Understanding Coding & Documentation
Requirements for ICD 10:
Coding Wounds & Integumentary
System
June 12, 2014
2:00 pm – 3:30 pm
PRESENTER:
JOAN L. USHER, BS, RHIA, COS-C, ACE
AHIMA Approved ICD-10-CM Trainer
JLU HEALTH RECORD SYSTEMS
TEL: (781) 829-9632 FAX: (781) 829-9636
www.jluhealth.com
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LEARNING OBJECTIVES:



Review how to code the specific types of wounds
 Trauma Wounds – requiring 7th character and
laterality
 Pressure Ulcers – requiring location and stage in one
code
 Non-pressure ulcers – requiring location and depth in
one code
Review the importance of assigning laterality
Review of the Official Coding Guidelines for Ulcers
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1
Injuries
S00-S99
Trauma Wounds
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Definitions Wounds





Laceration: caused by a jagged, irregular, or blunt edge resulting in
tearing of soft tissues. Bleeding may be heavy, and the wound may
be deep.
Puncture: a piercing wound that causes a small hole in the tissues.
Although the external wound is minor, there may be a more serious
internal injury.
Avulsion: a forcible tearing or partial tearing away of tissues typically
caused by gunshot wounds, explosions, and animal bites.
Abrasion: caused by rubbing or scraping the skin against a rough or
hard surface. Typically, the wound is superficial, and the bleeding is
limited.
Injury: internal, superficial
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2
Superficial Injury

Superficial Injury (other)
Contusion
 Abrasion
 Blister
 External constriction
 Superficial foreign body
 Insect bite (non-venomous)

 Unspecified
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WOUNDS – Determine the origin

Was the wound a result of a trauma/injury?
 Code to an open wound (S code)
 Wound due to an injury/fall
 Accidental injury due to a sharp object

Was the wound an outcome of surgery?
Aftercare
 Code to aftercare Z48.3, Z48.81 Expected post surgical incision/wound
 Encounter for change or removal of surgical dressing Z48.01

Is the primary diagnosis an ulcer?
 Pressure ulcer: L89.-code by location, laterality, stage
 Stasis ulcer (venous insufficiency) I83.-, I87. Diabetic ulcer: see Diabetes, by type, skin ulcer
 Type 1 E10.622, Type 2 E11.622
 Specific code for foot ulcer E11.621
 Lower extremity (non-pressure) ulcer: L97. Location, laterality, depth
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Trauma
Type of
Ulcer
6
3
Traumatic Wounds



Wounds are classified in the Injury Chapter (S00.-T88)
 Chapter is organized by body part – least severe to most
severe
 Require 7th character to identify the episode
 A-initial D-subsequent S-sequela
Traumatic wounds (open wound)
 Skin tears and lacerations code
 Requiring treatment or dressing
 S51.- Open wound elbow & forearm
 Open wound of right elbow S51.001Late Effects of Open Wound is utilized for non-surgical wounds
(traumatic wounds or injuries), which are not healing.
 Late Effect: A residual effect (condition produced) after an
acute phase of an illness or injury has terminated
 Code by the body part/location of the wound
 Require 7th character to identify the episode
 S-sequela
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Injuries Elbow & forearm
Include:










Superficial Injuries S50
Open wounds S51
Fractures S52
Dislocation S53
Injury of nerves S54
Injury of blood vessels S55
Injury of muscle fascia & tendon S56
Crushing Injury S57
Traumatic Amputation S58
Other unspecified injury S59
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Increasing
Acuity
Severity
8
4
Laterality

Right, Left, Bilateral, Unspecified
 An
unspecified side code is also provided
should the side not be identified in the
medical record.

For bilateral sites, the final character of the
codes in the ICD-10-CM indicates
laterality.
 If
no bilateral code is provided and the
condition is bilateral, assign separate codes
for both the right and left side.
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Anatomy of a Wound Code
Characters1-3 Type of injury by body site
Character 4
Specific body part
Character 5
Type of Wound
Character 6
Laterality
Character 7
Encounter
ICD-10-CM Format
Category
Etiology, Anatomical Site,
Severity
Alpha
X
X
X
X
X
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X
Extension
X
10
5
Wounds, Open


ICD-9
Same code


 Laceration
ICD-10
Different 5th character
in the code
 Puncture
 Laceration
 Bite
 Puncture
(human)
wound
 Bite
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Infected Open Wounds




ICD-9
Codes to wound,
“complicated”
Changes the 4th digit
Example: Infected
shoulder wound,
 complicated
 880.10




ICD-10
Code also any
associated wound
infection
Example: Infected
right shoulder wound
S41.001D
Infection MRSA
B95.62
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6
Foreign Body in Open
Wounds
 ICD-10

ICD-9


Codes to wound,
“complicated”




Primary infection, Foreign
body, delayed healing
Changes the 4th digit
Example: shoulder
laceration, with imbedded
gravel


complicated
880.10


Codes to either laceration with
or without foreign body
Codes to either puncture
wound with or without foreign
body
Example: Right shoulder
laceration with foreign body
S41.021D
Example: Right shoulder
puncture wound with foreign
body S41.041D
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Build a Code:
Puncture wound to left foot without
foreign body
ICD-10-CM Format
Category
Etiology, Anatomical Site, Extension
Severity
Alpha
X
X
X
S
9
1
S
9
1
3
S
9
1
S
9
1
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X
X
X
3
3
2
3
3
2
X
D
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Test Your Knowledge

While ambulating with walker, Mary caught
her heel on a sharp corner of the coffee
table which resulted in a 2 cm puncture
wound of the left heel with a deep
embedded splinter of wood.
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Answer
1.
2.
S91.342D Puncture, heel, left, with
foreign body
W45.8xxD Foreign body entering through
skin, splinter
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8
Test Your Knowledge

Sally fell resulting in an abrasion of left
knee and upon fall hit right shin on coffee
table with a 3 cm skin tear.
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Answers
1.
2.
3.
S81.811 Skin Tear right shin
S80.212D Abrasion left knee
W18. 09xD Fall, striking against an object
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9
Cellulitis of toe with Open
Wound


Code wound
Code cellulitis

L03.03 Cellulitis of toe
L03.031 Cellulitis of right toe
L03.032 Cellulitis of left toe
L03.039 Cellulitis of unspecified toe

L03.04 Acute lymphangitis of toe







Hangnail with lymphangitis of toe
L03.041 Acute lymphangitis of right toe
L03.042 Acute lymphangitis of left toe
L03.049 Acute lymphangitis of
unspecified toe
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Test Your Knowledge

John is admitted to home health with
cellulitis of the right arm and is receiving IV
antibiotics via PICC line with routine PICC
line maintenance. The MD ordered
antibiotics for two weeks.
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10
Answers
1.
2.
L03.113 Cellulitis, upper limb, arm, right
Z45.2 Admission for adjustment VAD
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Surgical Wounds



Routine wounds post
surgery
Code to Aftercare of
Body System
Z48.-


Complicated surgical
wounds
Code to
 Dehiscence
T81.31xD
 Post Operative Wound
Infection T81.4xxD
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11
Aftercare Following Surgery
Aftercare (see also Care) Z51.89
- following surgery (for) (on)
- - circulatory system Z48.812
- - delayed (planned)wound closure Z48.1
- - digestive system Z48.815
- - genitourinary system Z48.816
- - joint replacement Z47.1
- - neoplasm Z48.3
- - nervous system Z48.811
- - orthopedic NEC Z47.89
- - planned wound closure Z48.1
- - removal of internal fixation device Z47.2
- - respiratory system Z48.813
- - scoliosis Z47.82
- - sense organs Z48.810
- - skin and subcutaneous tissue Z48.817
- - specified body system
- - - circulatory Z48.812
- - - digestive Z48.815
- - - genitourinary Z48.816
- - - nervous Z48.811
- - - oral cavity Z48.814
- - - respiratory Z48.813
- - - sense organs Z48.810
- - - skin and subcutaneous tissue Z48.817
- - - teeth Z48.814
- - specified NEC Z48.89
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Test Your Knowledge
Mr. W was admitted to the hospital for
acute appendicitis and underwent an
appendectomy. He returns home for
assessment of the incision site. Mr. W
continues on his medication for
hypertension.
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12
Answers
Home Health Diagnosis
1. Z48.815 Encounter for surgical aftercare
following surgery on the digestive system
2. I10. Essential (primary) hypertension
Inpatient Diagnosis
1. K35.80 Unspecified acute appendicitis
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Surgical Wounds


Post-operative wound infection - If an infection develops post
operatively T81.4xxD Infection following a procedure
 Use additional code to identify infection
 Use additional code to identify severe sepsis if applicable
Disruption of Wound: (Dehiscence)
 T81.32x- Disruption of internal operation (surgical) wound
 Includes: fascia, muscle flap, tendon, deep disruption of
dehiscence of operation wound NOS
 T81.31x- Disruption of external operation (surgical) wound
 Includes: closure of: skin, subcutaneous tissue, full
thickness skin, superficial disruption of operative wound
 T81.30x- Wound disruption NOS
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13
Non-Healing Surgical
Wound

Non-Healing Surgical Wound: T81.89xD vs L76.82

WOCN Definition: Not healing
This guidance applies to surgical wounds closed by either primary
intention (i.e. approximated incisions) or secondary intention (i.e.
open surgical wounds)
 wound with 25% avascular tissue (eschar and/or slough) OR
 signs/symptoms of infection OR
 clean but non-granulating wound bed OR
 closed/hyperkeratotic wound edges OR
 persistent failure to improve despite appropriate comprehensive
wound management
After surgical wound has been epithelialized for 30 days = scar


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Test Your Knowledge
Mrs. A. was admitted to acute care facility
to undergo CABG due to CAD. Patient
returns home with S/P CABG x 3 with
autologous vein bypass graft and is
requiring daily care to chest incision site,
secondary due to dehiscence of operative
wound. She is a former smoker.
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14
Answers
1.
2.
3.
4.
T81.32xD Disruption of internal operation
(surgical) wound, not elsewhere classified,
initial encounter
Z95.1 Presence of aortocoronary bypass graft
I25.10 Atherosclerotic heart disease of native
coronary artery without angina pectoris
Z87.891 History tobacco use
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T81 Complications of
Procedures





Excludes 2:
Complications of transplanted organs
 T86.Complication of prosthetic devices, implants and grafts T82.-T85
 T84 Complications of internal orthopedic prosthetic devices,
implants & grafts
Intraoperative and post procedural complications of specific body
system
 D78.-, E36.- ,E89.-, G97.3-, G97.4-, H59.-, H59.3-, H95.2.-,
H95.3-, I97.4-, I97.5.-, J95.-, K91.-, L76.-, M96.-, N99.Ostomy complications
 J95.0-, K94.-, N99.5-
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Diseases of the Skin
& Subcutaneous
Tissue
L00-L99
Review coding guidelines for
ulcers
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Types of Ulcers

Pressure Ulcers L89.

Non-Pressure Ulcers L97

Also known as decubitus ulcers or bedsores, are localized injuries to the
skin and/or underlying tissue that usually occur over a bony prominence
as a result of pressure, or pressure in combination with shear and/or
friction.
Lower-limb ulceration are many different types of ulcers with several causes. The
most prevalent are those due to vascular disease, of which venous is the most
common, accounting for over two-thirds of all types of ulcers. There are also
many other causes for ulceration such as malignancy, infections, and skin, druginduced, and autoimmune diseases.
Stasis Ulcers I83- or I87
Venous ulcers (stasis ulcers, varicose ulcers) are wounds that are thought to
occur due to improper functioning of venous valves, usually of the legs (hence
leg ulcers). They are the major occurrence of chronic wounds, occurring in 70%
to 90% of leg ulcer cases. Venous ulcers develop mostly along the medial distal
leg, and can be very painful.
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Pressure Ulcer Stages

Codes from category L89, Pressure ulcer,
are combination codes that identify the site
of the pressure ulcer as well as the stage
of the ulcer
 Location
 Stage

Assign as many codes from category L89
as needed to identify all the pressure
ulcers of a patient
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Pressure Ulcers –
Unstageable


Assignment of the code for unstageable pressure ulcer
(L89.--0) should be based on the clinical documentation.
These codes are used for pressure ulcers whose stage
cannot be clinically determined
 ulcer is covered by eschar
 treated with a skin or muscle graft
 deep tissue injury (but not documented as due to
trauma)
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Pressure Ulcer
- pressure (pressure area) L89.9- - ankle L89.5- - back L89.1- - buttock L89.3- - coccyx L89.15- - contiguous site of back, buttock, hip L89.4- - elbow L89.04th character
- - face L89.81Location
- - head L89.81- - heel L89.6- - hip L89.2- - sacral region (tailbone) L89.15- - specified site NEC L89.89- - stage 1 (healing) (pre-ulcer skin changes limited to persistent focal edema)
- - - ankle L89.5- - - back L89.1- - - buttock L89.3- - - coccyx L89.15-
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Build A Code:
Pressure Ulcer, right hip, stage 3
ICD-10-CM Format
Category
Etiology, Anatomical Site, Extension
Severity
Alpha
X
X
X
X
X
L
8
9
2
L
8
9
2
1
L
8
9
2
1
X
X
3
36
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Test Your Knowledge
What does the following mean?

How do you code bilateral pressure ulcers
stage 3 of ankle?

L89.5--
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Answer
L89.513 Pressure ulcer ankle, right, stage 3
 L89.523 Pressure ulcer ankle, left, stage 3


There is no bilateral code available
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19
Test Your Knowledge
1.
2.
3.
4.
Pressure ulcer stage 2 left elbow
Pressure Ulcer stage 3 back
Pressure ulcer right upper back, stage 2
Pressure ulcer stage 4 to right buttock
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Answers
1.
2.
3.
4.
L89.022
L89.103
L89.112
L89.314
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L97 Non-pressure chronic ulcer
of lower limb, not elsewhere
classified

Code first any associated underlying condition, such as:
 any associated gangrene (I96)
 atherosclerosis of the lower extremities (I70.23-, I70.24-, I70.33-,
I70.34-, I70.43-, I70.44-, I70.53-,I70.54-, I70.63-, I70.64-, I70.73-,
I70.74-)
 chronic venous hypertension (I87.31-, I87.33-)
 diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621,
E10.622, E11.621, E11.622, E13.621,E13.622)
 postphlebitic syndrome (I87.01-, I87.03-)
 postthrombotic syndrome (I87.01-, I87.03-)
 varicose ulcer (I83.0-, I83.2-)
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Ulcer Lower Limb
lower limb (atrophic) (chronic) (neurogenic)
(perforating) (pyogenic) (trophic) (tropical)
L97.909
- - with
- - - bone necrosis L97.904
- - - exposed fat layer L97.902
- - - muscle necrosis L97.903
- - - skin breakdown only L97.901
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Unspecified Codes- Non
Pressure Ulcer
Unspecified Codes
 Non-pressure ulcer of
ankle



L97.309 Non-pressure
chronic ulcer of unspecified
ankle with unspecified
severity
More Specificity
 Non-pressure ulcer of left
ankle with fat layer
exposed L97.322
Missing laterality
Missing depth
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Non-Pressure Chronic Ulcer,
Ankle






L97.32 Non-pressure chronic ulcer of left ankle
L97.321 Non-pressure chronic ulcer of left ankle limited
to breakdown of skin
L97.322 Non-pressure chronic ulcer of left ankle with
fat layer exposed
L97.323 Non-pressure chronic ulcer of left ankle with
necrosis of muscle
L97.324 Non-pressure chronic ulcer of left ankle with
necrosis of bone
L97.329 Non-pressure chronic ulcer of left ankle with
unspecified severity
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22
Documentation for BMI, Non-pressure
Ulcers and Pressure Ulcer Stages


For the Body Mass Index (BMI), depth of non-pressure chronic
ulcers and pressure ulcer stage codes, code assignment may be
based on medical record documentation from clinicians who are not
the patient’s provider (i.e., physician or other qualified healthcare
practitioner legally accountable for establishing the patient’s
diagnosis), since this information is typically documented by other
clinicians involved in the care of the patient (e.g., a dietitian often
documents the BMI and nurses often documents the pressure ulcer
stages).
However, the associated diagnosis (such as overweight, obesity, or
pressure ulcer) must be documented by the patient’s provider. If
there is conflicting medical record documentation, either from the
same clinician or different clinicians, the patient’s attending provider
should be queried for clarification
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Build A Code:
Non- pressure Ulcer, right thigh,
with necrosis to the muscle
ICD-10-CM Format
Category
Etiology, Anatomical Site, Extension
Severity
Alpha
X
X
X
X
X
L
9
7
1
L
9
7
1
1
L
9
7
1
1
X
X
3
46
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Test Your Knowledge
1.
2.
3.
4.
Non-pressure ulcer left calf with skin
breakdown
Non-pressure ulcer right foot with muscle
necrosis
Non-pressure ulcer right midfoot with
bone necrosis
Diabetic ulcer of right toe with necrosis to
the bone
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Answers
1.
2.
3.
4.
L97.221
L97.513
L97.414
E11. 621, L97.514
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Stasis Ulcers M1330


Definition: An ulcer caused by inadequate venous
circulation in the area affected (usually lower legs). The
ulcer may have a moist, granulating wound bed, be
superficial, and have minimal to copious serous drainage.
Venous Peripheral Insufficiency I87.2
Use additional code for any associated ulceration
 Ulceration lower extremity L97.x


Varicose veins of the lower extremity with ulcer I83.0 Use additional code to identify severity of ulcer
 Ulceration lower extremity L97.x
 With ulcer & inflammation I83.2- -
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Stasis Ulcer
Ulcer,
stasis (venous) —see Varix, leg, with, ulcer
- - without varicose veins I87.2
Varix,
- with ulcer —see Varix, leg, with, ulcer, with inflammation
by site 183.0
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25
Test Your Knowledge
1.
2.
3.
Stasis ulcer of left calf with skin breakdown
Peripheral venous insufficiency
Varix with ulcer & inflammation of the right ankle
with skin breakdown
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Test Your Knowledge
Answers
1.
2.
3.
I87.2, L97.221
I87.2
I83.203, L97.311
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26
W73.xxxD
Accidental
Drowning
in OASIS
paperwork
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Questions????
Next Session
Musculoskeletal & Injuries
July 10, 2014
2:00 – 3:30PM EST
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27
ABOUT THE SPEAKER:
JOAN L. USHER, BS, RHIA, COS-C, ACE, President,
JLU Health Record Systems, Pembroke, MA







Degree in Health Information Management;
Certified OASIS and Coding Specialist
AHIMA Approved ICD-10-CM Trainer
Author, Rapid Reference Coding Guide, 2014
edition www.jluhealth.com © 2014
Author, Online ICD Coding Courses in
partnership with Libman Education 2012-2014
http://www.libmaneducation.com/healthcareeducation-training/home-health-coding/
Author, ICD-10 Essentials for Home Care:
Your Guide to Preparation & Implementation
www.hcmarketplace.com © 2011
Author, ICD-10 for Home Health: A Guide to
Medical Necessity and Payment
http://www.beaconhealth.org © 2014
Author/Editor Online E-Learning Coding
Courses: Home Health Diagnostic Coding;
Home Health Reimbursement Methods, Home
Health Documentation & Health Record
Requirements AHIMA www.ahimastore.org
© 2011








Contributing editor, Schraffenberger/Keuhn,
Effective Mgmt of Coding Services, AHIMA,
© 2009
Editor & Contributing Author, MaHIMA,
Medicio- Legal Guide to Health Record
Information, © 2004
Massachusetts Health Information
Management Association (MaHIMA), BOD
2004-2011
 President , 2006, under her leadership,
MA received 4 national awards from
AHIMA in Continuing Education
Programs, Support for Accredited HIM
Education Programs, Legislative
Advocacy and Electronic
Communications
 Co-Chair ICD-10 Task Force 2013-2014
Professional Achievement Award Recipient,
MaHIMA, 2008
American Health Information Management
Association (AHIMA) delegate 2002-2006
Taught ICD-9 coding for over 20 years and
has educated over 10,000 people nationwide
Home Care Alliance of MA, Board of Director
2012-2014, member QI Committee,
Facilitator ICD-10 Group 2013-2014
Hospice & Palliative Care Federation MA,
Board of Director 2008-2015, member QAPI
Committee
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www.jluhealth.com
2014 JLU Health Record Systems
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