressure Ulcer Coding New Staging Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, Copyright ligament, 2016 ICD10monitor.com, cartilage and/or a bone are not exposed. division If slough of Panacea or eschar Healthcare obscures Solutions, the extent of tissue loss this is an Unstageable Pressure Injury. 11 Pressure Ulcer Coding New Staging Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. 12 6

7 Pressure Ulcer Coding New Staging Unstageable Pressure Injury: Obscured fullthickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. 13 Pressure Ulcer Coding Index Synonymous terms for stages found in the Index Stage 1 pre-ulcer skin changes limited to persistent focal edema Stage 2 abrasion, blister, partial thickness skin loss involving epidermis and/or derma Stage 3 full thickness skin loss involving damage or necrosis of subcutaneous tissue Stage 4 necrosis of soft tissues through to underlying muscle, tendon, or bone 14 7

8 Index Pressure Ulcers (PU) 16 8

9 Pressure Ulcers (PU) Three factors have not changed. Always look for documentation of: Location - Must be documented by the physician. POA status - Must be documented by the physician. Stage - Can be documented by other clinicians such as, RN, wound care RN, PT, RD. (Coding Clinic, 4 th Quarter, 2008) Staging should only be used with pressure ulcers and not with any other type of ulcer. Query If any of these identifiers are not documented. If the physician is only documenting ulcer, clarify type. 17 Pressure Ulcers (PU) If the patient s PDx is a stage 3 or 4 pressure ulcer, this will count as its own MCC. Stage 3 & 4 pressure ulcers are MCCs when they are present on admission (POA). If these are not documented as POA by the physician, they are coded to a hospital acquired condition (HAC). If it appears the pressure ulcer was POA, and not documented as such, query the physician. 18 9

10 Chronic Skin Ulcers Non-pressure ulcers (L97.-, L98.4-) Coded by anatomic location, laterality (if applicable), and extent of breakdown More specific than ICD-9-CM Extent of breakdown terminology Skin breakdown only Muscle Copyright necrosis 2016 ICD10monitor.com, a Exposed fat layer Bone necrosis 19 Chronic Skin Ulcers Most common is the diabetic ulcer. Diabetes is coded first The ulcer location and extent of breakdown is coded second

Documentation Tips for Chronic Skin Ulcers and Infections Type Location Breakdown

Cellulitis Laterality Anatomic site Skin breakdown Muscle necrosis Exposed fat layer Bone

documentation will be used to assign the stage for each pressure ulcer that is treated.

11 Documentation Tips for Chronic Skin Ulcers and Infections Type Location Breakdown (nonpressure) Causative organism, if known Pressure Ulcer Chronic Skin Ulcer Abscess Cellulitis Laterality Anatomic site Skin breakdown Muscle necrosis Exposed fat layer Bone necrosis Appropriate when culture performed If significant to care provided Other clinical documentation will be used to assign the stage for each pressure ulcer that is treated. 21 Skin Layers Epidermis - The upper or outer layer of the two main layers of cells that make up the skin. Dermis - made of layers of cells, connective tissue and several structures that aid in maintaining its function. These structures include blood vessels, hair follicles, lymph vessels and glands. Hypodermis - deepest layer of skin, lying beneath the dermis and epidermis. It is also referred to as Copyright 2016 ICD10monitor.com, subcutaneous a tissue

off all or a portion of a body part by the use of force

12 ICD-10-PCS Coding TO CUT OR NOT TO CUT? 23 Root Operations Extraction - Pulling or stripping out or off all or a portion of a body part by the use of force Excision - Cutting out or off, without replacement, a portion of a body part 24 12

13 Excisional vs. Non-Excisional Debridement Key Words/Phrases Excisional Debridement Devitalized tissue Sharply removed Cutting away tissue Non-excisional Debridement VersaJet Brushing Irrigating Scrubbing Washing 25 Official Coding Guidelines for ICD- 10-PCS B3.5 Overlapping body layers If the root operations Excision, Repair or Inspection are performed on overlapping layers of the musculoskeletal system, the body part specifying the deepest layer is coded. Example: Excisional debridement that includes skin and Copyright subcutaneous 2016 ICD10monitor.com, tissue and a muscle is coded to the muscle body part

14 PCS Table Example Excisional 27 PCS Table Example Non-Excisional 28 14

15 Excisional/Non-Excisional Debridement Non-Excisional Debridement- defined by the American Hospital Association (AHA) as brushing, irrigation, scrubbing or washing away of devitalized tissue, necrosis or slough. This includes incision and drainage (I&D). Excisional Debridement- defined by the AHA as surgical removal or cutting away of devitalized division tissue, of Panacea necrosis Healthcare or Solutions, slough, which can be completed in the OR, ER or at the patient s bedside. 29 Excisional/Non-Excisional Debridement, cont. 5 required criteria to be included in the procedure note for debridement (CMS, 2012) Technique: Excisional, non-excisional, cut away, lavage, irrigated, scraped, scrubbed, etc. Instrument: Scalpel, blade, curette, scissors, brush, whirlpool, rongeur, Versajet, irrigator, etc. Nature of tissue: Devitalized, necrotic, slough, loose fragments, infected, non-viable, etc. Appearance Copyright and size 2016 of ICD10monitor.com, wound: Debrided a to fresh bleeding tissue, division 4 cm x of 7 cm, Panacea etc. Healthcare Solutions, Depth of debridement: Skin, subcutaneous, fascia, tendon, muscle, bone

Excisional/Non-Excisional Debridement, Documentation Challenges Non-excisional debridement doesn t fall into the surgical hierarchy for moving a DRG from medical to surgical.

16 Excisional/Non-Excisional Debridement, Documentation Challenges Non-excisional debridement doesn t fall into the surgical hierarchy for moving a DRG from medical to surgical. Documentation of sharp debridement, thorough debridement, tissue was excised, will result in the coding of a non-excisional debridement. Query if, all 5 criteria are met in the operative note and the documentation does not specifically state excisional debridement. 31 Excisional vs. Non-Excisional Debridement The latest debridement advice from Coding Clinic 32 16

17 Excisional vs. Non-Excisional Debridement The latest debridement advice from Coding Clinic 33 DRG Comparisons DRG w/mcc and Excisional Debridement DRG w/o CC or MCC and Non- Excisional Debridement MS-DRG 579 Other Skin, Subcutaneous Tissue, & Breast W MCC RW: RW: MS-DRG 594 Skin Ulcers w/o CC or MCC Reimbursement*: $13, Reimbursement*: $3, APR-DRG 364 Other Skin and APR-DRG 380 Skin Ulcers Subcutaneous Proc RW (2/2): RW (1/1): *Assumptions: MS-DRG FY17 grouper and $5,000 blended rate. APR-DRG FY16 grouper

18 CPT Coding TO CUT OR NOT TO CUT? 35 CPT Index The Index is found at the back of the CPT Manual. Debridement Bone , with Open Fracture and/or Dislocation Non Viable Tissue 25023, 25025, 27497, Skin Eczematous , Excision Infected Subcutaneous Tissue Infected , Necrotized

CPT Index The Index is found at the back of the CPT Manual. Debridement Wound Non Selective. 97602 Selective.

19 CPT Index The Index is found at the back of the CPT Manual. Debridement Wound Non Selective Selective , Wound Care Debridement Non Selective Selective division.97597, of Panacea Healthcare Solutions, CPT Code Guidance 38 19

20 CPT Code Guidance 39 CPT Code Guidance 40 20

21 CPT Code Guidance 41 CPT Code Guidance 42 21

22 CPT Code Guidance 43 CPT Code Guidance 44 22

23 CPT Code Guidance 45 CPT Code Guidance 46 23

CPT Code Guidance 47 Modifiers Four Level ll modifiers XE Separate encounter, a service that is distinct because it occurred during a separate encounter XS Separate structure, a service that is

24 CPT Code Guidance 47 Modifiers Four Level ll modifiers XE Separate encounter, a service that is distinct because it occurred during a separate encounter XS Separate structure, a service that is distinct because it was performed on a separate organ / structure XP Separate practitioner, a service that is distinct because it was performed by a different practitioner XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service Subset of Modifier 59 Have been available for use since January 1, 2015 Modifier 59 is not going away 48 24

Modifier Tip The Physician Fee Schedule can be used to determine if anatomic

The Bilat Surg column will indicate a 1 if the 50 modifier can be applied.

com, anatomic modifier can a be applied as well.

Healthcare modifier does Solutions, not apply.

25 Modifier Tip The Physician Fee Schedule can be used to determine if anatomic modifiers can be assigned. The Bilat Surg column will indicate a 1 if the 50 modifier can be applied. If the 50 modifier can be applied Copyright then any 2016 other ICD10monitor.com, anatomic modifier can a be applied as well. Values 0, 2, 3, and 9 indicate division that of the Panacea bilateral Healthcare modifier does Solutions, not apply. For these procedures, the anatomic modifiers and 50 modifier can not be utilized. This process of identifying if anatomic modifiers applies is not 100% accurate. 49 CPT Coding Process Tip Depth Deepest level debrided Number Single Multiple (sum area at the Copyright 2016 ICD10monitor.com, same level) a Type Excisional Non-excisional Selective Non-selective 50 25

Coding Examples PRACTICE, PRACTICE, PRACTICE 51 Practice Coding Scenario #1 62-year-old male is seen for diabetic non-pressure ulcer on the heel of his left foot.

26 Coding Examples PRACTICE, PRACTICE, PRACTICE 51 Practice Coding Scenario #1 62-year-old male is seen for diabetic non-pressure ulcer on the heel of his left foot. At this time the depth of the ulcer is limited to the breakdown of skin. He has type 2 DM and takes insulin on a daily basis. He also has diabetic neuralgia. What diagnosis codes are assigned? 52 26

At this time the depth of the ulcer is limited to the breakdown of skin.

27 Practice Coding Scenario #1 62-year-old male is seen for diabetic non-pressure ulcer on the heel of his left foot. At this time the depth of the ulcer is limited to the breakdown of skin. He has type 2 DM and takes insulin on a daily basis. He also has diabetic neuralgia. What diagnosis codes are assigned? 53 Practice Coding Scenario Index 54 27

28 Practice Coding Scenario Index Long term insulin use is reported when insulin is taken over a period of time, not temporarily. 55 Practice Coding Scenario Tabular Validate code in Tabular Follow coding guidelines and instructions 56 28

29 Practice Coding Scenario Tabular Code additional code for non-pressure ulcer 57 Practice Coding Scenario Tabular Validate Diabetic Neuralgia code in tabular 58 29

Practice Coding Scenario Tabular Validate Long term use of insulin in Tabular 59 Practice Coding Scenario Answer E11.621 Diabetes, diabetic (mellitus)(sugar), type 2, with, foot ulcer E11.

4 Long-term (current) (prophylactic) drug therapy (use of), insulin Rationale: There is a combination code for the type 2 diabetes with diabetic foot (heel) ulcer.

30 Practice Coding Scenario Tabular Validate Long term use of insulin in Tabular 59 Practice Coding Scenario Answer E Diabetes, diabetic (mellitus)(sugar), type 2, with, foot ulcer E11.42 Diabetes, diabetic (mellitus) (sugar), type 2, with, neuralgia L Ulcer, lower limb, heel, left, skin breakdown only Z79.4 Long-term (current) (prophylactic) drug therapy (use of), insulin Rationale: There is a combination code for the type 2 diabetes with diabetic foot (heel) ulcer. The instructional notes advise you to use an additional Copyright code to identify 2016 ICD10monitor.com, the location of the a ulcer. The diabetic neuralgia was division documented of Panacea and Healthcare should Solutions, be coded, but it requires a separate code. Since the patient has type 2 DM, and is on insulin, code Z79.4 should be assigned as indicated by the note at category E11 Use additional code to identify any insulin use (Z79.4) 60 30

31 Practice Coding Scenario Same patient who undergoes an excisional debridement to the skin of his left heel. The excisional debridement includes 3 square centimeters. 61 Practice Coding Scenario Index Coding Tip: Remember to include the type of tissue that was excised and not the anatomic site

32 Practice Coding Scenario Tabular 63 Practice Coding Scenario CPT Index Debridement Subcutaneous Tissue See the parenthetical note under 11042: (For debridement of skin [i.e. epidermis and/or dermis only], see 97597, ) Turn in the numerical section to This procedure is considered to be Active Wound Care Management

Practice Coding Scenario Answer 0HBNXZZ Excision, Skin, Left Foot 97597 Debridement, open wound, first 20 sq. cm.

33 Practice Coding Scenario Answer 0HBNXZZ Excision, Skin, Left Foot Debridement, open wound, first 20 sq. cm. PCS Rationale: The procedure was an excisional debridement to the level of skin of the left heel. There is not a specific entry for left heel, but the heel is part of the foot so the body part of foot would be appropriate based on ICD-10-PCS Official Coding and Reporting Guidelines 2017, B4.2 Branches of a Body Parts. CPT Rationale: The area debrided is 3 square centimeters. This procedure is excisional debridement to the skin only. There is a note under CPT code 11042: For debridement of skin [i.e. epidermis and/or dermis only], see 97597, The Conclusion DON T WORRY, BE HAPPY 66 33

Conclusion Ulcers are now reported as a combination code which includes the anatomic site, laterality (if applicable), and stage/extent of breakdown. Each ulcer should be coded separately.

The coder must know the site and type of debridement (excisional vs. non-excisional) to code accurately. Code the procedure to the tissue depth excised/removed.

34 Conclusion Ulcers are now reported as a combination code which includes the anatomic site, laterality (if applicable), and stage/extent of breakdown. Each ulcer should be coded separately. The provider must document the presence and type of ulcer, but non-physician clinician may provide the stage or extent of breakdown. Excisional debridements are still problematic. The coder must know the site and type of debridement (excisional vs. non-excisional) to code accurately. Code the procedure to the tissue depth excised/removed. 67 Additional Panacea Resources To order, call Customer Care at ext. 2 or visit our web store at shop.medlearn.com. (previously Coding Essentials for Hospital Infusion Services Also available in ebook format! 2016 Essentials of Observation: The Basics Also available in ebook format! 2016 Emergency Department Charging and Coding Handbook Also available in ebook format! FREE sign up for enews at RACmonitor.com The single most important source of regulatory audit news and information 68 34

35 THANK YOU FOR ATTENDING

Pressure Injury Staging Update 2016

Pressure Injury Staging Update 2016 A Review of the New Changes for Pressure Injury Documentation and Staging Jeanne Terefenko, BSN, RN, CWOCN Ext. 5855 Pressure Ulcer Staging Updates: In April, 2016,