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ICD-9 Coding for Skin Wounds, Ulcer, Abscesses and Cellulitis

October 20, 2019

Q: [Integumentary ICD-9 Skin Issues] Can you
please discuss ICD-9 coding for skin wounds, ulcer, abscesses, infections, and cellulitis?
I am looking to clarify the difference between wound and other types of skin issues previously
listed.” Well, I am going to give you a little heads-up,
guys, you know I kind of like pictures, so I did go pull some pictures. JoAnne: Thank you Alicia! Alicia: I am just telling you now nothing
too bad. My children came in throughout the day and said,
“What are you looking at?” but they are so used to me looking at these stuff. Boyyd: Am I going to be able to post this
to YouTube? Alicia: Yeah! I do not think, yeah. One of
my favorite educational doctors on YouTube got, someone turned in or whatever they do
to him because he said this stuff was too gross to see. Again, they wanted some clarifications and
it is very confusing. Some of these terms they kind of play into each other but you
want to make sure that you understand the differences and I give a little example of
some ICD-9 coding that would be involved in that. A: Wounds – First off, you need to know
whenever you are doing wounds, the primary thing you are going to think about the location.
Where is the wound at? What is the dictionary definition of a wound, it would be, “an
injury to living tissue caused by a cut, blow, or other impact typically one in which the
skin is cut or broken.” They’ve got “cut, gash, laceration, tear, slash.” This is incised, a cut to the palm of the
hand. This is a no-jagged edges, it’s straight, this would be considered a laceration, and
he is probably going to get some stitches in there and antibiotic. To go look at those codes, and I didn’t
do them on ICD-10, I should have. Open wound of hand, your choices are going to be: open
wound of hand, open wound hand complicated, or open wound hand with tendon involvement.
There is going to be 882 and you have got (.0), (.1), or (.2). This obviously is going
to be an 882.0 because there is no complication here. There are no jagged edges, you do not
have to debride anything, and they are probably just going to clean it and just do a blanket
stitch and stitch that thing up. Again, complicated, the doctor will tell you
it is complicated, it is more involved than just stitching up. They may have to realign
the edges if it is real jagged because some of that tissue may not have good blood supply
so they will cut away some of the skin and debride some stuff, then that would be complicated.
Or, if it was so deep and it could be this small of a cut, but if it went in so deep
like a stabbing wound, then again a tendon could be involved and then they have to go
in and sew that back together. There might be surgery involved or you might not be able
to ever move your thumb again. Tendon and ligaments are important to know. That will
be in your documentation. You do not have to guess at this stuff. Ulcers – Again, very important the location
and often the stage but there are so many kinds of ulcers, and so I took the three different
ones here. It is “an open sore on an external or internal surface of the body caused by
a break in the skin or mucous membrane that fails to heal.” This is
actually the stomach or the esophagus and I do not know if you can see that. There is
the ulcer, you can even see it was bleeding a little bit. This would be, I just decided
it was an esophageal ulcer but your esophagus really does not look quite like that. That
is more into getting into the stomach. That would be 530.21 – ulcer of the esophagus
with bleeding. And they want to know is it bleeding or not bleeding, especially internally,
and the way they know that is either they have, they call it coffee ground emesis. It
looks like you are throwing up coffee grounds and that is blood, or it passes in your stool,
it’s very, very dark. They will ask about that. This is actually an ulcer. When I had braces
and I got hit in the mouth, you get these little ulcers and stuff or little cold sore-type
ulcers, and some people just have enough of these herpes complex thing that is not the
bad herpes that you think of, but they are just in your system and some people are predestined
to get these more often than others. Again, you get any type of a little cut or nick inside
there and it will ulcerate before it heals; but the inside of your mouth heals very, very
quickly. The next one would be like a pressure ulcer,
and these are the ones where location as well as stage is very, very important. An example
of those would be ulcer of other part of the foot that is what this would be, 707.15 for
this ulcer. Or you could have one of the back which I did not get a picture of the ones
for the back because those are pretty gross, but that would be 707.03 pressure ulcer of
lower back. But note that when you have an ulcer of the foot or the back, these pressure
ulcers or decubitus ulcers they are going to want to know the stage, and you will always
see this indication: “Use additional code to identify pressure ulcer stage (707.20 – 707.25).”
So it is very important with this type of an ulcer that the stage is in there and the
physician will put the stage. They are trained to do that. That information will be included. Abscesses – Is classified as “a swollen
area within body tissue containing an accumulation of pus.” That is really all it is. It is
an accumulation of white blood cells. You have got a little problem, let’s say he’s
got a little problem here on his jaw and it could have started out like an ingrown hair.
It could be anything, and it got a little infection in there, kind of closed over but
the white blood cells started accumulating just trying to kill this infection, so it
swells up under the skin and gets very, very painful. This would be a 682.0 – other cellulitis and
abscess to the face. Then it says: cheek external or chin. This is the code that I would have
used for that. Then it tells you to: “Use an additional code to identify the organism.”
Let’s say that they drain this. They’ll go and they will drain it, they will irrigate
it real good and try to get the infection out, and then they will swab it and send the
culture off, and they want to know what is it? If it’s a staph infection, the staphylococcus
it would be 041.1. When you do these, sometimes you won’t know
what the organism is right away because they had to go do a culture. Again, this would
be one from the hand. It could have been a bug bite. It could have been a little nick
or something but you get some staph in there or some other type of infection, like, MRSA
or something; then that is, the white blood cells are going to congregate and go to attack
that and it is going to be under the skin again. It is very, very painful, and you do
have to have an antibiotic. It is really, really bad. They will put you on IV antibiotic,
because this type of stuff can go septic if it is not taken care of. This redness, they
do not want that redness to start travelling up your arm. The 682 that is going to be abscesses that
are acute. Again, you are going to have to know another digit here, lymphangitis, except
for finger or toes, cellulitis and stuff. Cellulitis was one of the terms that were
asked about… infection is next. I told you about the staphylococcus, but there
is one that you hear about a lot that is kind of scary and we call it MRSA. That is M-R-S-A
but they call it MRSA. That is 041.12 and that is an infection and it says, “Infection
in condition classified elsewhere. It’s a Methicillin-resistant Staphylococcus aureus
and it is resistant to medication. MRSA is just out there. It is everywhere but
most of us have enough antibiotics. We do not really get, not everybody gets MRSA. However,
if they just cannot get it to heal, say you had this hand condition up here and it was
healing, it was looking pretty good and then it gets really bad again and they go in and
they swab it and now they say, “Oh that is MRSA. That is why it is not getting better.”
There are treatments for that but it is a big bad thing. Can you recover? Yeah, but
that is when you start going to wound care clinics and stuff like that, they want to
stay on top of it. What type of infections are there? Well, the
way they know what type of infection it is, is by the shape. They will go in and they
will do a culture. They will grow something and these are the different shapes that will
tell them what type of infection or bacteria is involved or a virus. They mentioned cellulitis and a lot of people
get cellulitis confused. Cellulitis is actually a bacterial skin infection, so it is on the
skin. That is how you know it is different. You will see it. It will be red, swollen,
it will be painful, and when you touch it, it’s hot to the skin and real tender. This is a child that has cellulitis. A hand,
you can see they often draw a line because it is very important they want to know if
it is spreading. That means it is getting worse, versus they want to see that pink going
away 24 hours later after you’ve been on antibiotics. Here is one on the inside of
the leg and see they were really paying attention to where that was at, for it to spread. One of my children, he had banged the back
of his heel, you know how you get caught in the door and it just really scuffed the back
of his foot up. He did not think anything of it, he ran around barefoot. And my mother-in-law
had noticed, a few days later she said, “Man, that is really red and swollen,” and I kept
thinking, “No, I think it is okay.” Then, the next day she said, “No, you better take
him in.” The red was going up the back of his leg and that is where you could have blood
poisoning, and sure enough, we got into the doctor and he said, “Yeah, this was starting
to look bad.” There was no pus involved or anything. It
didn’t really look like it was infected, but it was cellulitis and you do not want
those lines. The old (inaudible) , you don’t want it going towards your heart. The limbs
will come in and up the legs. Those for cellulitis would be 682, and notice
that’s same as the abscess. “Other cellulitis and abscess,” so that is included, “leg
except foot,” so that’s what we would classify this picture. The next one, “other
cellulitis and abscess, hand, except fingers and thumb,” and that is what you got there.
They want you to identify if there is an organism and they give you a suggestion of 041.1, staphylococcus,
but it could be MRSA; so often you are going to have two codes and you may not know what
that is, yet. That is the difference between cellulitis
infection that causes these type of things. An abscess is an infection that is under the
skin and growing, ulcers, that type of wound, or another type of wound, which is just breaking,
a lesion or cutting of the skin. Wound can be several types of injuries but the skin
is broken. Think of it that way. That was a fun one. I got to give you pictures.

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