30 Questions
What should be done if the documentation does not provide information about the stage of a healing pressure ulcer?
Assign the appropriate code for unspecified stage
What should be done if a patient is admitted with a pressure ulcer that progresses to a higher stage during their stay?
Assign two separate codes - one for the site and stage on admission, and one for the highest stage reported
How should non-pressure ulcers that are documented as healing be coded?
Both a and b
What should be done if a patient is admitted with a non-pressure ulcer that progresses to a higher severity level during their stay?
Assign two separate codes - one for the site and severity on admission, and one for the highest severity level reported
How should the site of a musculoskeletal condition be coded if more than one bone, joint, or muscle is involved?
Use multiple codes to indicate the different sites involved
What should be done if a patient is admitted with a pressure ulcer that is completely healed at the time of admission?
No code is assigned
How should pressure-induced deep tissue damage or deep tissue pressure injury be coded?
Assign only the appropriate code for pressure-induced deep tissue damage
What should be done if a patient is admitted with a non-pressure ulcer that is completely healed at the time of admission?
No code is assigned
How should the site of a musculoskeletal condition be coded if the bone is affected at the upper or lower end, such as in avascular necrosis of bone or osteoporosis?
The site should be coded as the bone, not the joint
What should be done if the documentation is unclear as to whether the patient has a current (new) pressure ulcer or is being treated for a healing pressure ulcer?
Query the provider
Where should recurrent bone, joint or muscle conditions be coded?
Chapter 13
Which character is used for encounters after the patient has completed active treatment for a pathological fracture?
D
Which category should be used for coding osteoporosis without a current pathological fracture?
M81
How should a site be coded for osteoporosis without a current pathological fracture?
Site is not a component of the codes
If a patient with known osteoporosis suffers a fracture due to a minor fall or trauma, which category should be used for coding?
Category M80, Osteoporosis with current pathological fracture
What additional code should be used for patients with a history of osteoporosis fractures?
Z87.310, Personal history of (healed) osteoporosis fracture
Which chapter should be used to code an acute, current injury?
Chapter 19
If it is difficult to determine which code best describes a condition, what should be done?
Query the provider
Which character should be used for subsequent encounters for treatment of problems associated with the healing of a pathological fracture, such as malunions or nonunions?
Other 7th characters listed under each subcategory
How should care for complications of surgical treatment for fracture repairs during the healing or recovery phase be coded?
With the appropriate complication codes
What is the purpose of the pressure ulcer stage codes in category L89?
To classify the severity of the pressure ulcer
What is the difference between an unstageable pressure ulcer and an unspecified stage pressure ulcer?
An unstageable pressure ulcer is covered by eschar or has been treated with a skin or muscle graft, while an unspecified stage pressure ulcer has no documentation regarding the stage.
What should be done if the stage of an unstageable pressure ulcer is revealed after debridement?
Assign the code for the stage of the pressure ulcer that is revealed after debridement.
How should pressure ulcer stage codes be assigned when a patient has multiple pressure ulcers?
Assign a separate code for each pressure ulcer, including the stage of each ulcer.
What should be done if there is no documentation regarding the stage of a pressure ulcer?
Assign the code for an unspecified stage pressure ulcer.
What is the primary purpose of the pressure ulcer stage codes in category L89?
To identify the location and severity of the pressure ulcer.
Which of the following is a key characteristic of an unstageable pressure ulcer?
The ulcer is covered by eschar or has been treated with a skin or muscle graft.
What is the difference between an unstageable pressure ulcer and an unspecified stage pressure ulcer?
An unstageable pressure ulcer is one where the stage cannot be clinically determined, while an unspecified stage pressure ulcer is one where there is no documentation regarding the stage.
How should pressure ulcer stage codes be assigned when a patient has multiple pressure ulcers at different stages?
Assign a separate code for each pressure ulcer, including the stage of each ulcer.
What is the purpose of the pressure ulcer stage documentation by clinicians other than the patient's provider?
To provide additional information to the patient's provider about the pressure ulcer.
Test your knowledge on pressure ulcer stage codes and the classification of pressure ulcer severity based on stages 1-4, deep tissue pressure injury, and unstageable conditions. Identify pressure ulcer sites and stages using ICD-10-CM codes from category L89.
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