Diabetic ulcer vs Pressure ulcer (injury)

jadeed@unionhospital.org

In ICD 9, we could code both a pressure ulcer & diabetic ulcer at the same site. With ICD 10, it didn't seem to be the case. Currently, there are several conditions that are automatically assumed as diabetic conditions/complications, including foot ulcers. Clinically, it is known that heel ulcers are commonly pressure ulcers in patients who may be bedbound.
In ICD 10, as CDI, is it considered leading to ask/query a physician to specify whether a heel ulcer is pressure vs non-pressure if they have either already called it a diabetic ulcer or if they just call it a heel ulcer, if an automatic link is already assumed?
Sorry if this has already been discussed, I did a quick search and didn't see any forum topic that already addressed this. Thanks for any input on this manner.

evanspx@sutterhealth.org

Hello:  I have not 'researched' this in Coding Clinic or the code books, but I'd agree it may be valid to query for a pressure ulcer in this situation since the location is the heel, a common site for a pressure ulcer.  I've not seen an ulcer of this site stated as a diabetic manifestation given most diabetic foot ulcers are of the digits.  I'd suggest you do search in your coding reference for ulcer of the heel as I recall AHA had a very good discussion of this topic.

jadeed@unionhospital.org

Thank you for your response.

Our coders feel that we should not query, (and they believe we are being leading by querying by asking " You documented a diabetic ulcer of the heel. Is the ulcer non-pressure vs pressure ulcer vs other?") especially when the doctor already called an ulcer a diabetic ulcer. due to:

Under Section I, General Coding Guidelines, 14 on the ICD 10 coding guidelines (Documentation for BMI, Depth of NOn-pressure ulcers, pressure ulcer stages, coma scale, and NIH stroke scale),
at the end, it states, "If there is conflicting medical record documentation, either from the same clinician or other clinicians, the pt's attending provider should be queried for clarification."

However, under the coding handbook rules:

Endocrine, Nutritional, and Metabolic Diseases Complications and Manifestations of Diabetes Mellitus

 Ulcers of the lower extremities, particularly the feet, are common complications of diabetes. The code for the diabetic foot ulcer complication (E08-E13 with .621) is assigned first, with an additional code of L97.4-, L97.5- indicating the specific site of the ulcer. If gangrene is present, code E08-E13 with .52 should be assigned as an additional code. It is important to recognize that not all ulcers in patients with diabetes are diabetic ulcers; if there is a question as to the relationship, the physician should be consulted. Other diabetic skin ulcers are coded to E08-E13 with .622 and an additional code to identify the site of the ulcer (L97.1-L97.9, L98.41-L98.49).

We(CDI) think we should be able to query the physician based on what I have highlighted and italicized above. Are we, as CDI, going out of our bounds to query when we feel that an ulcer may not be due to diabetes, but a different cause? (is there some rule against asking a provider when we believe their documentation is erroneous? We are both nurses here).

evanspx@sutterhealth.org

I have limited time right now, and need to revisit...however, I have not seen an ulcer of the HEEL termed a diabetic ulcer?   I can see why the coders may be concerned given the MD, however, has stated this is a 'diabetic ulcer of the heel'.  More later..gotta run.

lprescott1

diabetic ulcers and pressure ulcers clinically present much differently. An ulcer on the heel in most cases is pressure in etiology. If you have a wound care clinic or wound care nurse, i would suggest you provide education to both your coders & CDI about how different ulcers present and their specific treatment protocols. If the clinical indicators support the assignment of a more different code it should be clarified in query. The diagnosis of the type of ulcer is owned by the provider, but often providers will just write whatever the nurse calls it (unfortunate but true). i would suggest developing a protocol of nurses photographing all ulcers- they look different are found in different locations and will require different responses. The more educated coding and CDI are the more they will be able to support query (based on the evidence) to assign the most appropriate code. it is not leading if you have the indicators to support the question. 

evanspx@sutterhealth.org

Great suggestions...for this particular case, perhaps consult with the Wound Care Nurse and gain her/his perspective in regards to the etiology of this particular ulcer.  Then consider approaching the MD.  If Wound Care RN consultation indicates this is most like a pressure ulcer rather than diabetic, then please recall that a CDI can issue a query asking for confirmation of certain conditions  (see Best Practice Guidelines)... this could be accomplished ensuring the query offered a full range of compliant choices, to include diabetic ulcer as well as pressure.

jadeed@unionhospital.org

Ok. This really helps. This is the first time I have used this forum, I need to use this resource more often. Thank you, thank you for your input.

evanspx@sutterhealth.org

Welcome:  Suggest you use the 'search' option and view Best Practice Guidelines for more references found there pertaining to confirmation of conditions   (AHIMA/ACDIS Best Practice)  - could be helpful.  We have many, many, references and postings in the Library, and elsewhere citing references very helpful and germane.  I'd send you a link, but am midst of large Sepsis review myself. 

Paul Evans, RHIA, CCDS

proddy@clarionhospital.org

Interesting that this scenario came up today.  The resident said it was a pressure ulcer that was secondary to diabetes.  When I coded this out, it gave me a pressure and and non-pressure code, so I did query for which one: diabetic or pressure.  The attending said that diabetes literature indicates that any ulcer that is below the ankle is considered diabetic and she signed my query as diabetic foot ulcer.

evanspx@sutterhealth.org

I'd ask if we have a Wound Care nurse that may want to weight in on this issue - . 

P. Evans RHIA

proddy@clarionhospital.org

The wound care nurse had evaluated the patient and was calling it a pressure ulcer unstageable.  The attending called her during our discussion and the wound care nurse stated that the area of the heel that was affected was more often caused by pressure than diabetes.  After they discussed it at length though, the attending still said diabetic foot ulcer.