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Provider Manual

Ulcers and Wounds

Last Updated on January 24, 2019

Ulcers, wounds and Hierarchical Category Condition Coding

Ulcers are associated with Hierarchical Category Condition Coding (HCC) while wounds are not. Please note that these two conditions are not synonymous.

  • Wounds are due to trauma or surgery.
  • Ulcers are caused by skin break down from pressure or other chronic conditions.

When known, it is important to document and code the condition that is causing an ulcer. Peripheral vascular disease (PVD), sometimes caused by diabetes or arteriosclerosis may be a cause of skin ulcer. It is important to be as specific as possible in documentation and coding to assure diagnostic accuracy and HCC coding.

Wounds - documentation for wounds should include the following:

  • Location
  • Complications if present

Ulcers - documentation for ulcers should include the following:

  • Location
  • Type of ulcer
    • Chronic or non-pressure
    • Pressure/Decubitus (include stage)
      • Stage I - Pressure pre-ulcer skin changes limited to persistent focal erythema
      • Stage II - Pressure ulcer with abrasion, blister, partial thickness skin loss involving epidermis and/or dermis
      • Stage III - Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue
      • Stage IV - Pressure ulcer with necrosis of soft tissues through to underlying muscle, tendon, or bone
      • Unstageable – ulcer covered by eschar or that has been treated with skin or other graft, or is documented as a deep tissue injury, but not due to trauma

Additional considerations - please document and code the following details when present:

  • Gangrene
  • Rest pain
  • Intermittent claudication
  • Cellulitis - Documentation should include location and organism
  • Amputation – Identify the specific extremity and level of amputation

Questions

Brenda Anderson
Revenue Management Educator
Security Health Plan 
Telephone: 715-221-9598
Email:rf.shp.risk.adjustmnt@securityhealth.org