Pressure ulcers (also called pressure sores or bed sores) are areas of skin that break down when you stay in one position for too long without shifting your weight. Depending on how a physician treats the ulcer will depend on how it is coded and billed. This article will address the formation of pressure ulcers, treatment of pressure ulcers, and coding of pressure ulcers.
Pressure Ulcers
A pressure ulcer starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater. The most common places for pressure ulcers are over bony prominences (bones close to the skin) like the elbow, heels, hips, ankles, shoulders, back, and the back of the head. Anatomically, the buttock region is by far the most common area for pressure sores to develop. These account for over 70% of all occurrences, with sacral (46%) and ischial (26%) locations being most common.
These factors increase the risk for pressure ulcers:
- Being bedridden or in a wheelchair
- Fragile skin
- Having a chronic condition that prevents areas of the body from receiving proper blood flow (diabetes or vascular disease)
- Inability to move certain parts of your body without assistance, such as after spinal or brain injury or if you have a neuromuscular disease (like multiple sclerosis)
- Malnourishment
- Mental disability from conditions such as Alzheimer's disease -- the patient may not be able to properly prevent or treat pressure ulcers
- Older age
- Urinary incontinence or bowel incontinence
The National Pressure Ulcer Advisory Panel (NPUAP) has developed illustrations of the stages of pressure ulcers (Stage I-IV). NPUAP updated the stages of pressure ulcers in 2007 and these stages are commonly cited in references and in lectures.
Stage I:
Intact skin with non-blanchable (does not turn white) redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Stage II:
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Stage III:
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage IV:
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Unstageable:
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Treatment of Pressure Ulcers
Pressure reduction is a frontline defense against pressure ulcers. Pressure reduction is accomplished by careful positioning of the patient and using protective devices. Bedbound patients are normally turned every two hours to prevent pressure from building up. Chair bound patients are normally repositioned every hour and should change positions on their own every 15 minutes for optimal results. Protective padding and air mattresses are also utilized in an attempt to keep pressure ulcers from forming.
Debridement of the pressure ulcer may become necessary to remove any dead tissue from the ulcer site and to promote healing. There are four major debridement techniques: autolytic, chemical, mechanical, and surgical. Autolytic debridement uses synthetic dressings to facilitate digestion of dead tissues by enzymes normally present in the wound fluids. Chemical debridement makes use of certain enzymes and other compounds to dissolve necrotic tissue. In mechanical debridement, a saline-moistened dressing is allowed to dry overnight and adhere to the dead tissue. When the dressing is removed, the dead tissue is pulled away too. It is the oldest, and most painful, methods of debridement. Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other instrument to cut necrotic tissue from a wound. It is the quickest and most efficient method of debridement.
Coding Pressure Ulcers
From an ICD-9 standpoint, pressure ulcers usually will have two codes: one for the site of the pressure ulcer, and one for the stage (defined above). The code range for pressure ulcers is 707.00-707.09 for the site. The code range for the stage of pressure ulcer is 707.20-707.25. As an example, a Stage IV pressure ulcer of the Sacrum would be coded as 707.03, 707.24. The site of the pressure is always coded first as under the 707.0 category the guidelines state to "Use additional code to identify pressure ulcer stage ", and under the 707.2 category the guidelines state to "Code first site of pressure ulcer ".
From a CPT perspective, there is a special group of codes for surgical excision of pressure ulcers. The code range is 15920-15999. The codes are specific to site, type of closure, and whether or not bone was removed (ostectomy). One reason the type of closure is important is that sometimes the wound is not closed. If the ulcer is not closed at the time of excision, it is considered a debridement and would be coded using the 11040-11044 set of CPT codes. The other reason is that if a flap or skin graft is used to close the ulcer, then additional coding is allowed. In the Professional Edition 2010 CPT manual, if you look under code 15946, for example, it states, "For repair of defect using muscle or myocutaneous flap, use code(s) 15734 and/or 15738 in addition to 15946. For repair of defect using split skin graft, use codes 15100 and/or 15101 in addition to 15946. " So, watch for additional coding opportunities to ensure full reimbursement of the physicians work.
To wrap up, from a coding perspective, a coder would need to know location of the pressure ulcer, the stage of pressure ulcer (for ICD-9), the type of closure (if any), and whether or not an ostectomy was performed. I hope this article has helped with your understanding of the causes, treatments, and coding of pressure ulcers.
