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Inpatient wound care: Bad news for Jack

HIM-HIPAA Insider, November 25, 2013

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Jack is back in to Stitch ‘Em Up Hospital for inpatient wound care.

Dr. Carver first diagnoses Jack with a fungal infection of the skin due to Podosphaera xanthii. When we look up infection in the ICD-10-CM Alphabetic Index, we find quite a list of potential codes. We know Jack has a skin infection, so if we go to Infection, Skin, we find an entry for “due to fungus.” We actually have two choices:

• B36.8, other specified superficial mycoses
• B36.9, superficial mycosis, unspecified

Since we know the causative organism, we would use B36.8. Remember that other specified is not the same as unspecified. We know the cause, we just don’t have a code for it. Some antibiotics should clear that right up.

Sadly, that is not the extent of Jack’s woes. Dr. Carver also diagnoses him with gangrenous cellulitis, an infection of soft tissue that produces extensive tissue necrosis and local vascular occlusions. Basically, Jack’s rotting from the inside.

If we look up cellulitis, gangrene in the ICD-10-CM Alphabetic Index, we are directed to Gangrene. However, gangrene does not list cellulitis as one of the sub-terms. The main code for gangrene is I96 (gangrene, not elsewhere classified). When we look that up in the Tabular List, we find gangrenous cellulitis listed under I96.

Dr. Carver also documents gangrene of the abdominal wall, which also maps to code I96.

Dr. Carver determines that Jack needs some excisional debridement to remove the gangrene so he can return to health.

In ICD-9-CM procedure coding, we would code excisional debridement using 86.22. How would we code it in ICD-10-PCS?

In order to get to the correct ICD-10-PCS table, we need to know the section, body system, and root operation. Section is easy. We know we are coding for a surgical procedure, which gives us an initial character of 0 (zero, not a capital O).

Let’s skip the body system for a minute and figure out which root operation we’re going to use. When you look up debridement in the ICD-10-PCS Alphabetic Index, you find two choices:

• Excisional, see Excision
• Non-excisional, see Extraction

We need to do a little investigating in Dr. Carver’s operative report to find out exactly what she did, so we know whether we’re coding excisional or non-excisional debridement.

Excisional debridement involves removing or cutting away devitalized tissue, necrosis, or slough. It is always a surgical procedure. Physicians use a recognized sharp instrument, such as a cutting curette, laser, scissors, or scalpel, to perform the excisional debridement.

Dr. Carver documents removal of devitalized tissue using a scalpel, so we are coding an excisional debridement.

On to the body system. Where specifically is Jack’s gangrene? Hopefully, Dr. Carver is very specific in her documentation, otherwise we’ll need to query.

We know some of the gangrene is located in the abdominal wall. ICD-10-PCS classifies the abdominal wall as a general anatomical region, which leads us to table 0WB.

Abdominal wall gives us a fourth character of F.

Now we need the approach. We have three choices:

• Open (0)
• Percutaneous (3)
• Percutaneous endoscopic (4)

Because of the extent of Jack’s abdominal gangrene, Dr. Carver elects an open approach. We have no device choice, which makes the sixth character Z. Our final character can be either X (diagnostic) or Z (no qualifier).

For Dr. Carver’s excisional debridement of Jack’s abdominal gangrene, our code is 0WBF0ZZ.

What about the rest of the debridements? Again, we need to know where exactly Dr. Carver is performing the debridements, as well as how deep the debridements are.

ICD-10-PCS guidelines state that an excisional debridement that includes skin, subcutaneous tissue, and muscle is coded to the muscle body part.

Dr. Carver documents the following debridements:

• 13 sq cm of the left quadriceps, percutaneous
• 9 sq cm of the right flexor pollicis longus and pronator quadratus, percutaneous
• 10 sq cm of subcutaneous tissue in the right lower leg, percutaneous
• 8 sq cm of dermis on the scalp, external approach

For each debridement, we need a specific code. Each one will vary based on the body system, the body part, and the approach. All of the codes will include the same section, root operation, device, and qualifier.

If you don’t know where the flexor pollicis longus and pronator quadratus muscles are, check the body part guide in the back of your ICD-10-PCS Manual (For the record, they are arm muscles).

• 0KBR3ZZ, excision of left upper leg muscle, percutaneous approach
• 0KB93ZZ, excision of right lower arm and wrist muscle, percutaneous approach
• 0JBN3ZZ, excision of right lower leg subcutaneous tissue and fascia, percutaneous approach
• 0HB0XZZ, excision of scalp skin, external approach

Hopefully, Dr. Carver excised all of the dead tissue and Jack will soon be on the mend.

This article originally appeared on HCPro’s ICD-10 Trainer blog.

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