Today we're going to talk about
the guidelines for Chapter 12 in the code book. Chapter 12 is the
Diseases of the Skin and the
Subcutaneous Tissue.
For the first guideine, here is some general
information before we get to an example.
Category L89 is for pressure ulcers and
it identifies both the site of the
ulcer as well as the stage of the ulcer. So
you're going to see them as sub terms
for the various stages as well as where
they are. We'll be talking a little
bit about the difference between an
unspecified stage and an unstageable
ulcer. They are two different things. An
important thing to remember is to assign as
as many codes from category L89 as we need
to identify all the pressure ulcers a
patient has, if that's applicable. It's
not uncommon if someone has come in with
pretty bad skin breakdown for them to have
multiple ulcers so we want to be sure
that we capture all of those.
Here's an example of that first
guideline. Patient has s Stage 4 pressure
also over the right heel that's 9x10
centimeters. It invades muscle and
fascia as well as a stage 2 pressure
also of the left elbow. So we want to get
both of those. It's interesting to me
that they're telling you not only this
stage but also how deep it goes. Usually you
will have one or the other in the real world.
In this case, the documentation is telling us
both, so here on the right I have the
index pathway for both of the pressure
ulcers, the heel and the elbow It
refers back to this guideline that you
put as many codes in there as you need
from this category to identify all the
pressure ulcers a patient has. I also
have here for the instructional note
choose the 5th character "1" for the "right"
heel, the 5th character "2" for the "left"
elbow. The 6th character is indicating
the stage for each of those. Wen we talk
about "unstageable" pressure ulcers, this
just means the doctor can't see them to
see how deep they go therefore they're
called "unstageable". This would happen
especially when you have a burn and
you have a very thick eschar over the burn.
The doctor cannot see how deep the ulcer goes. He just
knows it's there, for whatever reason.
Different radiological studies could
show the skin is missing below the
eschar which is like a really thick scab
over the tissue. For whatever reason. the
doctor cannot tell you what stage it is.
This is an unstageable ulcer. An
"unspecified" stage is when the
ulcer is there, you can see it but the
doctor did not, in his documentation, stage it.
In this
particular example, the pressure ulcer of the
right back, lower back, was documented as
"unstageable" due to the eschar covering the ulcer
There's your index pathway. The
5th character is "3" for the right lower
back and the 6th character is "0" for
unstageable. The next guideline has to do
with the documented stage, where the
doctor does not give you the stage but
does describe how deep the ulcer goes.
There is a diagram in the code book
that shows this on page 697 in the 2017
code book. In future versions of the code
book, it may be on a different page. Iit
is there as well as being described in
the stage 2 or whatever stage, it
describes the thickness, how deep
the ulcer goes on the skin. Don't be
surprised if sometimes you don't get a
stage (in the documentation) but you are told how deep it goes.
Then you have some resources here
for knowing how to stage that. The next
guideline has to do with pressure ulcers
that are documented as healed. The
guideline tells us that when that is so,
we don't have to have any code for the
ulcer. You're going to code what's going
on. In other words, in this case, there's a
follow-up exam and a history of a skin
disease but no code for the ulcer is cited.
This guideline has to do with patients
admitted with pressure ulcers documented
as "healing". The actual language in the
code book says "healing". You see (in the pathway)
ulcer, pressure, stage 2, sacral region
with a 6th character of "2" for stage 2
gives us L89.152. I also have
here in red (font color) on the right, you see
that this is a new guideline for ulcers
that were present on admission but
healed at the time of discharge. You're
assigning the code for the site and the
stage of the ulcer at the time of
admission. This is new, so even though
the ulcer is healed by the time of discharge,
you are going to code what it was at the
time of admission. The next guideline has to
do with those times when a pressure
ulcer becomes worse during admission and
this particular guideline was changed in
2017. In 2016, if that happened, we would
just code the worse or the higher stage
but now our guidelines tell us to have
two codes, one for the site and stage
where it was on admission and a second
code for that same ulcer site and the
highest stage reported during this stay.
This did change. This is one of those times where
a coder who's not paying attention to
the guidelines could really get
caught because he or she is going to
code to the earlier guidelines and not
realize that it's changed. If you have
any questions about Chapter 12 coding
guidelines, please post them in the
discussion board and I will attempt to
answer them. I hope you have a good day.