Q:  Can diabetic foot ulcer code be used with pressure ulcers?  The code book seems to indicate it would not.
A:  You cannot assume a link with pressure ulcers and diabetes.  Quick tip!

Q:  Regarding diabetic foot ulcer. I did see the quick tip, but ICD10 indicates foot ulcer would use additional code of L97.4-L97.5–which are non-pressure.  If the doctor documents the link, do we use L11.662 for other skin ulcer rather than foot ulcer–even if site is the foot?
A:  If the patient has a non-pressure ulcer of a site other than foot (ankle, leg) and diabetes, you may assume a link.  Use E11.622 + the code for the ulcer.

Q:  So, if documentation indicated DFU but it’s a pressure ulcer stage 2 of toe.  Both codes can be used.
A:  I would query the physician to clarify if the pressure ulcer is due to the diabetes.  They need to document a link and that does not tell me the conditions are linked.

Q:  If you had a doctor only document non-pressure wound, would you consider that an ulcer?
A:  No, I would not.  In order for it to be coded as an ulcer, they need to say ulcer somewhere in their documentation.

Q:  Can you tell me if a nurse completes documentation, does the physician need to co-sign the documentation?
A:  I’m assuming this means if a nurse (that is not legally responsible for establishing a diagnosis) sees the patient, can the physician co-sign the documentation so the coder and pull a diagnosis from it.

This is mentioned in a Coding Clinic dealing with malnutrition (I knew I saw it somewhere!).  Take a look at Coding Clinic First Quarter 2020 page 4.  The very last question asks if a physician can co-sign for a registered dietician.  It specifically states the inpatient setting, but I think their answer applies to outpatient as well.

“It is beyond the scope of the Editorial Advisory Board for Coding Clinic for ICD-10-CM/PCS to address this type of documentation issue. Your hospital may develop a facility-based policy to address whether documentation that is signed-off by the patient’s provider is allowed to be used for coding purposes.”

We would not consider a co-signature to be best practice.  An order from the provider would be best practice.

Q:  I always thought the 97597-97606 was used more by physical therapists. what does it take for a physician to bill those codes?
A: A physician can bill those codes – there is nothing that says they cannot. A physician, NPP, or therapist acting within their scope of practice and licensure may provide debridement services.

This is from CPT Assistant, August 2016, Volume 26, Issue 8, page 9 and may offer some insight:

Question: If the physician removes nonviable subcutaneous tissue using a selective, nonexcisional technique, which code should be reported: code 97597 for active wound management or code 11042 for a subcutaneous tissue debridement?

Answer: If the tissue removed is at a subcutaneous tissue level or deeper, it would be appropriate to report codes 11042-11047, depending on the deepest level of tissue removed and the total surface area of that depth removed. Multiple debridements at different depths should be added together and reported for a total surface area of each depth. However, if the tissue removed is only at the epidermis/dermis level, then it may be appropriate to report active wound care management codes (97597-97598), based on the total surface area removed.

Terri Reid, CCS, CCS-P, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer

Terri Reid, CCS, CCS-P, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer

Senior Coding Quality Auditor

Terri comes to Haugen Group with 20+ years of health information management experience in coding, auditing, and education.    She began her career coding emergency room records and wound care records where she helped develop coding and E/M protocols and met with the providers to help them improve their documentation.  Terri transitioned to an auditing role when she realized how much she enjoyed sharing her coding knowledge and experiences with other coders to help improve their skills and confidence. Terri brings her expertise in coding and auditing to the Haugen Consulting Group, having worked in previous roles leading and performing inpatient and outpatient coding audits.  She is passionate about learning new medical technology and how the disease process affects illnesses.

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