Documentation and ICD10 Coding Jeffrey D Lehrman DPM

DFU Coding Type 2 diabetic patient with a chronic diabetic left lateral midfoot ulcer

• L 97. 423 • Non-pressure chronic ulcer of left heel and midfoot

• E 11. 621 • Type 2 diabetes mellitus with foot ulcer

DFU Coding Type 2 diabetic patient with chronic diabetic left foot lateral midfoot ulcer

DFU Documentation ICD 9 Chronic Midfoot ulcer in Type 2 diabetic ICD 10 Chronic,

ICD 9 vs. ICD 10 Initial encounter for a closed, nondisplaced, Left 2 nd

ICD 9 vs. ICD 10 • Initial encounter for a closed, nondisplaced, Left 2

ICD 9 vs. ICD 10 ICD 9 Fracture, phalanx, closed ICD 10 Closed, nondisplaced

$• Non-fracture care • A – initial encounter • D – subsequent encounter$

Sequela • Generally 2 codes need to be used in the following order: •

Sequela of Prior Ankle Sprain • Chronic left ankle instability following Grade III sprain

Sequela of Prior Ankle Sprain ICD-10 • M 24. 272 : Disorder of ligament,

Ligamentous Laxity Documentation ICD 9 Assessment: Ligamentous Laxity, Ankle ICD 10 Assessment: Ligamentous laxity,

Resources • Fife, C. E. , MD, FAAFP, CWS. The debridement dilemma returns, http:

Resources • Kesselman, P. , DPM. (September, 2013). Wound care billing update, Podiatry Management

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Documentation and ICD-10 Coding Jeffrey D. Lehrman, DPM, FASPS, MAPWCA APMA Coding Committee Expert Panelist, Codingline APMA MACRA Task Force Fellow, American Academy of Podiatric Practice Management Board of Directors, ASPS Board of Directors, APWCA Twitter: @Dr. Lehrman

DFU Coding Type 2 diabetic patient with a chronic diabetic left lateral midfoot ulcer with necrosis of muscle. The patient takes insulin on a daily basis.

• L 97. 423 • Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle

• E 11. 621 • Type 2 diabetes mellitus with foot ulcer

DFU Coding Type 2 diabetic patient with chronic diabetic left foot lateral midfoot ulcer with necrosis of muscle. The patient takes insulin on a daily basis. • E 11. 621 Type 2 diabetes mellitus with left foot ulcer • Z 79. 4 Long term (current) use of insulin • L 97. 423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle

DFU Documentation ICD 9 Chronic Midfoot ulcer in Type 2 diabetic ICD 10 Chronic, non-pressure left midfoot ulcer with necrosis of muscle in a type 2 diabetic with long term insulin use

ICD 9 vs. ICD 10 Initial encounter for a closed, nondisplaced, Left 2 nd toe proximal phalanx fracture ICD 9: 826. 0: Closed fracture of phalanx of foot ICD 9 documentation: X-ray shows fracture of phalanx Fracture, phalanx, closed

ICD 9 vs. ICD 10 • Initial encounter for a closed, nondisplaced, Left 2 nd toe proximal phalanx fracture • ICD 10: S 92. 515 A (nondisplaced fracture of proximal phalanx of left lesser toe(s), initial encounter for closed fracture • Documentation: • Closed, nondisplaced left 2 nd toe proximal phalanx fracture

ICD 9 vs. ICD 10 ICD 9 Fracture, phalanx, closed ICD 10 Closed, nondisplaced left 2 nd toe proximal phalanx fracture

$• Non-fracture care • A – initial encounter • D – subsequent encounter$

• Non-fracture care • A – initial encounter • D – subsequent encounter • S – sequela • Fracture care • • A – initial encounter for closed fracture B – initial encounter for open fracture D – subsequent encounter for normal healing fracture G – subsequent encounter for delayed healing fracture K – subsequent encounter for fracture with non-union P – subsequent encounter for fracture with mal-union S – sequela of fracture

Sequela • Generally 2 codes need to be used in the following order: • The condition or nature of the sequela is coded first. • Then the sequela code (what caused it) is second.

Sequela of Prior Ankle Sprain • Chronic left ankle instability following Grade III sprain of the calcaneofibular ligament six months prior. ICD – 9: 728. 4 – Ligamentous Laxity, Ankle

• M 24. 272

Sequela of Prior Ankle Sprain ICD-10 • M 24. 272 : Disorder of ligament, left ankle • S 93. 412 S : Sprain of calcaneofibular ligament of the left ankle, sequela

Ligamentous Laxity Documentation ICD 9 Assessment: Ligamentous Laxity, Ankle ICD 10 Assessment: Ligamentous laxity, left ankle as a result of a calcaneofibular ligament sprain

Thank You!!

Resources • Fife, C. E. , MD, FAAFP, CWS. The debridement dilemma returns, http: //www. todayswoundclinic. com/debridement -dilemma-returns? page=4, • National Government Services LCD for Debridement Services (L 27373), http: //apps. ngsmedicare. com/lcd/LCD_L 27373. h tm, • Just Coding News. (August 8, 2012). Differentiate between types of wound debridement. Just. Coding News: Outpatient • Novitas Local Coverage Determination (LCD): Wound Care (L 35139) https: //www. cms. gov/medicare -coverage-database/details/lcddetails. aspx? LCDId=35139&ver=40&Cntrctr. Selected=324 *1&Cntrctr=324&s=45&Doc. Type=Active&bc=Agg. AAAIAI AAAAA%3 d%3 d&

Resources • Kesselman, P. , DPM. (September, 2013). Wound care billing update, Podiatry Management pg 53 -59 • Le. Grand, M. , RN, MA CCS-P, CPC. , Changes in reporting wound débridement, http: //www. aaos. org/news/aaosnow/jun 11/managing 2. asp • CGS Medicare. (May 9, 2012). Documenting surgical debridement services – Measurements matter. https: //www. cgsmedicare. com/ohb/pubs/news/2012/0512/cope 18819. html, • Noridian Medicare, Wound care and debridement – Provided by physician, NPP or as incident-to services, https: //www. noridianmedicare. com/cgibin/coranto/viewnews. cgi? id=EFFZFZyy. Ep. AJGDJCx. K&tmpl=part_a _viewnews&style=part_ab_viewnews