ICD-10-CM Lessons Learned: Examining Controversies in Pressure Ulcer Coding Post-Implementation

For many areas of diagnosis coding, ICD-10 guidelines are very clear.However, pressure ulcers have some areas of inconsistency that affect the assignment of the appropriate stage. This article will address some of the many questions wound care clinicians and program mangers have related to the difficulties in selecting the correct ICD-10 codes for pressure ulcers based on the documentation in the medical record.

It’s no surprise that, as members of the healthcare industry, wound care clinicians and program mangers are encountering difficulties related to selecting the correct ICD-10-CM codes for pressure ulcers based on the documentation in the medical record. For many areas of diagnosis coding, ICD-10 guidelines are very clear. However, pressure ulcers have some areas of inconsistency that affect the assignment of the appropriate stage. This inconsistency can exist among general documentation issues, national staging guidelines, and between coding for inpatient versus long-term care. In addition, many concerns have been raised pertaining to the need to create a separate category for deep-tissue-injury (DTI) pressure ulcers as opposed to coding them utilizing the ICD-10 codes for unstageable pressure ulcers. This author has received many questions on these issues as a coding expert and ICD-10 trainer. This article will discuss what’s been learned to date.

Documentation Issues

A common question regarding documentation is, “How do I represent the improvement of the depth of a pressure ulcer on an inpatient case?” This practice is also known as “reverse staging,” according to the National Pressure Ulcer Advisory Panel (NPUAP).

The answer is not very simple. According to current NPUAP guidelines, the rule is (for example), if an ulcer is a stage IV it is always a stage IV. However, Medicare requires that reverse staging is acceptable for long-term care.

It is not known at this time how this issue will play out as we move forward with ICD-10. This concept of reverse staging is now more difficult with ICD-10, especially since most coverage policies require proof that the pressure ulcer is healing. This is also causing a problem with other chronic wounds because coders want to say that once the wound is necrotic, it is always necrotic.

The question then becomes, “How do you represent improvement of pressure ulcers over the inpatient stay of a case?” As most are aware, pressure ulcers must be documented if they were present on admission to the facility. The reason behind this requirement is to be able to identify whether the pressure ulcer developed prior to admission or developed during the course of the admission. Why? Medicare does not want to pay for care that is related to hospital-acquired pressure ulcers, as the hospital is then perceived as responsible for the creation of the condition. 

Another problem is, if the physician or nurse documents improvement to the ulcers, there is currently no way to reflect this news in the diagnosis codes. One way to possibly solve this would be to create a seventh character for the ICD-10 code that would indicate the amount of improvement shown with a guideline to code the stage on admission and the stage at discharge.

This could result in a sure way to demonstrate improvement over the course of the admission. The NPUAP would have to be involved in the development and revision of the existing codes and possibly try to include the “before” and “after” codes as a quality measure that should show improvement. It would also allow payers to readily identify if the pressure ulcer improved during the course of the admission, got worse, or the patient was readmitted with a higher-stage ulcer than what was staged during the patient’s last hospital stay.

DTI Pressure Ulcers in ICD-10

Currently, there is no specific ICD-10 code for DTI pressure ulcers, which are described in the NPUAP guidelines as “purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. DTI may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.”

Since these types of pressure ulcers have specific clinical descriptions, the question from practitioners tends to be, “Why are there not specific codes for these DTI pressure ulcers?” The ICD-10 code set is expandable and the suggestion should be raised to the ICD-10 Coordination and Maintenance Committee (www.cms.gov/medicare/coding/icd9providerdiagnosticcodes/meetings.html) established by the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS [www.cdc.gov/nchs]).

The NCHS is responsible for the diagnosis portion of the classification system.

Unstageable Pressure Ulcers: Official 2016 Guidelines

Assignment of the ICD-10 code for unstageable pressure ulcer (L89.000) should be based on the clinical documentation. This code is used for pressure ulcers when the stage cannot be clinically determined (eg, the ulcer is covered by eschar or has been treated with a skin graft or a muscle graft) and for pressure ulcers that are documented as DTI, but are not documented as “due to trauma.” This code should not be confused with the code for unspecified stage (L89.009). When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.009). However, unstageable ulcers are often debrided, which is not true for purple intact skin/thin-blistered DTI. As discussed previously, it might be possible to expand the ICD-10 code set to have a separate code for DTI if the clinical community agrees this would be helpful.

End-of-Life Care for Pressure Ulcers 

Currently, there are no pressure ulcer codes to represent end-of-life pressure ulcers. This may be another area worth exploring an application for a new ICD-10 code in the pressure ulcer category.

Pressure Ulcers Documented as “Healing” 

The current 2016 guidelines for pressure ulcers state, “Pressure ulcers described as ‘healing’ should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage. If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.”

What to Do?

The question here is whether to stay with the guideline that a stage IV pressure ulcer is always a stage IV, or will the industry change toward the long-term care guideline that documentation should show indication of closure of the wounds. For example, a patient may present with a pressure ulcer stage IV and gradually go from stage IV to stage I. The coder will code whatever site and stage the practitioner documents. It would be difficult and confusing to have a stage IV ulcer at the beginning of the admission that, as it heals during the course of that particular admission, shows multiple stages on the same claim. However, as suggested previously, it could be possible to code the stage on admission and discharge if the ICD-10 code set were modified.

To institute some kind of change in this arena, the actual guideline would have to be re-examined. Also, within this article, we have now seen multiple opportunities to propose changes to the NCHS for the ICD-10 Coordination and Maintenance Committee. These code modifications would allow for much greater specificity in the pressure ulcer codes and hopefully resolve an unmet need for the specific issues mentioned in the article. 

Resources:

1. ICD-10 2016 Coding Guidelines. Accessed online: www.cms.gov/medicare/coding/icd10/downloads/2016-icd-10-cm-guidelines.pdf

2. National Pressure Ulcer Advisory Panel Guidelines. Accessed online: www.npuap.org

3. Centers for Medicare & Medicaid Services. ICD-10 Code Lookup. Accessed online: www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx

Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, is senior director, reimbursement services, national policy and payer access at Integra LifeSciences Corp., Plainsboro, NJ, and an approved ICD-10 trainer by the American Health Information Management Association. She may be reached for questions at 609-936-2265 or at donna.cartwright@integralife.com