Chapter 12: Diseases of the skin and subcutaneous tissue (L00-L99)
A. Pressure ulcer / Decubitus ulcer / Pressure sore / Bedsore:
Category L89: Combination codes (Pressure ulcer as well as the stage of the ulcer).
Based on severity classified into Stage 1 – 4 (0- unstageable and
9-unspecified stage)
A) Unstageable – Stage cannot
be clinically determined.
B) Unspecified stage – No
info regarding the stage of the pressure ulcer
C) Stage 1 - (Pre-ulcer skin changes limited to focal edema)
D) Stage 2 - (Abrasion, blister, partial thickness skin loss of epidermis & Dermis
E) Stage 3 - (Full-thickness skin loss with necrosis of subcutaneous tissue)
F) Stage 4 - (Necrosis of underlying muscle/tendon or Bone)
Don’t assign codes for completely healed pressure ulcer. But we
can code for healing ulcers.
If the ulcer stage progress to one stage to next stage – Two separate codes should be assigned (One for site and stage at the time of admission and second code for the same ulcer site and the highest stage reported during the stage.
Assign all the codes based on the pressure ulcers patient has.
B. Non - Pressure ulcer
Don’t assign codes for completely healed Non-pressure ulcer. But we can code for healing ulcers.
If the ulcer stage progress to one stage to next stage – Two separate codes should be assigned (One for site and stage at the time of admission and second code for the same ulcer site and the highest stage reported during the stage.
Chapter 13: Diseases of Musculoskeletal system and connective
tissue (M00-M99)
A) Laterality and Site:
The site represents the bone, joints or the muscle.
Laterality represents the right and left side.
Multiple sites code is available if not; use multiple codes for
different sites.
Chapter 13 includes Chronic / Recurrent MusculoSkeletal conditions.
For Acute Traumatic / current injury of MusculoSkeletal conditions refer
Chapter 19 ("S" series codes).
B) 7th Character for Pathological Fracture codes
A – Active treatment / ED encounter / surgical treatment / E&M
a new patient.
D – Subsequent encounters, routine healing
G – Subsequent encounters, delayed healing
K – Subsequent encounters, nonunion
P – Subsequent encounters, malunion
S – Sequela
C) Osteoporosis – Is a systemic condition (All bones of the MS system
are affected)
-
Category M81 for Osteoporosis without
pathological fracture
-
Category M80 for osteoporosis with current pathological fracture
-
For H/o osteoporosis fractures – Z87.310,
& code from M81
A code from category M80 should be used for any patient with known
osteoporosis who suffers a fracture, even a minor fall or trauma that would not
usually, break a normal healthy bone.
Chapter 14: Disease of Genitourinary system (N00-N99)
A) CKD (Chronic kidney disease)
Codes are based on severity (Stage 1 to 5) Category N18
- Stage 2
(Mild)
- Stage 3
(Moderate)
- Stage 4
(Severe)
N18.6 is for ESRD (End-stage renal disease)
- If both CKD and ESRD
documented – Code N18.6
CKD with related DM / HTN sequencing – See the guidelines under
tabular list.
Ref Z94.0 – kidney transplant status. Any complication related to kidney transplant, refer complication section.
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