Today we’re going to talk about chapter 22, Diseases of the Skin and Subcutaneous
Tissue.
This corresponds with Chapter 12, in the ICD-10-CM code book.
From your reading you probably realize that ulcers are classified as either pressure or
non-pressure ulcers.
So, depending on whether they are pressure or non-pressure, they are identified different ways.
The staging of an ulcer is usually related to the pressure ulcers, and for the non-pressure
ulcers, they’re more identified by how deep they go.
This particular exercise, 22.1, number one, has to do with varicose ulcers.
These are ulcers that are lying along a varicose vein, and they are classified as non-pressure
chronic ulcers.
And here we have the pathway to show you how to get there.
And you’re coding both the varicose vein, and the ulcer itself.
Varicose ulcer, sorry, and the ulcer itself.
The ulcer itself is where it’s identified how deep it is, and the first code more identifies
the fact that it’s an ulcer on the leg.
The next exercise is 22.1 number five, and it has to do with a keloid scar from a previous
burn.
A previous burn, you’re immediately going to think sequelae.
So, when you’re coding any injury code, your seventh character is an initial (encounter), a subsequent (encounter),
or a sequelae.
And, in this case, that seventh character is "S" for Sequelae.
Scars are always considered Sequelae.
Number twelve has to do with a gangrenous diabetic ulcer, due to peripheral circulation
problems.
Whenever you see diabetes, it’s a very good chance you’re going to be coding more than
one code.
And the guidelines tell us, we can use as many codes as we need of the diabetes codes to
describe a situation or an encounter.
In this case, we would be coding the diabetes with an ulcer, and the diabetes with gangrene.
They are two separate codes.
Then you’re also going to code the ulcer itself, which describes the depth of the ulcer.
The ingrown toenail, you’re going to be coding not only the toenail, being ingrown,
but also cellulitis.
If you’ve ever had an infected toenail, it gets very red around it, and that’s that
cellulitis.
So, you would be having two codes for this particular (case), number fourteen.
Now, let’s do some exercises not in the Coding Handbook.
I’ve chosen this one because even though our diagnostic statement says bilateral axilla,
when we look up the code, there is no option for laterality.
So, there are cases where that is the case.
That you won’t always be looking for that laterality code.
But it’s always good to keep it in mind because you want to code it, if it’s there.
Just as in a CPT coding, if you’ve had that course yet, you would be coding using a left
and right modifier to indicate laterality. In the ICD-10-CM, and (ICD-10-)PCS, you want
to indicate laterality when you can.
But, in this case, there isn’t any.
And here’s a case I wanted to bring up with stasis ulcers, because they are very common
in hospitals.
If the physician has stated that these stasis ulcers are not varicose veins, they are not
coded with an ulcer varicose vein code.
They’re coded rather as peripheral venous insufficiency.
So, even though our code book does give us that "without varicose veins" (as a) sub term, you
could have also looked at it through "insufficiency", and found the very same code, either one.
So, let’s look at the code book.
I can show you a little bit about what I’m talking about.
We have here stasis, venous, and if you just read the first line, see varix,
leg with ulcer.
But if you read up to the next sub term, "without varicose veins", there’s the I87.2 code.
So, just keep in mind, a stasis ulcer does not necessarily have to do with varicose veins.
Actinic keratosis, right temple due to excessive exposure to sunlight.
I’m bringing this one to your attention because I wanted to show you – I don’t
know if we’ve talked at all about external causes yet, but I wanted to spend a little
bit of time on that.
This particular L57 category has an instructional note.
Use additional code to identify the source of the UV radiation.
And it can be either W89, or X32.
So, if we looked at the Index to External Causes, that’s located right after the Table of
Drugs and Chemicals, and if we go to this path, exposure, sunlight, it is the X32 code.
But you notice that the code has to have seven characters.
And that means we’re going to need some placeholders.
So, let’s look at the Index of External Causes.
So, let me just get you there.
If you see here, in my book, I have the tabs – maybe you have some similar tabs for you.
But I have, in the Neoplasm table, I have the Table of Drugs and Chemicals, and I have
the External Causes table here.
So, we’re going to look at exposure.
So, let me get up here.
Exposure, sunlight, X32.
You see that additional characters are needed.
Now, notice that if we were using a sunlamp, like a tanning bed, those are W codes.
But if we were looking at good old God given sunlight, that’s an X32 code.
So, then you go back to the Tabular, and look up your X32, and when you go to X32, see this
little seventh here?
We know we need seven characters for X32.
And the seventh character is going to be our encounter, which I believe our documentation
said it was an initial encounter, so our seventh character is A. But we have only three characters.
X32.
They have one, two, three.
So, then four, five, six are going to have to be X’s (placeholders) for that seventh
character A to be in place.
And that’s why you get this.
X32.xxxA.
We won’t do a lot of external causes in this course.
A little bit.
Just so you’re aware of them.
But many hospitals do not use them.
And if you hope to be a professional coder, and sit for the CCS coding exam, they do
not require the assignment of external cause on that exam.
I bring this one to your attention.
Acute, lymphadenitis bilateral lower limbs, because in many of our codes, there is a bilateral.
There’s a right, and a left, and a bilateral, depending on the code, it would be your 5th or 6th
character.
In this case, with this particular diagnosis, you have separate codes, not separate characters.
Not the same code with a different character.
But different codes for the right and left.
Just something to keep in mind.
Now, let’s look at some longer ones.
Patient was seen for initial treatment of a fine rash that had developed on the patient's trunk over
the last three or four days.
The patient was diagnosed with hypertension seven days ago, and started Ramipril, 10 milligrams
daily.
The physician determined the rash to be dermatitis due to Ramipril.
The medication was discontinued, and the patient was prescribed an anti-hypertensive, Captopril.
In addition, the physician prescribed a topical crème for the localized dermatitis.
Now, because the Ramipril was taken as prescribed, it is adverse effect (of the Ramipril), and not a poisoning.
So, the first thing we’re going to do is look at the dermatitis due to the drugs with
a sub term of localized skin eruption.
That’s not always given in the documentation, but in this case, it is.
So, we would pick up on that.
L27.1 code, then we would go to the Table of Drugs and Chemicals, looking Ramipril as our
substance, under the Adverse Effect column, we would get T46.4X5A.
Hypertension, I10, would also be coded because that is the reason why the patient is taking
the medication.
So, here I have some – the rationale and the pathway.
And please, let me know if you have any questions about that.
We’ve done a few of those T-codes.
I think you probably know – feel pretty good about them right now.