ICD 10 CM Chapter Specific Guidelines I. C12

Dr. Lisa L Campbell®

11 Feb 201907:03

EducationalLearning

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TLDRIn this informative session, Dr. Campbell delves into ICD-10-CM Chapter 12, focusing on coding for diseases of the skin and subcutaneous tissue. He emphasizes the importance of accurately identifying and coding pressure ulcers using category L89, detailing the staging and documentation requirements. The discussion also covers non-pressure ulcers, highlighting the distinction between healed and unhealed conditions, and the necessity of clear clinical documentation for precise coding. Dr. Campbell stresses the need for querying providers in cases of unclear documentation and provides guidance on coding for ulcers present on admission and those that heal or progress during hospital stays.

Takeaways

📚 ICD-10-CM coding guidelines for Chapter 12 focus on diseases of the skin and subcutaneous tissue, with codes ranging from L00 to L99.
🩺 Pressure ulcer stage codes (L89 category) identify both the site and the stage of the ulcer, with stages 1 through 4 and unspecified and unstageable options.
📌 It is crucial to assign codes for all pressure ulcers present in different anatomical locations to accurately capture the patient's condition.
🚫 Unstageable ulcers are documented when the provider cannot determine the stage, and should not be confused with unspecified codes.
🔍 Clinical documentation should guide code assignment for unstageable ulcers, and in cases of ambiguity, query the provider for clarification.
🌟 If a pressure ulcer has completely healed, no code is assigned; however, if healing is documented, the stage at the time of documentation is used for coding.
🏥 For patients admitted with a pressure ulcer that progresses to a higher stage, two codes should be assigned: one for the admission stage and another for the highest stage during the hospital stay.
🛑 Non-pressure ulcers are coded based on whether they are completely healed or healing, with unspecified codes used when documentation lacks detail.
🔄 When non-pressure chronic ulcers evolve in severity, two codes are assigned: one for the admission severity level and another for the highest level reached during the hospital stay.
🗣️ Communication with providers is essential for accurate coding, especially when documentation is unclear regarding the presence or healing of pressure or non-pressure ulcers.

Q & A

What is the ICD-10-CM chapter focused on in this transcript?
-The transcript focuses on Chapter 12 of ICD-10-CM, which deals with diseases of the skin and subcutaneous tissue.
What is the code range for the diseases of the skin and subcutaneous tissue?
-The code range for these diseases is L00 through L99.
What does the L89 category in ICD-10-CM represent?
-The L89 category represents pressure ulcers stage codes, which identify both the site and the stage of the ulcer.
How many stages are there for pressure ulcers according to the guidelines?
-There are four stages (1 through 4) for pressure ulcers, plus an unspecified stage and unstageable.
What should be considered when assigning pressure ulcer codes?
-Assign as many codes as needed from category L89 to identify all pressure ulcers at different anatomical locations the patient has.
What is the difference between 'unstageable' and 'unspecified' pressure ulcer codes?
-Unstageable codes are used when the provider cannot clinically determine the stage of the pressure ulcer, while unspecified codes are for situations where the documentation does not provide enough information to assign a specific stage.
What should be done if a pressure ulcer has completely healed?
-If a pressure ulcer is completely healed, no code is assigned.
How should coding be handled for a healing pressure ulcer with unclear documentation?
-Assign the appropriate code for unspecified stage if the documentation does not provide information about the stage of the healing pressure ulcer.
What codes should be assigned for pressure ulcers present on admission but healed at discharge?
-Assign the code for the site and stage of the pressure ulcer at the time of admission.
How are non-pressure chronic ulcers documented in the medical record?
-Non-pressure chronic ulcers are documented based on whether they are completely healed, healing, or if the severity is unspecified, with the appropriate codes assigned accordingly.
What is the coding process for non-pressure ulcers that are present on admission but heal during the hospital stay?
-Assign the code for the site and severity of the non-pressure ulcer at the time of admission and another code for the highest severity level reported during the hospital stay if it progresses.

Outlines

00:00

📚 ICD-10-CM Coding Guidelines: Chapter 12 - Skin and Subcutaneous Tissue Diseases

This paragraph focuses on ICD-10-CM coding guidelines for diseases of the skin and subcutaneous tissue, specifically chapter 12. It discusses the coding range from L00 to L99 and emphasizes the coding of pressure ulcers under category L89. The speaker clarifies that these codes identify the site and stage of pressure ulcers, with stages 1 through 4 and additional categories for unspecified and unstageable ulcers. The importance of clinical documentation in guiding code assignment is highlighted, including the need to query the provider for unclear documentation. The paragraph also addresses coding for healed pressure ulcers and those that have progressed during hospital stays.

05:03

🩺 Management of Non-Pressure Ulcers and Admission Coding

The second paragraph delves into the coding of non-pressure ulcers, emphasizing the difference between healed and unhealed states. It provides guidance on assigning codes based on provider documentation, with specific attention to the use of unspecified codes when documentation is unclear. The paragraph also covers coding practices for ulcers present on admission that have healed by the time of discharge, and the assignment of two codes in cases where a non-pressure ulcer progresses to a higher severity level during a hospital stay.

Mindmap

Keywords

💡ICD-10-CM

ICD-10-CM stands for the International Classification of Diseases, 10th Revision, Clinical Modification. It is a coding system used in the United States for documenting diagnoses and procedures for medical records and billing purposes. In the video, Dr. Campbell reviews guidelines for using this system, particularly for coding diseases of the skin and subcutaneous tissue.

💡Pressure Ulcers

Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue caused by prolonged pressure on the skin. They are commonly associated with patients who are bedridden or in wheelchairs for extended periods. In the context of the video, Dr. Campbell discusses the specific ICD-10-CM codes for documenting the site and stage of pressure ulcers, emphasizing the importance of accurate coding to reflect the severity and location of these ulcers.

💡Staging of Ulcers

Staging of ulcers refers to the classification of pressure ulcers based on their severity. The stages range from 1 to 4, with each stage indicating a deeper level of tissue damage. Unspecified and unstageable categories also exist for situations where the stage cannot be determined. In the video, Dr. Campbell explains that the stage of a pressure ulcer should guide the code assignment, and that multiple codes may be needed to capture all ulcers in different anatomical locations.

💡Clinical Documentation

Clinical documentation refers to the recording of patient health information, including symptoms, diagnoses, treatments, and other relevant medical data. In the context of ICD-10-CM coding, accurate clinical documentation is crucial for determining the correct codes to use for billing and record-keeping. Dr. Campbell emphasizes the importance of using clinical documentation to guide code assignment for both pressure and non-pressure ulcers.

💡Non-Pressure Ulcers

Non-pressure ulcers are wounds that develop due to factors other than pressure, such as poor circulation, infection, or trauma. They differ from pressure ulcers in their causes and may require different treatment approaches. In the video, Dr. Campbell distinguishes between pressure and non-pressure ulcers and explains how to code for healed or healing non-pressure ulcers based on the documentation provided.

💡Unstageable Ulcers

Unstageable ulcers are those where the clinical provider cannot determine the stage due to factors such as the presence of eschar (dead tissue) or deep tissue injury that遮住 the underlying tissue. This category is distinct from 'unspecified' ulcers, which lack enough information to determine the stage. In the video, Dr. Campbell clarifies the difference between unstageable and unspecified ulcers and how to code them based on the clinical documentation.

💡Healing Ulcers

Healing ulcers refer to wounds that are in the process of recovery, where the tissue is regenerating and the wound is closing. In the context of ICD-10-CM coding, it is important to document and code the stage of a healing ulcer to accurately reflect the patient's condition. Dr. Campbell discusses how to code for healing ulcers, whether they are pressure or non-pressure ulcers, based on the documentation in the medical record.

💡Admission and Discharge

Admission and discharge refer to the process of a patient being admitted to a healthcare facility and later released or discharged. In the context of ICD-10-CM coding, it is important to note the stage and site of ulcers at the time of admission and discharge to accurately capture the patient's condition over the course of their stay. Dr. Campbell provides guidelines for coding ulcers that were present on admission and how to handle situations where ulcers heal or progress during the hospital stay.

💡Querying the Provider

Querying the provider refers to the process of seeking additional information or clarification from the healthcare provider when the medical documentation is unclear or incomplete. This is a crucial step in ensuring accurate ICD-10-CM coding. In the video, Dr. Campbell emphasizes the importance of querying the provider when there is uncertainty about the stage or status of an ulcer.

💡Unspecified Codes

Unspecified codes in the ICD-10-CM system are used when there is not enough information to determine a more specific code. These codes are necessary for situations where the documentation does not provide the detail required to assign a more precise code. In the video, Dr. Campbell explains the use of unspecified codes for ulcers when the documentation lacks information about the stage or severity.

Highlights

Focus on Chapter 12 of ICD-10-CM coding guidelines, which covers diseases of the skin and subcutaneous tissue.

ICD-10-CM codes for skin and subcutaneous tissue diseases range from L00 to L99.

Pressure ulcer stage codes are categorized under L89, identifying the site and stage of the ulcer.

Pressure ulcer codes specifically pertain to pressure ulcers, not to be confused with non-pressure ulcers.

Stages of pressure ulcers are designated based on severity, with stages 1 through 4 and unspecified and unstageable categories.

Clinical documentation should guide code assignment for unstageable pressure ulcers, used when the stage cannot be clinically determined.

Unspecified stage codes start with 'U' and are different from unstageable codes, which also start with 'U'.

Code decisions for staged pressure ulcers should be based on clinical documentation or terms found in the alphabetical index.

If a pressure ulcer has healed, no code is assigned unless the provider states it is completely healed; then, the appropriate code is used.

For healing pressure ulcers, assign the code for the stage documented in the medical record or unspecified stage if unclear.

Query the provider if documentation is unclear regarding the presence or treatment of current or new pressure ulcers.

If ulcers were present on admission and healed at discharge, assign the code for the site and stage at the time of admission.

For pressure ulcers that progress during hospital stay, assign two codes: one for the site and stage at admission and another for the highest stage reported.

Non-pressure ulcers are addressed with specific guidelines for coding based on documentation of complete healing or severity.

Assign the appropriate non-pressure ulcer code based on documentation or use the unspecified code if severity is not detailed.

Query the provider for clarification on non-pressure ulcers if documentation is unclear or if it's a current or healing ulcer.

For non-pressure ulcers present on admission and healed at discharge, assign codes for the site and severity at the time of admission.

If a non-pressure chronic ulcer progresses during hospital stay, assign two codes: one for the site and severity at admission and another for the highest severity reported.

Transcripts

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ICD 10 CM Chapter Specific Guidelines I. C12

Takeaways

Q & A

What is the ICD-10-CM chapter focused on in this transcript?

What is the code range for the diseases of the skin and subcutaneous tissue?

What does the L89 category in ICD-10-CM represent?

How many stages are there for pressure ulcers according to the guidelines?

What should be considered when assigning pressure ulcer codes?

What is the difference between 'unstageable' and 'unspecified' pressure ulcer codes?

What should be done if a pressure ulcer has completely healed?

How should coding be handled for a healing pressure ulcer with unclear documentation?

What codes should be assigned for pressure ulcers present on admission but healed at discharge?

How are non-pressure chronic ulcers documented in the medical record?

What is the coding process for non-pressure ulcers that are present on admission but heal during the hospital stay?