July 31, 2012

Be Alert, Keep Up to Date: Changes are Coming for Rehabilitation Facilities


The Oct. 1, 2014 scheduled implementation of ICD-10-CM  will impact the coding process by introducing new codes and different methods of reporting certain diagnoses for patients receiving rehabilitation services.

Set to impact rehabilitation providers prior to the implementation date are several changes that do not always involve assignment of an ICD code, but could affect the processes and responsibilities of coders. These changes include reporting quality indicators, a revised Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI), the Post-Acute Care (PAC) demonstration project (with the completion of the CARE tool), and continued audits performed by multiple contractors hired by the government. It is important to keep abreast of these matters so they do not distract from the actual introduction of ICD-10.

Quality Indicators

The Aug. 5, 2011 IRF PPS final rule included a provision for a quality reporting program. The first two indicators to be implemented are for pressure ulcers and catheter-associated urinary tract infections (CAUTI), with reporting of such data to start on Oct. 1, 2012. As mentioned, the IRF PAI also has been revised and will be required for discharges occurring on or after that date. Items 48A–50D have been added to report data on unhealed pressure ulcers present upon admission and/or discharge. These items provide information about the pressure ulcer stage and whether there was a worsening in the ulcer status (or whether the ulcer healed). Information on CAUTI will not be reported on the IRF PAI, but it will be reported to the National Healthcare Safety Network. An IRF that decides not to report data for quality indicators will receive a 2 percent payment reduction starting in the 2014 fiscal year.

A pressure ulcer is an injury to the skin that can affect underlying tissue due to pressure. This also could be caused by shear and/or friction. A healed pressure ulcer is completely closed and covered with epithelialized tissue (or resurfaced with new skin). The highest stage of a pressure ulcer is reported until the ulcer is healed, even if the stage has improved prior to complete healing.

A pressure ulcer is considered to have worsened when a deeper level of tissue is involved and the stage has increased, i.e. going from Stage 2 to Stage 4.

There are three types of unstageable pressure ulcers:

  1. Deep-tissue injury – The skin is intact but there is discoloration of the skin and the injury affects soft tissue from pressure (so the depth of the injury cannot be determined).
  2. Slough and/or eschar – Slough and/or eschar cover the wound bed, or the base of the ulcer is otherwise covered and the depth of the injury cannot be determined.
  3. The dressing is non-removable.

Only data on stageable ulcers will be reported in IRF PAI items 48A–50D. ICD diagnostic codes for unstageable ulcers will be reported on the IRF PAI as the etiology, comorbid condition and/or complication.

Pressure Ulcer Stages

  • Stage 1 – Pressure-related, pre-ulcer skin changes are limited to persistent focal erythema.
  • Stage 2 – A shallow, open ulcer without slough (or an intact or ruptured blister).
  • Stage 3 – Full thickness tissue loss with subcutaneous fat possibly visible. Bond, tendon and/or muscle is not exposed. Slough could be present, but it does not cover the depth of the tissue loss.
  • Stage 4 – Full thickness tissue loss with bone, tendon and/or muscle exposed.

Identical ICD-9-CM and ICD-10-CM Guidelines

Both the site and the stage of the pressure ulcer need to be indicated when reporting such an injury. Code assignment generally is based on the physician’s documentation; however, code assignment for the stage of the pressure ulcer may be based on documentation by other clinicians involved in the patient’s care, (nurses, wound care specialists, etc.).

A code is not assigned for pressure ulcers documented as healed when the patient is admitted.  When documentation indicates that the pressure ulcer is healing, however, assign the appropriate code.

The codes for pressure ulcer stages define the severity of the ulcer as Stages I-IV (or unspecified and unstageable). When documentation does not provide information about the stage, assign code 707.20 for pressure ulcer, stage unspecified. Query the physician if documentation is unclear.

Again, a code for the highest documented stage should be assigned for a pressure ulcer that changes stages during the encounter.

ICD-9-CM code assignment for pressure ulcers requires two codes to describe the ulcer. A code from subcategory 707.0 identifies a pressure ulcer; the site is reported by the addition of a fifth digit. A code from subcategory 707.2 is required to report the stage.   The subcategory 707.0 code is sequenced first, and a code from subcategory 707.2 is reported as an additional diagnosis. Codes from the 707.2 subcategory are not assigned as the principal diagnosis.

Pressure ulcer stage codes should not be used to document other types of ulcers (like diabetic ulcers). Bilateral pressure ulcers with the same stage require one code for the site and one code for the stage. Bilateral pressure ulcers with different stages require one code for the site and a code for each stage. Multiple pressure ulcers with different sites and stages require a code for each different site and a code for each different stage.

ICD-10-CM codes for pressure ulcers are reported using combination codes from Category L89 that identify both site and stage. For bilateral or multiple pressure ulcers, it is necessary to assign multiple codes from Category L89 to report all of the ulcers.

The following ICD-10-CM codes describe a pressure ulcer of the left lower back:

L89.140     Pressure ulcer of left lower back, unstageable

L89.141     Pressure ulcer of left lower back, Stage 1

L89.142 Pressure ulcer of left lower back, Stage 2

L89.143  Pressure ulcer of left lower back, Stage 3

L89.144     Pressure ulcer of left lower back, Stage 4

L89.145 Pressure ulcer of left lower back, unspecified stage

Now would be a good time to educate physicians about what to include in their documentation (ulcer type, site, laterality and stage) to allow the coder to assign specific, accurate ICD-9-CM or ICD-10-CM codes.

About the Author

Patricia Trela, RHIA, is the director of HIM and rehabilitation services for Diskriter, Inc., a consulting firm offering integrated HIM rehabilitation consulting services, including HIM Interim management, IRF PPS compliance and education, coding and auditing support, dictation/transcription, and other solutions. Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP). Pat is an AHIMA Approved ICD-10-CM/PCS Trainer

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