Chapter 12: Diseases of Skin and Subcutaneous Tissue
This week the focus is on Chapter 12 – Diseases of Skin and Subcutaneous Tissue. Like many chapters in ICD-10-CM, Chapter 12 has also been restructured. Diseases that are related in one way or another have been grouped together. In ICD-10-CM, Chapter 12 has 9 subchapters:
- L00 – L08 Infections of the skin and subcutaneous tissue
- L10 – L14 Bullous disorders
- L20 – L30 Dermatitis and eczema
- L40 – L45 Papulosquamous disorders
- L49 – L54 Urticaria and erythema
- L55 – L59 Radiation-related disorders of the skin and subcutaneous tissue
- L60 – L75 Disorders of skin appendages
- L76 Intraoperative and post-procedural complications of skin and subcutaneous tissue
- L80 – L99 Other disorders of the skin and subcutaneous tissue
There is greater specificity for many of the codes at the fourth, fifth and sixth character. Examples for Decubitus (Pressure) Ulcers would be:
- Specified site (elbow, hip, sacral, ankle, back, buttock, heel, other site, unspecified site and contiguous site of back, buttock and hip)
- Laterality (right, left)
- Severity (stage)
- Classified Stage 1 through Stage 4
- Unspecified Stage
Under ICD-9-CM 2 codes were required for Decubitus (Pressure) Ulcers. One code in ICD-10-CM provides:
- Ulcer site
- Additional code should be assigned and sequenced first for any associated Gangrene.
Different stages for Pressure Ulcers:
- Stage 1 – Wounds that only involve the upper epidermis. Pre-ulcer skin changes limited to persistent focal edema
- Stage 2 – A wound progressing toward the dermis. An abrasion, blister and partial skin loss involving epidermis and/or dermis.
- Stage 3 – A wound involving the subcutaneous tissue. Full skin loss involving damage or necrosis of subcutaneous tissue
- Stage 4 – A wound that goes down into the deeper tissue. Necrosis of soft tissue through to underlying muscle, tendon, or bone.
Coding Guidelines for healed or healing Pressure Ulcer
- Section I.C.12.a.4 – Pressure Ulcer documented as healed – no code would be assigned.
- Section I.C.12.a.5 – Pressure Ulcer documented as healing – assign 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 Ulcer, assign the appropriate code for Unspecified Stage.
Codes for Non-pressure Ulcers of the lower extremity also include site, laterality and severity (depth of the Ulcer). Examples of depth description for Chronic Ulcer of Right Ankle:
- Limited to breakdown of skin – L97.311
- With fat layer exposed – L97.312
- With necrosis of muscle – L97.313
- With necrosis of bone – L97.314 With unspecified severity – L97.319
Code first any associated underlying condition:
- Diabetic Ulcers
- Varicose Ulcer
- Chronic Venous Hypertension
- Post-phlebitic Syndrome
- Post-thrombotic Syndrome
In ICD-10-CM, terms “Dermatitis” and “Eczema” are used synonymously and interchangeably.
Radiation-related disorders of the skin and subcutaneous tissue now have their own subchapter. Previously in ICD-9-CM, Sunburns were listed in the Injury and Poisoning Chapter.
Anyone that has coded for any length of time knows the difference between Excisional and Non-excisional Debridement. This procedure has been under scrutiny by Medicare’s Recovery Auditors (RA previously known as RAC) due to the vast difference in DRG payment. One of the biggest problems is getting required documentation necessary to code Excisional Debridement. I hate to say, but ICD-10-PCS is not going to make it any easier.
Unlike ICD-9-CM, ICD-10-PCS codes according to root operations. Depending on the method used, a Debridement procedure could actually fit into two different root operations.
- Excision – Cutting out or off, without replacement, a portion of a body part.
- Excisional Debridement would fit this category
- Extraction – Pulling or stripping out or off all or a portion of a body part by the use of force.
- Non-excisional Debridement would fit this category
It is not enough for a physician to state they did an Excisional or Non-excisional Debridement. In order to code this procedure correctly there are documentation requirements that must be met.
- Condition requiring Debridement
- Location of wound
- Depth of Debridement – code to the deepest layer
- Method of Debridement (sloughing off tissue, cutting away etc.)
- Specific tissue removed (skin, bone, muscle etc.) – cutting back to pink tissue or removal of necrotic tissue does not help with coding the procedure. It does not describe the type of tissue removed.
- Instruments used (scissors, scalpel etc.)
Sometimes coders tend to think that the type of instrument alone is indicative as to the type of Debridement that was performed. This is not always true. A scalpel and/or scissors can be used to cut or scrap the wound. The physician should accurately describe in detail each bullet listed above in his/her procedure note.
Please note, there is no default code for Debridement. There must be precise documentation within the record and/or procedure note. Physicians should always be queried anytime documentation provided is not clear.
Article by Marsha Manning
This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.