A 74-year-old male was referred to home care after hospitalization for exacerbation of severe venous stasis wounds resulting from venous hypertension and pitting edema from chronic systolic CHF. The wounds are located on the shin and calf of bilateral lower extremities and the clinician noted breakdown to the fat layer. The patient also has anxiety and hypertension confirmed in his medical history. Due to the difficulty with medical complications, the record indicates he was unable to obtain his second dose of a two-dose requirement to be fully vaccinated for COVID-19. The patient also has a diagnosis of alcoholic dementia with a history of alcohol abuse. The provider notes that the alcohol abuse is in remission.
|
Primary and Secondary Diagnoses |
|
|
M1021a: Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity |
I87.313 |
|
M1023b: Non-pressure chronic ulcer of left calf with fat layer exposed |
L97.222 |
|
M1023c: Non-pressure chronic ulcer of right calf with fat layer exposed |
L97.212 |
|
M1023d: Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed |
L97.822 |
|
M1023e: Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed |
L97.812 |
|
M1023f: Hypertensive heart disease with heart failure |
I11.0 |
Rationale:
I87.313 (Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity) should be the first assigned code in this scenario.
The focus of care is wound care of the multiple chronic ulcers. However, coding tips under L97 advise that when coding any non-pressure chronic ulcer classifiable to L97, the coder must first code the underlying cause of the ulcer if known. The scenario confirms venous hypertension as the cause of the ulcers. Since there are ulcers on both extremities and you have the option of using a bilateral code for the venous hypertension, I87.313 is the appropriate code choice.
Code the chronic ulcers next. Guidelines under L97 state that there are a few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (in other words, a physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). One of these exceptions covers coding for the depth of non-pressure chronic ulcers. The severity of the ulcer may be determined and coded based upon nursing documentation, but the diagnosis of the ulcer must come from the physician (patient’s provider). More than one L97 code may be used as long as there is no duplication of codes.
Add L97.222 (Non-pressure chronic ulcer of left calf with fat layer exposed) next to describe the location and severity of one of the wounds. There is no bilateral code for non-pressure chronic ulcers so each wound must have a different code.
Report L97.212 (Non-pressure chronic ulcer of right calf with fat layer exposed) for the wound to the other calf.
L97.822 (Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed) and L97.812 (Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed) capture the non-pressure chronic ulcers of the shin. The location of the ulcer is known and there is no code for shin ulcer, so this is the best code choice for this scenario.
I11.0 (Hypertensive heart disease with heart failure) is the correct choise for this patient’s hypertension since the coding guidelines include an assumed relationship between heart failure and hypertension.
Next, list I50.22 (Chronic systolic (congestive) heart failure) to follow the use additional code instruction at I11.0 and identify the heart failure.
Tip: Don’t include an additional code for edema because it is inherent to the disease process of congestive heart failure.
Add F10.188 (Alcohol abuse with other alcohol-induced disorder) next, followed by F02.80, (Dementia in other diseases classified elsewhere without behavioral disturbance).
ICD-10-CM does not provide a specific code for alcoholic dementia due to alcohol abuse. Q1 2022 Coding Clinic advised that when there is documentation that a patient’s memory impairment is due to alcohol abuse the coder should assign F10.188 (Alcohol abuse with other alcohol-induced disorder) and then F02.80 (Dementia in other diseases classified elsewhere without behavioral disturbance for alcoholic dementia).
F10.11 (Alcohol abuse, in remission) should also be added to capture the alcohol abuse.
Include F41.9 (Anxiety disorder, unspecified) to capture the confirmed anxiety diagnosis. Q1 2022 Coding Clinic advises that the coder cannot assume a relationship between alcohol abuse and/or dependence and anxiety.
Coding Clinic also states that although the Alphabetic Index links “alcohol with anxiety disorder” and “alcohol-induced anxiety disorder” is part of the code narrative, an alcohol-induced anxiety disorder is not the same as having anxiety and alcohol use/abuse/dependence.
Further, the Tabular list for codes in subcategory F10.18- (Alcohol abuse with other alcohol-induced disorders) indicates these codes are assigned for “alcohol-induced disorders” and that such a relationship must be documented by the provider. While chronic alcohol dependence, abuse or use may lead to an alcohol-induced anxiety disorder, there can be other underlying causes of anxiety. These conditions should not be linked unless the provider clearly documents a relationship.
Report Z28.311 (Partially vaccinated for COVID-19) to capture the under-immunized status of the patient since only one dose of the two-dose requirement was administered.
Lastly, include Z28.89 (Immunization not carried out for other reason). A use an additional code note instructs listing a code to identify the reason that the immunization was not carried out, if applicable. In this scenario, all you know is that the immunization was not completed due to difficulty with medical complications. You are not told that it is because of a medical contraindication, or you would have added a code from the Z28.0- series.
Additional diagnoses: I50.22 (Chronic systolic (congestive) heart failure), F10.188 (Alcohol abuse with other alcohol-induced disorder), F02.80 (Dementia in other diseases classified elsewhere without behavioral disturbance), F10.188 (Alcohol abuse with other alcohol-induced disorder), F02.80 (Dementia in other diseases classified elsewhere without behavioral disturbance), F10.11 (Alcohol abuse, in remission), F41.9 (Anxiety disorder, unspecified), Z28.311 (Partially vaccinated for COVID-19), Z28.89 (Immunization not carried out for other reason)