icd-10-cm diagnosis coding documentation tips … · how to properly use this grid to begin your...
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ICD-10-CM
www.todayswoundclinic.com30 April 2014 Today’s Wound Clinic®
As a reminder, refer to the original ICD-10-CM article in the October 2013 issue of Today’s Wound Clinic for instructions on how to properly use this grid to begin your documentation improvement program. Pointers: Remember to have any operative reports and documentation regarding the circumstances surrounding the injury readily available. Stay tuned for a new ICD-10-CM topic next month! n
ICD-10-CM DIAGNOSIS CODING DOCUMENTATION TIPS FOR VENOUS ULCERS
(CATEGORIES 170-174; 180.00-187.9)
ICD-10-CM Diagnosis Coding Documentation Tips for Venous Ulcers (Categories 170-174; 180.0-187.9)
Topic ICD-10-CM Code Ranges Documentation Tips/Guidelines
Requirement of a 7th Character for Trauma Codes
I70.201-I70.209: Atherosclerosis of extremities, unspecified
I70.231-I70.25: Atherosclerosis of extremities with ulceration
I70.262-I70.269: Atherosclerosis of the extremities with gangrene
Documentation should include specific site of thigh, calf, ankle, heel, midfoot, and other or unspecified, as well as any laterality. In addition, it is important to specify if the disease is with ulceration or gangrene.
Note: If ulcer is present, be sure to document depth and tissue involved with the ulcer. Coders will need to use additional codes to identify the specific ulcers.
Raynaud’s Syndrome
Peripheral Angiopathy in Diseases Classified Elsewhere (ie, Diabetes)
I73.00: Without gangreneI73.01: With gangrene
I79.1-I79.8: Plus code from diabetes (E08.51-E13.5)
Document with or without gangrene.
Be sure to document whether angiopathy is due to any underlying disease such as diabetes.
Arterial Embolisms I74.2: Upper extremityI74.3, I74.4: Lower extremityI74.5: Iliac artery
Specify site of embolism.
Phlebitis/Thrombophlebitis Lower Extremity Superficial Vessels
Phlebitis/Thrombophlebitis Lower Extremity Deep Vessels
I80.00-I80.03: Superficial vessels
I80.10-I80.299: Deep vessels
Document laterality.
Specify femoral, popliteal, tibial, other, unspecified, and laterality.
Varicose Veins Lower Extremity
I83.001-I83.029: With ulcer I82.201-I83.229: With ulcer and inflammationI83.811-I83.999: With other complication
Document thigh, calf, ankle, heel, midfoot, other, unspecified laterality. May use additional code for specific ulcer site.
Document any other complications, such as pain.
Postphlebitic Syndrome
I87.011-I87.019: With ulcer I87.031-I87.039: With ulcer and inflammation Document laterality. (May use additional code for specific ulcer site.)
Chronic Venous Hypertension
I87.311-I87.319: With ulcer I87.331-I87.339: With ulcer and inflammation I87.391-I87.399: With other specified complication Document laterality. (May use additional code for specific ulcer site.)
National Center for Health Statistics: www.cdc.gov/nchs/icd/icd10cm.htm
T he arrival of ICD-10-CM has been pushed back to at least October 2015, but Today’s Wound Clinic is still helping wound care practitioners get an early start on refining their documentation skills in preparation for the new coding format. In an effort to assist our readers as they continue to transition from ICD-9-CM, we’re offering an assortment of ICD-
10-CM documentation tools on particular disease states or medical conditions that have been developed to help improve documentation habits, which will be vital to the success of wound clinics in the ICD-10-CM environment. The tools may also contain information on coding guidelines when appropriate. This month’s tool covers the category of venous ulcers.
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