Scenario: Mrs. C is a 69-year-old female referred to home care for skilled nursing wound care due to a Diabetic venous stasis ulcer of the left anterior lower leg.
| Code | Code description |
| M1021a: Z48.00 | Encounter for change or removal of nonsurgical wound dressing |
| M1023b: E11.51 | Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene |
| M1023c: I87.2 | Venous insufficiency (chronic) (peripheral) |
| M1023d: L97.829 | Non pressure chronic ulcer of other part of left lower leg with unspecified severity |
Rationale:
- Code Z48.00 primary — prior to the diabetes code — to capture the wound clinical grouping, since wound care is the focus of care.
- Next, list E11.51(Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene), because the wound is a diabetic venous stasis ulcer.
- Stasis ulcers are venous in nature but are assumed to be related to the DM unless otherwise stated and are captured by assigning I87.2 (Venous insufficiency (chronic) (peripheral)).
- Assign L97.829 (Non pressure chronic ulcer of other part of left lower leg with unspecified severity).
Note: Using this same scenario, if you assigned E11.51 as primary, this patient would fall into the MMTA - Endocrine primary diagnosis clinical group, and you would lose capturing the wound grouping as primary.