Health Information Management

Ask the expert: Assigning ICD-9 codes for pressure ulcers that progress from one stage to another

HIM Connection, October 28, 2008

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Q: An admitting physician in an acute care facility documents that a patient has a pressure ulcer on the right hip. During the admission, a nurse places the patient on a pressure relief mattress, evaluates the ulcer, and treats it with dressings. The nurse also frequently repositions the patient’s hip. The nurse’s note states that the hip ulcer progressed from a stage II to a stage III ulcer during the stay. What are the appropriate codes for the pressure ulcer?

A: The coder should assign only one code for the highest stage of a given ulcer during an admission per the ICD-9-CM Official Guidelines for Coding and Reporting. In this case, coders should report code 707.04 (pressure ulcer, hip) and code 707.23 (pressure ulcer, stage III).

Editor’s note: Gloryanne Bryant, RHIA, CCS, senior corporate director of coding and HIM compliance at Catholic Healthcare West in San Francisco, and Shannon E. McCall, RHIA, CCS, CPC-I, director of HIM and coding for HCPro, Inc., in Marblehead, MA, answered this question. The Q&A was excerpted from the October issue of Briefings on Coding Compliance Strategies. For more information, click here.

 



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