Common Pathologies
of the Integumentary System
©Irene Mueller, EdD, RHIA
Montana Hospital Association
June 20, 2012
http://etc.usf.edu/clipart
Objectives
• Review Integumentary System Pathologies
for ICD-10-CM/PCS Coding
– ICD-10-CM
• Chapter 12 (L00-L99) – Diseases of Skin & SubQ
• Chapter 19 (S00-T88) – Injury, Poisoning, & Other
consequences of External Causes
• Chapter 2 (C00-D49) – Malignant Neoplasms
– ICD-10-PCS
• 0 - Medical & Surgical Section
• H – Skin and Breast
• J – SubQ tissue and fascia
Skin Chapter vs Other Chapters
• Certain Skin Conditions in Other ICD-10
Chapters
– Complications of Preg, Childbirth, Puerperium
– Congenital
– Infectious
– Neoplasms
– Parasitic
– Perinatal
– Systemic connective tissue disorders
Outline
• General Skin Lesions
• Inflammations
• Infections
–
–
–
–
–
–
Abscess
Cellulitis
Furuncles/Carbuncles
Impetigo
Pilonidal cyst/sinus
Warts
• Lesions
–
–
–
–
Bullous
Cicatrix
Corns/Calluses
Other
• Abnormal Skin
Pigmentations
• Pressure Ulcers, Ulcers
• Scalded Skin Syndrome
• Hair Pathologies
– Alopecia
– Folliculitis
• Nail Pathologies
– Paronychia
• Tumors
– B9, Malignant
• Injuries
– Burns, Wounds
General Skin lesions
•
• Bulla
• Excoriation
•
•
• Burrow
• Fissure
•
• Comedo
• Freckle
•
• Comedone • Induration
•
• Crust
• Keloid
•
• Cyst
• Lichenification •
•
• Ecchymosis • Macule
•
• Erosion
• Mole
•
• Eschar
• Nodule
Papule
Petechia
Plaque
Purpura
Pustule
Scale
Scleroma
Telangiectasia
Ulcer
Vesicle
Wheal
• WOW: Check a good medical dictionary for pictures of these;
• Should know differences between them
Patterns & Distribution of Lesions
•
•
•
•
•
•
•
•
•
Annular
Discrete
Clustered
Confluent
Dermatomal,
Zosteriform
Eczematoid
Follicular
Guttate
Iris/Target
• Koebner Phenomenon,
Isomorphic response
• Linear Lesions
• Morbilliform
• Multiform
• Reticular
• Satellite lesions
• Scarlatiniform
• Serpiginous
• Strawberry tongue
• Universalis
Skin Conditions and Stress
• Many conditions
– Aggravated by stress
– Cause of stress
Infections of Skin/SQ (L00-L08)
•
•
•
•
•
Abscess/Furuncle/Carbuncle
Scalded Skin Syndrome
Impetigo
Cellulitis and Acute Lymphangitis
Acute Lymphadenitis
Bullous Disorders (L10-L14)
•
•
•
•
Bulla = blister, bleb
Latin bulla (pl. bullae), "bubble"
Circumscribed elevation of skin
0.5 cm+ diameter containing a liquid
– Vesicle = <0.5 cm in diameter
• Acantholytic disorders
• Pemphigoid
• Pemphigus
Acantholytic Disorders
• Gk akantha, thorn or prickle, & lysis, loosening
• Primary disorder of skin (sometimes mucous
membranes)
– characterized by loss of cohesion between
epidermal cells, resulting in intraepidermal clefts,
vesicles, and bullae
– Inflammatory, viral & autoimmune skin diseases,
particularly pemphigus complex
Dermatitis (L20-L30)
• Inflammation of skin
• Many types/forms
– Acute
– Subacute
– Chronic
• Manifestations
– Pruritus, Erythema
– Cutaneous Lesions
• Most common
– Atopic (Eczema)
– Contact
– Seborrheic
http://www.nlm.nih.gov/medlineplus/ency/imagepages/19323.htm
Papulosquamous Disorders
(L40-45)
• Skin eruption
– Both papular (pimple-like) AND scaly
•
•
•
•
Psoriasis
Parapsoriasis
Pityriasis rosea
Lichen planus
Urticaria and Erythema (L50-L54)
• Urticaria
– Many types
• Erythema
– Multiforme
– Marginatum
– Many other types
Radiation-Related Disorders (L55-59)
• Actinic keratosis
– AKA Solar keratosis
• Radiodermatitis
– AKA radiation dermatitis
• Sunburn
– 1st
– 2nd
– 3rd
Disorders of Skin Appendages
(L60-L75)
• Nail Disorders
– Ingrowing Nail
– Onycholysis
• Hair Disorders
– Acne
– Rosacea
• Sweat Gland Disorders
Hair Pathologies
• Follicular cysts
Alopecia areata
Androgenic alopecia • Eccrine sweat disorders
Nonscarring hair loss • Apocrine sweat disorders
Cicatricial alopecia
Hair color/shaft
abnormalities
• Hypertrichosis
• Acne
• Rosacea
•
•
•
•
•
http://etc.usf.edu/clipart
Nail Pathologies
•
•
•
•
•
Ingrowing nail
Onychia/Paraonychia - Gk, onyx, nail
Onycholysis
Onychogryphosis
Psoriasis
Intraop/Postop Complications
of Skin (L76)
•
•
•
•
Hemorrhage/hematoma of skin
Accidental puncture/laceration of skin
Postprocedural hemorrhage/hematoma
Other information
– Dermatologic procedure vs other procedure
Other Disorders of Skin/SQ
(L80-L99)
• Vitiligo
• Pigmentation
Disorders
• Seborrheic keratosis
• Pressure Ulcers
• Atopic Disorders of
skin
• Hypertrophic
Disorders of skin
• Lupus erythematosus
• Vasculitis limited to
skin
• Non-pressure chronic
ulcers
• Keloid
• Corns & Calluses
Abscess/Furuncle/Carbuncle
• Abscess - collection of pus & infected
material in or on skin – anywhere on body
• Furuncle (Boil)
– Abscess involving hair follicle and Subq tissue
• Carbuncle
– Very large boil OR multiple furuncles joined by
many drainage canals
• Carbunculosis
– Many carbuncles
Acantholytic Disorders
• Acquired keratosis
follicularis
– NOT congenital
– NOT Darier Disease
• Transient acantholytic
dermatosis
–
–
–
–
Etiology – Unknown
Itchy red spots on trunk
Usu. older men
Usu. Lasts 6-8 mos,
can be much longer
– AKA Grover disease
– Tx: Cortisone cream,
Accutane, Tetracycline,
Phototx, antifungals,
Cortisone Injections
Actinic Keratosis (L57.0)
• Small, rough, raised area found on skin
– In sun for long period of time – can become SCC
• RF: Fair skin, Blue/green eyes, Blond or red
hair
• Kidney or other transplant
• Take medicines to suppress immune system
• Lot of time each day in sun
• Many, severe sunburns early in life
• Older
Actinic Keratosis
• Face, scalp, back of hands, chest, or other
sun-exposed areas
– Flat, scaly areas
– Color -gray, pink, red, or same color as skin
– Often, white/yellow crusty "scale" on top
– Later – develops hard & wart-like or gritty,
rough, surface
– May be easier to feel than see
Acne vulagis
• L aknas, misreading of Gk. akmas, "points,
dots” L. vulgaris “common”
• Inflammatory disease of sebaceous glands
& hair follicles
– Overproduction of sebum, faster shedding of
skin cells = plug and growth of bacteria in
follicles
• Papules, putules, comedones, nodules,
possible scars
– Face, neck, shoulders, chest, back
Acne vulgaris
•
•
•
•
Unknown etiology
Hormonal changes
Hereditary tendencies
Any age, most common in Adolescents
– 14-17 Girls
– Late teens Boys
• Precipitating factors
– Food allergies, carbonated drinks, endocrine
disorders, psychological factors, fatigue,
steroid drugs
Acute Lymphangitis
• Bacterial infection in lymphatic vessels
– Streptococcus pyogenes most often; Staph
• “Flesh-eating” bacterium
– Characterized by painful, red streaks below
skin
– Potentially serious/fatal infection
• Can rapidly spread to bloodstream
– Cut, scratch, insect bite, surgical wound, other
skin injury
Acute Lymphadenitis
• Inflammation of lymph node
– Neck, arms, or legs; chest or abdomen
– Often complication of bacterial wound infection
• Hemolytic Streptococci or Staphylococci
– Caused by viruses/other disease agents also
• Viruses, protozoa, rickettsiae, fungi, tuberculosis
– Generalized: number of lymph nodes
– Localized: limited to few nodes in infection area
– Sometimes accompanied by lymphangitis
Alopecia
• Loss of hair
• 2 main types
• Alopecia areata = body's immune system
mistakenly attacks hair follicles
Androgenetic alopecia = inherited
– Head hair thins & falls out
• Men = male pattern hair loss
• Women = female diffuse hair loss
Carbuncle (L02)
• Usu. caused by Staphylococcus aureus
– Contagious
– Back, Nape of Neck, Anywhere
– Friction from clothing, shaving
– More common in Men than Women
• Composed of several skin boils (furuncles)
• Infected mass filled w/ fluid, pus, & dead
tissue – up to golf ball size
– May or may not drain
• RF: DM, dermatitis, weak immune system
Cellulitis (L03)
• Acute, diffuse, bacterial infection
– Infection spreads over 2 days
– Deep Skin and SubQ
– Lower extremities most often, anywhere
• Signs
– Erythema, pitting edema
– Skin is tender and hot
– Red lines/streaks PROXIMAL
• Along lymph vessels to lymph glands
Cellulitis
• Streptococcus or Staphylococcus
– Small cut/lesion
– Enzymes from bacteria
• Break down skin cells
• Prevent body responses
• Can lead to
– Abscesses
– Bacteremia
• Tx: Antibiotics (IV)
http://www.nlm.nih.gov/medlineplus/ency/imagepages/8743.htm
Corns & Calluses (L84)
• Localized,
hyperplastic areas
– Stratum Corneum of
Epidermis
• Calluses AKA Tylosis
– Larger (up to 1 inch)
– Ball of foot, palms
• Corns AKA Clavus
– Smaller, on toes
– Glassy core
– More painful
• Pressure/friction
–
–
–
–
Shoes
Orthopedic deformity
Faulty weight-bearing
Repeated trauma
• (Musicians)
• Impaired Circulation
– Foot
– Peripheral Neuropathy
– DM
Dermatitis, Atopic (Eczema) (L24)
• Inflammation of skin
– Patients w/ family hx of allergic conditions
– Vesicular eruptions
• Exudative in children
• Dry, Leathery in adults
– Characteristic pattern
• Face, neck, elbows & knees, upper trunk
– Pruritis
• Idiopathic
• Allergic connection assumed
Dermatitis, Atopic (Eczema)
Gk, ekzein, to boil over
• Infants
– Sensitivity to milk, OJ, other foods
• Flare-up Triggered by
– Stress, anxiety, conflict
– Wool clothing, blankets
– Frequent bathing/handwashing
• May improve in summer
• Tends to improve with time
Dermatitis, Contact (L23-24)
• Acute inflammation of skin
– Irritants on surface
– Allergic reaction
– Erythema, edema, small vesicles, itching,
stinging
• Causes: Poison Ivy, Oak, Sumac; Dyes,
Latex, Furs, Preservatives, Drugs,
Detergents, Cleaners, Cosmetics,
Chemicals, Acids, Metals, Sunshine,
Tanning Beds (ICD-10-CM specific codes)
Dematitis, Seborrheic (L21)
• One of most common skin conditions
• Inflammation of Oil glands in skin
– Areas with greatest # of glands
– Scalp, eyebrows, eyelids, sides of nose,
behind ears, middle of chest
– Skin is reddened, covered with scales
(yellowish, greasy-looking)
– May be itching, usu. mild
Dermatitis, Seborrheic
• Any age; most common during infancy
– Cradle cap
• Clears w/in 8-12 months (no tx)
• Adults w/ CNS disorders (ex. Parkinson)
• Adults w/ stress
– AMI, long LOS in hospital/nursing home
– Immune system disorders (AIDS)
– Psoriasis
• Idiopathic; heredity predisposition
• Tx: Corticosteroids; dandruff shampoos
Furuncle (L02)
• Usu. caused by Staphylococcus aureus
– Other bacteria or fungi found on skin surface
• Face, neck, armpit, buttocks, thighs, anywhere
• One OR many boils
http://upload.wikimedia.org/wikipedia/commons/9/95/Furuncle-MIN-IMG_2589.jpg
Impetigo (L01)
• Superficial skin infection
– Staphylococcus aureus or Streptococcus
– Insect bites, scabies, poor hygiene, anemia,
malnutrition, eczema (loss of skin integrity)
– Highly contagious, Warm weather
– Face, arms/legs, anywhere
• Vesicular/Pustular lesions,
– Rupture -Form thick, yellow crusts
• Children, 2 – 6 yo
MedlinePlus
Ingrowing nail (L60.0)
• Edge of nail grows down/into skin of toe
– Can be pain, redness, and swelling around nail
– Cause: usu. Poorly fitting shoes & improperly
trimmed nails
• Dangerous for DM
http://www.nlm.nih.gov/medlineplus/ency/article/001237.htm
Lupus erythematosus (L93.0)
• AKA Local, Discoid, Chronic Cutaneous
Lupus (CCLE), Discoid Lupus (DLE)
• Chronic skin disease
– Primarily women 20 – 40
– Characterized by eruption of red lesions over
cheeks & bridge of nose
– Scarring w/ altered pigmentation
• Exacerbated by trauma & sunlight
• Tx: Sunscreen, Topical Corticosteroids
– Systemic Agents
Onychia/Paraonychia (L03.0)
• Onychia
– AKA onychitis
– Inflammation of finger/toenail matrix; may lose
• Paraonychia
– Superficial infection of epithelium lateral to nail plate
– Acute More painful (usu. Bacterial)
– Chronic (often several nails) (usu. Fungal)
• Culture of exudate to determine etiology
– RF – Hands in water for long periods
Onycholysis (L60.1)
• Spontaneous separation of nail plate
– Starting at distal free margin & progressing
proximally
– Beginning at proximal nail & extending to free
• Most often in psoriasis of nails (onychomadesis)
– Just at lateral borders (Rare)
• Etiology
– Endogenous, exogenous, hereditary, &idiopathic
Contact irritants, trauma, & moisture
– Associated with many other diseases
• Tx: Depends on Cause
Onychogryphosis (L60.2)
• Gk, onyx + gryphein, to curve
• Abnormal hypertrophy & curving of nails
• Gives a claw-like appearance
Parapsoriasis (L41)
• 2 general forms
– Small plaque type, usu. B9
– Tx: emollients, topical tar, steroids, phototx
– Large plaque type, precursor of cutaneous Tcell lymphoma (CTCL).
– Tx: phototherapy or topical corticosteroids
Parapsoriasis (L41.x)
• No uniform, accepted definition
• Group of skin diseases characterized by
– Scaly patches OR
– Slightly elevated papules and/or plaques
– Resemblance to psoriasis
• BUT includes several inflammatory
cutaneous diseases unrelated in
pathogenesis, histopathology, & tx response
Pemphigoid vs Pemphigus
•
•
•
•
•
•
Separate autoimmune diseases
Both have sub types
Both cause burn-like blisters
Both very rare; can’t be cured
PemphigoiD = Deep PemphiguS = Superficial
Pemphigoid more common, less dangerous
– Tends to affect older people, usually 60+
Pemphigoid (12.9)
• Gk pemphix, blister
• Autoantibodies –
– Against basement membrane of epidermis
– Not against epidermal cell junctions
• Intact, tense bullae up to 3 cm
– Trunk, arms, & legs
– Rare in mouth
Pemphigus (L10)
• Group of disorders caused by autoantibodies against some part of epidermis
– Including Oral mucosa
– Lead to disruption of intercellular junctions
and blisters
– Ruptured bullae covered with scabs
– Tx: Immunosuppressive agents
– Prognosis is variable
– Many patients - higher than normal mortality
rate
Pemphigus Risk Factors
• Possible triggers
• Non-steroidal anti-inflammatory drugs
such as ibuprofen
• Drugs derived from penicillamine
• Herpes simplex virus
• Exposure to sunlight
• Long-term stress
Pilonodal Cyst/Sinus
• Latin - pilus (hair); nidus (nest) nest
• Abnormal pocket in skin, usu. contains hair,
skin debris & other abnormal tissue
• Almost always located near tailbone at top
of buttocks cleft (small pit)
• Affect men more often; most commonly in
young adults
• When becomes infected (abscess)
– causes pains, inflammation & usu. drainage of
fluids
Pilonidal Cyst (L05)
• Risk Factors
– Obesity, Inactive lifestyle
– Occupation or sports requiring prolonged sitting
– Excess body hair; Stiff or coarse hair
– Poor hygiene; Excess sweating
• When chronically infected pilonidal cyst isn't
treated properly
– Increased risk of developing squamous cell
carcinoma.
Pilonidal Sinus
• Hair may protrude from tract below skin’s
surface that connects infected pilonidal cyst
to opening on skin's surface
– More than one sinus tract may form
• Tx: I&D, currettage
– May be left open to heal
MedlinePlus
Psoriasis, Gk - itch
• Non-infective
• Thick, flaky, various-sized red patches
– Covered with white, silvery scales
– Scales progress to plaques, sometimes pustules
• Chronic condition, most common bet. 10-30 yo
• Scalp, outer arms/legs, trunk, palms/soles,
nail beds (nails thicken, crumble)
• Genetic basis
• Maybe autoimmune
• Whites - more common
Psoriasis, Arthropathic (L40.50)
• Several different forms
– Small distal joints, fingers & toes
– Joints on one side of body only
– Bilateral larger joints
– Back and spine
– psoriatic arthritis mutilans (rare) - joints & bones
destroyed (gnarled,club-like hands & feet) (L40.52)
• Symptoms of psoriasis usu. Precede arthritis
– Clue to possible joint disease is pitting and other
changes in fingernails
Psoriasis (L40)
• Precipitating factors
– Hormonal changes, climate changes,
emotional stress, poor health
• Remissions and Exacerabations
• Guttate psoriasis – Rare form
– Frequently follows Strep infection
– L, drop
MedlinePlus
Psoriasis and Nails
• Nail changes occur in
– Up to 50 % of psoriasis patients
– Up to 80 % psoriatic arthritis patients
• Most common Nail problems in psoriasis
– Pitting—shallow or deep holes in nail
– Deformation—alterations in normal shape of nail
– Thickening of nail
– Onycholysis—separation of nail from nail bed
– Discoloration—unusual nail coloration, such as
yellow-brown
Radiodermatitis (L58)
• Cutaneous inflammatory reaction
– Acute or Chronic
– Exposure to biologically effective levels of ionizing
radiation
• Most common example of normal tissue
damage as a result of radiotherapy
– About 95% of radiation oncology patients
– 87% moderate to severe radiodermatitis
Radiodermatitis
• Includes
– Localized erythema & edema Grade 1
– Skin shedding (desquamation)
– Hair loss (epilation)
– Fibrosis
– Necrosis (ulcers/hemorrhages) Grade 4
• Late effects (90 days to years after tx)
– Result of permanent damage to dermis
– Atrophy, fibrosis, telangiectasias, & pigmentation
changes
• Tx: Depends on Grade
Rosacea
L, rosaceus, rosy
• Facial skin redness, where blushing occurs
• Insidious onset
– Mistaken for sunburn or acnes
•
•
•
•
Becomes more noticeable /does not go away
Dryness, pimples (pustular)
Small blood vessels dilate
Knobby bumps on nose, looks swollen
– Usu. Male patients
Rosacea (L71)
• Unknown etiology
– May be inherited
• Lighter complexions – higher risk
• Not infectious/contagious
• Triggers vary from person to person
– Sunlight, hard exercise, extreme heat/cold,
stress, spicy foods, hot drinks, alcohol,
hot/cold weather, wind
• Tx: topical antibiotics, Finacea, laser
surgery, sunscreens
Scalded Skin Syndrome (L00)
• AKA - Ritter disease; Staphylococcal scalded
skin syndrome (SSS)
• Infection - skin becomes damaged & sheds
– certain strains of Staphylococcus
– Toxin causes skin damage
– Blisters as if skin were scalded
• Most commonly in infants & children under 5
• Tx: IV antibiotics and fluids
Seborrheic Keratosis (L82)
• AKA Seborrheic
Wart
• B9 skin tumor
• Usu. After age 40
• Runs in families
• S&S
• Often waxy surface
• Round-to-oval
• “Pasted-on"
appearance
• S&S, cont.
• Located on face, chest, shoulders,
back, or other areas
• Usu. painless, but may irritate &
itch
• Yellow, brown, black, or other
colors
• Slightly raised, flat surface; rough
or wart-like texture
• May be single, but usually many
Sunburn (L55)
• Severity determined by depth of burn
• 1st
– Damage to epidermis
– Erythema (Pain, Redness, Swelling)
• 2nd
– Damage to Dermis; Erythema, Blisters
• 3rd degree
– Damage to Hypodermis & Nerve supply
– Numbness; then scars
– Loss of sensation/function possible
Burn Severity
http://www.nlm.nih.gov/medlineplus/ency/imagepages/1078.htm
Ulcers
• L, ulcus, a sore
• Circumscribed, craterlike lesion of he skin
or mucous membrane
• Resulting from necrosis accompanying
some inflammatory, infectious, or
malignant processes
• Produced by sloughing of necrotic
inflammatory tissue
Ulcers, Non-Pressure (L97)
•
•
•
•
Arterial ulcers
Venous stasis ulcers
Diabetic ulcers
Neurotrophic ulcers
• NOT pressure ulcers
Arterial ulcers
• Complete or partial arterial blockage
– Causes tissue necrosis and/or ulceration of
extremity
• AKA Ischemic ulcer
• Large/small vessel; toes, ankles, fingers
• Risk Factors
– Peripheral vascular disease (PVD)
– Diabetes mellitus
– Advanced Age
• Tx: Surgical or Medical to increase circulation
S&S of Arterial Ulcer
•
•
•
•
No pulse in area of extremity
Painful ulceration
Cool or Cold skin
Small, punctate ulcers; usually well defined
Delayed capillary return time
– Briefly push on end of toe and release
– Normal color should return to toe in <3 seconds
• Atrophic appearing skin (shiny, thin, dry)
• Loss of digital & pedal hair
• Frequently on dorsal foot; occur anywhere
Venous stasis ulcers
• AKA Varicose Ulcers
• Venous Stasis
– Cessation or impairment of venous flow
– AKA phlebostasis, venostasis
• Location
– Below knee – usu. Inner part of leg, just above
ankle. Can be uni/bilateral
• Tx: Bed rest, elevation, & pressure bandages
– Antibiotics if needed for infection
Venous stasis ulcers (I83)
• Common in patients
– w/Hx of leg swelling
– Varicose veins
– Hx of blood clots in superficial OR deep leg veins
• Affect 500,000 - 600,000 people in US yearly
• Account for 80 to 90 % of all leg ulcers
Diabetic ulcers (E08-E11)
• Most common foot injuries leading to lower
extremity amputation
– Risk of LE amputation - 15 - 46 times higher in
diabetics
– Early detection/appropriate treatment of diabetic
ulcers may prevent up to 85 % of amputations
• Ulcers almost always form in patients with
neuropathy
– Typically painless
Neurotrophic ulcers
• Occur primarily in Diabetics – see Diabetic
ulcer
– 60 - 70 % of Diabetics - mild to severe forms of
nervous system damage
• Can affect anyone w/ impaired sensation in
feet
– Predominantly sensory neuropathy, Sensorymotor neuropathy, or Autonomic neuropathy
– Essential cryoglobulinemic vasculitis
Ulcers, Pressure (L 89)
• Localized injury to skin and/or underlying
tissue
– Usually over bony prominence
– Result of pressure, or
– Pressure in combination w/shear and/or friction
• 6 stages
– NPUAP, 2007
• Tx: Decrease pressure, friction and shear
Ulcers, Pressure
•
•
•
•
•
•
•
AKA
Bed Sore
Decubitus ulcer
Plaster ulcer
Pressure area
Pressure sore
Slough [sluf] Layer/mass of dead tissue
separated from surrounding living tissue
• Eschar - hard crust or scab
Pressure Ulcer Stages
• Suspected Deep
Tissue Injury
– 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
• Stage I
– Intact skin w/ nonblanchable redness of
localized area
– Usu. Over bony
prominence
– Darkly pigmented skin
may not visibly blanch
– Color may differ from
surrounding area
Pressure Ulcer Stages
• Stage II
– Partial-thickness loss
of dermis
– Shallow open ulcer w/
red pink wound bed,
w/o slough
– May also present as
an intact or
open/ruptured serumfilled blister
• Stage III
– Full-thickness tissue loss
– SQ fat may be visible but
bone, tendon or muscle
are NOT exposed
– Slough may be present
but does not obscure
depth of tissue loss
– May include undermining
and tunneling
Pressure Ulcer Stages
• Stage IV
– Full thickness tissue
loss w/ exposed bone,
tendon or muscle
– Slough or eschar may
be present on some
parts of wound bed
– Often includes
undermining &
tunneling
• Unstageable
– Full thickness tissue
loss in which base of
ulcer is covered by
slough (yellow, tan,
gray, green or brown)
– and/or eschar (tan,
brown or black) in
wound bed
http://www.nlm.nih.gov/medlineplus/ency/imagepages/19092.htm
Risk Factors for Pressure Ulcers
• Age
– Reduced skin cell turnover, drier skin, reduction
of collagen & elastin, & reduced vascularity at
dermal/epidermal junction cause
• Skin less resistant to shear forces
• Increased surface area (potential fluid loss
increase)
• Increased traumatic injury risk (e.g. skin tears)
• Decreased homeostasis
• Reduction of barrier function
RF for Pressure Ulcers
• Thin Body
– More prone to develop pressure ulcers over
bony prominences
• Nutrition & Hydration
– hypoalbuminemia, weight loss, cachexias,
dehydration, and malnutrition
– commonly reported risk factors predisposing
persons to pressure ulcer.
– Pressure ulcers can generate stress response,
which further adds to nutritional needs
• Lower dietary protein intake
RF for Pressure Ulcers
• Inability to feed oneself
• Particular Medical Conditions
– Diabetes
Malnutrition
– Altered mental status
– Spinal cord injury
Orthopedic injury
– Depression
Vascular disease
• Anaerobic waste products
– believed to accumulate due to pressure-induced
occlusion of lymphatic vessels & contribute to
tissue necrosis
PU Assessment Tools
• Braden Scale
• Norton Scale
– Most researched, validated,
& nationally recognized tool
– Comprehensive
– May not have same
predictive value & accuracy
in LTC
– Not readily used in
outpatient clinic setting
– View tool at
• www.bradenscale.com/imag
es/bradenscale.pdf
– Short, straightforward,
easy to complete
– Does NOT address
nutrition
– View tool at
• http://www.ruralfamilyme
dicine.org/educationalstr
ategies/braden_scale_for
_predicting_pres.htm
Unavoidable Pressure Ulcers
• CMS definition in LTC
• “An unavoidable pressure ulcer occurs when
facility staff evaluated resident’s clinical
condition and pressure ulcer risk factors,
defined and implemented interventions
consistent with resident needs, goals, and
recognized standards of practice, monitored
and evaluated impact of interventions, and
revised approaches as appropriate.”
Urticaria L, urtica, nettle
•
•
•
•
AKA – Hives
Severe itching, then redness, then wheal
Localized, various sizes
Can include
– GI tract – abdominal colic
– Pharynx – can cause asphyxiation
– Deep tissues = angioedema – more serious
• Usu. Short duration, can become chronic
Urticaria (L50)
•
•
•
•
•
Dermis
Acute hypersensitivity
Release of histamine
Local inflammation, vasodilation, edema
Allergic reaction
– Shellfish, strawberries, peanuts, etc.
– Insect stings
• Infection, Sunlight, Temperature extremes
• Tx: epinephrine, prednisone
Skin Injuries & Neoplasms
• Chapter 19 (S00-T88) – Injury, Poisoning, &
Other consequences of External Causes
• Chapter 2 (C00-D49) – Malignant Neoplasms
Skin Injuries in ICD-10-CM
• Abrasion
• Exfoliation
– Desquamation
– Excoriation
• Avulsion
– Wound, Open
• Bite (nonvenomous)
– Superficial
– Open
•
•
•
•
Blister (nonthermal)
Burn
Contusion
Corrosion
•
•
•
•
•
•
External Constriction
Foreign Body
Frostbite
Incision
Laceration
Wound
Abrasion
• L: abradere, to scrape off
• Rubbing away of skin surface by friction
against rough surface, usu. Not deeper than
epidermis, can bleed
• Mild abrasion (Graze) does NOT scar
• Deep abrasion may scar
• AKA – Scrape, Scratch, Excoriation
• Types
– Rope burn, friction burn, road rash, rug burn
Avulsion of Skin
• L, avulsio, a pulling away
• Avulsion injury - removal of all layers of skin
– Chunk of tissue removed from body
– Includes all 3 layers of skin at minimum
• More than simple lacerations; less than amputations
• Etiology: Animal bites, industrial equipment,
or MVAs
• Skin flap or Degloving
• Higher Risk of Infection
Bite (Non-venomous)
• Wound or puncture made by living organism
• Superficial = Skin
• Open = Communicates directly with
atmosphere
• Pets, Humans, Insects, Snakes, etc.
• Can be heavily contaminated
Blister (Non-thermal)
• Friction (New Shoes)
– Abrasion Blister
•
•
•
•
•
Electricity
Chemicals
Radiation from sun
Cold
Pinched skin (blood blister)
Burn (T20-T25)
• Electrical heating
appliances
• Electricity
• Flame
• Friction
• Hot air and hot gases
• Hot objects
• Leading cause of
injury in US
• Lightning
• Radiation
• Scalds
• Chemical Burn
(Corrosion)
• NOT Sunburn
Burns
• 85%–90% caused by heat
• 10%–15% frostbite, chemical, & electrical
damage
• 1.5 - 2.0 million burns each year in U.S
• 60,000 to 80,000 burn victims hospitalized
• 5,000 people die
• 35,000 to 50,000 people - temporary or
permanent disability 2ndary to burns
Degrees of Burns
• Older Terminology
• 1st degree; outer layers of
epidermis injured, erythema,
but no blistering
• 2nd degree; epidermis into
dermis but basal layer
remains, blistering
• 3rd degree; all epidermis &
dermis destroyed; only white
eschar remains
• 4th degree; muscle, nerve
and bone damaged
• Newer terminology
• Superficial partial
thickness; epidermis
and upper part of
dermis injured
• Deep partial
thickness; epidermis
& large upper
portion of dermis
injured
• Full thickness; all
layers destroyed
Degrees of Burns
• 4th degree burns extend to tissue
• 5th degree extends to bone
• 6th degree burns are through bone
• Old classification system
http://www.ncbi.nlm.nih.gov/books/NBK27295/
Rule of Nines for Burn Extent
• Total Body Surface Area (BSA)
(Adults)
• Age Infants, children, & elderly
survival
• Total Body Surface Area
– greater area of involvement ~
prognosis
• Depth of Burn— More Total BSA
~ full thickness, prognosis
• Other Injuries - Prognosis
concurrent injuries increase
http://www.ncbi.nlm.nih.gov/books/NBK27295/
as
Burn Treatment
• Determined by Degree and Extent of Burns
• Table of Treatment Modalities by Burn Degree
– Rehabilitation of Burn Injuries
– http://www.ncbi.nlm.nih.gov/books/NBK27295/
Contusion
• L, contundere, to bruise
• AKA Bruise
• Injury that does not
disrupt integrity of skin
– Caused by blow to body
– Characterized by
swelling, discoloration, &
pain
Corrosion (T20-T25)
• L, corrodere, to gnaw away
• Tissue damage due to exposure to strong
alkali or acid
• Main types of irritant and/or corrosive
– Acids, bases, oxidizers, solvents, reducing
agents and alkylants
– Types of chemical weapons
• Vesicants or Urticants
External Constriction
• Classified as superficial injury
• Ex: Hair tourniquet syndrome
– AKA hair strangulation
• External constriction of finger, toe, or external
genitalia by hair
– OR thread, ring, rubber band, other object that
can go around a body part
– Relatively common in infants
– Can be emergency situation
• Object NOT removed; infection or amputation
Foreign Body
• Any object or
substance found in
organ or tissue in
which it does NOT
belong under normal
circumstances
• Superficial
• Open Wound w/FB
http://upload.wikimedia.org/wikipedia/commons/7/74/Knee_puncture.JPG
Foreign Body
• Iatrogenic
– Sutures, sponges,
instruments left during
surgery
– Metals & plastics
replacing/enhancing
failing/non-functioning
body parts
• Accidental/unintentional
– From abrasions & open
wounds in various
accidents or GSWs,
– May elicit FB-type
granuloma formationr
• Intentional
– Introduced in context of
sexual deviancy
– Anorectum or vagina vibrators, bottles, light
bulbs, eggs, etc.
Frostbite
• Superficial
– Damage to skin caused by extreme cold
– Red, painful, Blisters, Gangrene
– Hands, feet, nose, & ears most common areas
• RF:
– Beta-blockers
– Peripheral vascular disease
– Smoke, Diabetes
– Raynaud phenomenon
• IF blood vessels NOT damaged
– Complete Recovery Possible
Incision
• Neat, Clean cut
– Surgery
– Sharp instrument, such as knife
Wound
• Laceration
– Dull, Blunt instrument
– Jagged, irregular wound
– Some tearing, breaking of tissue
• Puncture wound
– Sharp, pointed object pierces skin
– Can be deep; look insignificant
– Anaerobic infection risk
• W/Without FB
Lacerations
• From shallow cuts to deep gashes penetrating
thru muscle to internal organs/bone
– Superficial laceration involves only skin
– Deeper laceration may penetrate veins or arteries
– Blood vessel may require repair
• Causes - include accidents at home & work,
motor vehicle crashes, & violence
Open Wound vs Superficial
• Open wounds
– Animal bites, avulsions, cuts, lacerations,
puncture wounds, traumatic amputations
• Superficial injuries
– Animal bites that do NOT break all skin layers
– Abrasions or contusions
– Skin tears (Elderly, etc.)
Gunshot wounds
• Skin Damage = external, surface wounds
caused by a bullet
• Usually, entrance wound smaller/tidier than exit
site
• Amount of injury at entrance/exit (if present)
sites related to
– Caliber of bullet
– Angle at which bullet traverses tissues
– Distance from gun
– Type of bullet
Integumentary System Neoplasms
• Benign usu. Need ONLY cosmetic tx
• Most common cancers in US
• C43-44 Melanoma and Other malignant Neoplasms
of Skin
–
–
–
–
BCC
SCC
Melanoma
Merkel Cell Ca
• C50 Malignant Neoplasm of Breast
• C79.2 2ndary Malignant Neoplasm of Skin
• C84.0 Cutaneous Lymphoma
Benign Neoplasms of Skin
• Acrochordon
– Skin tag
• Cherry angioma
• Dermatofibroma
• Dermatosis papulosa
nigra
• Ephilides
– Freckles
• Epidermal inclusion cyst
• Lentigines
– Liver spots
• Lipoma
• Milium
• Nevus
– Mole
• Pyogenic granuloma
• Sebaceous hyperplasia
• Seborrheic keratosis
Keratinocyte cancers
• Most common non-melanoma skin cancers
– Cells share some features of keratinocytes
– Most abundant cell type of normal skin
• Most common types of keratinocyte cancer
– Basal cell carcinoma
– Squamous cell carcinoma
Other Skin Cancers
• Other non-melanoma skin cancers include
– Merkel cell carcinoma
– Kaposi sarcoma
– Cutaneous (skin) lymphoma
– Skin adnexal tumors
– Various types of sarcomas
Basal Cell Carcinoma
•
•
•
•
•
•
•
About 80% of skin cancers
Sun-exposed areas, especially head & neck
Slow growing, seldom spread
BUT IF left untxed; can invade & metastasize
Can recur at same place
Increases chance of getting BCC elsewhere
Up to 50% of people will get new BCC w/in 5
years
Breast Cancer
• 2 main types
• Ductal carcinoma
– Begins in tubes (ducts) that move milk from
breast to nipple
– Most breast cancers
• Lobular carcinoma
– Begins in lobules that produce milk
• Rarely, can begin in other breast areas
Breast Cancer
• Invasive
– Spread from milk duct or lobule to other
breast tissues
• Noninvasive
– NOT yet invaded other breast tissue
– “In situ“
• Women - 1 in 8 will be DX w/breast cancer
• Men - <1% of all cancers in men
–
< 1% of all diagnosed breast cancers
Breast Ca Risk Factors
• Age and gender
– 50 +
– Women - 100 times more likely to get than men
• Family Hx of breast cancer
– Close relative had breast, uterine, ovarian, or colon cancer
– 20 - 30% of women w/ breast cancer have family hx
• Genes
– BRCA1 and BRCA2 genes
• Menstrual cycle
– Early periods (before age 12)
– Menopause late (after age 55)
Breast Ca Risk Factors
• Alcohol use
– 1 - 2 glasses + daily
• Childbirth
• DES –
– Increased risk of breast
cancer after age 40
– NO children or after age • HRT –
30
– Estrogen for several years
– Being pregnant 2+ times • Obesity –
reduces risk
– Link is controversial
– Pregnancy at early age
• Radiation Tx
reduces risk
– Child or young adult
• Dense Breast tissue
– Treat ca of chest area
• Being White
Breast Cancer Tx
• Six types of standard treatment
– Surgery
– Sentinel lymph node biopsy followed by surgery
– Adjuvant Tx
• Radiation therapy
• Chemotherapy
• Hormone therapy
– Targeted therapy
• Various combinations based on Pt and Stage
Breast Cancer Surgery
• Breast-conserving surgery
– Remove cancer but not breast
– Lumpectomy: Surgery to remove a tumor (lump)
& small amount of normal surrounding tissue
– Partial mastectomy: Remove part of breast
w/cancer & some normal tissue
• Lining over chest muscles below cancer may be
removed
• AKA segmental mastectomy
– Lymph Node Dissection (separate incision)
Breast Ca Surgery
• Total (Simple) Mastectomy
– All breast tissues
• Modified Radical Mastectomy
– Whole breast, many of lymph nodes, lining
over chest muscles; sometimes, part of chest
wall muscles
• Breast Reconstruction
– At same time OR later
Radiation for Breast Ca
• External radiation therapy
– Machine outside body sends radiation to
cancer
• Internal radiation therapy
– Radioactive substance sealed in needles,
seeds, wires, or catheters
– Placed directly into or near cancer
Chemotx for Breast Cancer
• Systemic chemotherapy
– Chemotherapy taken by mouth or injected into
vein or muscle
– Drugs enter bloodstream, & can reach cancer
cells throughout body
• Regional chemotherapy
− Chemotherapy placed directly into CSF, organ,
body cavity (such as abdomen)
− Drugs mainly affect cancer cells in those areas
Hormone Tx for Breast Ca
• Hormone therapy
– Removes hormones OR blocks action
– Stops cancer cells from growing
• Some hormones can cause certain Ca
• When tests show cancer cells have
hormone receptors
– Drugs, surgery, or radiation tx used to reduce
production of hormones or block them from
working
Targeted Tx for Breast Ca
• Uses drugs or other substances
– ID & attack specific cancer cells without
harming normal cells
– Monoclonal antibodies and Tyrosine kinase
• Used to treat Breast Ca
Cutaneous (skin) lymphoma
• Cancers of lymphocytes (white blood cells)
– Primarily involving skin
• Classification is based on lymphocyte type
– B-lymphocytes (B-cell)
– T-lymphocytes (T-cell) (CTCL)
• Most common
• Red, scaly patches or thickened plaques of skin
– Often mimic eczema or chronic dermatitis
• More common in men; after age 50
CTCL
• Most common type of
Skin Lymphoma
– Red, scaly patches or
thickened plaques of skin
– Often mimics eczema or
chronic dermatitis
• More common in men; after
age 50
• Two most common types
– Mycosis fungoides &
Sezary syndrome
• Treatment
– Topical
• Corticosteroids,
Topical Chemo,
Retinoids
– Systemic
• IV Steroids
• IV Retinoids
• IV/ Oral Chemo
– Light Therapy
– Immunotherapy
– Radiation Therapy
Melanoma
• Less than 5% of skin cancer cases
• BUT causes large majority of skin ca deaths
• 2012 - About 76,250 new melanomas dx
– 44,250 men & 32,000 women
– Incidence rates for melanoma rising for 30+ yrs
• 9,180 are expected to die of melanoma
– 6,060 men & 3,120 women
– 2004 to 2008 - Death rate in whites
• Dropped those < 50
• Stable in women
• Rising in men > 50
Melanoma
• Lifetime risk
– 2% (1 in 50) for whites
– 0.1% (1 in 1,000) for blacks
– 0.5% (1 in 200) for Hispanics
• Risk increase with age
– One of more common cas in young adults
Melanoma Risk Factors
• Ultraviolet (UV) light
exposure
– Sun and Tanning beds
• Dysplastic nevi
• Congenital melanocytic
nevi
• Fair skin, freckling, &
light hair
• Personal Hx of
melanoma
•
•
•
•
Immune suppression
Age
Gender (Male)
Xeroderma
pigmentosum
S&S of Melanoma
• ABCDE rule
– Asymmetry One half of mole or birthmark does not
match other half
– Border Edges irregular, ragged, notched, or blurred
– Color NOT same all over & may include shades of
brown/black, sometimes patches of pink, red, white, or
blue.
– Diameter Spot >6 mms across– size of pencil eraser,
BUT melanomas can be smaller
– Evolution Any changes in skin lesions, new skin
lesions, or growths that look different from moles
S&S of Melanoma
• Other warning signs
– Sore doesn’t heal
– Pigment spreads from border of spot to
surrounding skin
– Redness or new swelling beyond border
– Change in sensation
• itchiness, tenderness, or pain
– Change in surface of a mole
• scaliness, oozing, bleeding, or bump/nodule appears
Melanoma Staging
• The American Joint Committee on
Cancer (AJCC) TNM system
• T ~ Tumor 0-4 a, b
• N ~ Node 0-3 a, b, c
• M ~ Metastasis
• Tx: Based on Stage
• Surgery Chemotherapy
• Immunotherapy Radiation therapy
Melanoma Survival Rates
Stage IA
5-year ~ 97%
10-year ~ 95%
Stage IB
5-year ~ 92%
10-year ~ 86%
Stage IIA
5-year ~ 81%
10-year ~ 67%
Stage IIB
5-year ~ 70%
10-year ~ 57%
Stage IIC
5-year ~ 53%
10-year ~ 40%
• Stage IIIA
•
5-year ~ 78%
• 10-year ~ 68%
• Stage IIIB
– 5-year ~ 59%
– 10-year ~ 43%
• Stage IIIC
– 5-year ~ 40%
– 10-year ~ 24%
• Stage IV
– 5-year ~ 15%-20%
– 10-year ~ 10%-15%
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001853/figure/A000850.B3200/?report=objectonly
Merkel Cell Ca
•
•
•
•
Rare skin ca, but incidence increasing world-wide
Metastasizes quickly
Merkel cells at base of epidermis
Nodule
– flesh-colored OR bluish-red, shiny, painless
• Usu. on face, head, neck; also on limbs or trunk
• Risk Factors
– Age, sun exposure, weak immune system, other skin ca,
light skin
– 80% of 10 Merkel cell cas are thought to be related to
MCV (Merkel Cell Polyomavirus)
• AKA
– Neuroendocrine carcinoma of skin
Merkel Cell Ca
• Metastasis
– Liver, Bones, Lungs, Brain
• Prognosis
– 33% fatality rate
• Diagnosis
– PE, Bx, Sentinel Node Bx, x-rays, CT, PET,
octreotide scan
• Tx
– Surgery (Mohs), Radiation, Chemo
Squamous Cell Carcinoma
• About 20% of skin
cas are SCC
• Sun-exposed areas of
body
• Sometimes begin in
actinic keratoses
• Genital area skin
– Face, ears, neck, lips,
& backs of hands
• Scars or skin ulcers
elsewhere
http://www.nlm.nih.gov/medlineplus/ency/imagepages/2475.htm
Squamous Cell Ca
• More aggressive than BCC
– More likely to invade fatty tissues just under
skin
– More likely to spread to lymph nodes and/or
metastasize
• Squamous cell carcinoma in situ
– AKA Bowen disease
– Still w/in the epidermis
http://www.nlm.nih.gov/medlineplus/ency/ima
gepages/1516.htm
2ndary Skin Cancers
• Cancer cells can grow in skin
– NOT skin cancer, melanoma, or cutaneous T
cell lymphoma
– Secondary cancer may start to grow
• On/ near operation scar where primary cancer
was removed
• In other parts of body
• Secondary skin cancer looks like a
pink/red raised lump
– These nodules can be treated
Questions from Last Session
• ICD-10-CM/PCS Implementation date
– Proposed Rule – 10-1-2014
• Federal Register on April 17,
• Proposed rule available for comment for 30 days
– Announcement in June?
• http://www.cms.gov/Medicare/Coding/
ICD10/index.html
Questions from Last Session
• Timeline for Required ICD-10-CM/PCS CEs?
– “CCHIIM will send out a communiqué within 30
days of final decision by HHS on ICD-10
implementation date to address ICD-10 CEU
requirements and launch date for ICD-10
compliant exams. Certified professionals are still
encouraged to obtain their ICD-10 required CEU’s
for submission by December 31, 2013.”
– Please be aware that delay is not finalized until
official notice is send out from HHS
• Linda DeViller, AHIMA 6/18/2012
Query Example
• Liposuction of lipomas
• ICD-10-CM
– Location of lipomas
• ICD-10-PCS
– INTENT of Root operation
• Medical reason ~ Extraction
• Cosmetic reason ~ Alteration
What is missing from above statement?
What would we need to query for?
Homework
• Pressure Ulcer Online Training. The National
Database of Nursing Quality Indicators®
– https://www.nursingquality.org/NDNQIPressureUlcer
Training/
• Four Modules
–
–
–
–
CEs
Pressure Ulcers and Staging
Other Wound Types and Skin Injuries
Pressure Ulcer Survey Guide
Community vs. Hospital/Unit Acquired Pressure
Ulcers
• CE certificate when all completed w/tests
General Resources
• Cohen, B. A., Lehmann, C. U. Dermatology Image
Atlas. Johns Hopkins University, 2000-2012.
– http://dermatlas.med.jhmi.edu/derm/
• Dermatology A to Z. AAD.
– http://www.aad.org/skin-conditions/dermatology-a-to-z
• MedlinePlus
• Swanson, J. R. & Melton, J. L. Dermatology Atlas.
Chicago: Loyola University Dermatology Medical
Education Website
– http://www.meddean.luc.edu/lumen/MedEd/medicine/der
matology/melton/title.htm
Resources
• About Cutaneous Lymphoma. Cutaneous
Lymphoma Foundation.
– http://www.clfoundation.org/about-cutaneous-lymphoma
• Acute Lymphangitis. Medical Dictionary Article.
– http://medicaldictionary.thefreedictionary.com/Acute+Lymphangitis
• Armstrong, D. G. & Lavery. L. A. Diabetic Foot
Ulcers: Prevention, Diagnosis and Classification.
AAFP.
– http://www.aafp.org/afp/1998/0315/p1325.html
Resources
• Breast Cancer Treatment (PDQ®). National Cancer
Institute.
– http://www.cancer.gov/cancertopics/pdq/treatment/breast
/Patient/page1
• Characteristics of Arterial Ulcers. Wound
Educators. YouTube.
– http://www.youtube.com/watch?v~QDbknssi5H4&feature
~related
• Common Benign Growths. Dermatology. Cleveland
Clinic.
– http://www.clevelandclinicmeded.com/medicalpubs/disea
semanagement/dermatology/common-benign-growths/
Resources
• Cutaneous Lupus Erythematosus. Family Practice
Notebook.
– http://www.fpnotebook.com/rheum/Derm/CtnsLpsEryth
mts.htm
• Evaluation of an Acute Wound. Chapter 6.
– http://practicalplasticsurgery.org/docs/Practical_06.pdf
• Gunshot Wounds. Chapter 7.
– http://practicalplasticsurgery.org/docs/Practical_07.pdf
Resources
• Gun Shot Wounds. Wheeless' Textbook of Orthopaedics.
Duke Orthopedics.
– http://www.wheelessonline.com/ortho/gun_shot_wounds
• Lymphadenitis. Medical Dictionary Article.
– http://medical-dictionary.thefreedictionary.com/lymphadenitis
• Practical Plastic Surgery.
– http://practicalplasticsurgery.org/the-book/
Resources
• Peripheral Neuropathy Fact Sheet. NINDS.
– http://www.ninds.nih.gov/disorders/peripheralneuropathy/
detail_peripheralneuropathy.htm
• Rashes: MedlinePlus Medical Encyclopedia.
– http://www.nlm.nih.gov/medlineplus/ency/article/003220.
htm
Resources
• Rose, L. C. Recognizing Neoplastic Skin Lesions:
A Photo Guide. Am Fam Physician. 1998 Sep 15:
58 (4): 873-884.
– http://www.aafp.org/afp/1998/0915/p873.html
• Skin Lesions. Article. Medical Dictionary.
– http://medicaldictionary.thefreedictionary.com/Skin+Lesions
• ICD-9-CM Coordination and Maintenance
Committee Meeting December 6, 2002
– http://www.cdc.gov/nchs/data/icd9/agendadec02.pdf
ILEMten@gmail.com