A patient presented to wound care for debridement of a non-pressure chronic ulcer of the left lateral foot. The ulcer is documented as having visible skin breakdown prior to debridement and visible subcutaneous tissue without necrosis, post-debridement. In the outpatient setting, when a non-pressure chronic ulcer is documented as one severity pre-debridement and a different severity post-debridement, are one or two codes reported? If one, which severity level is assigned?
Assign only code, L97.512, Non-pressure chronic ulcer of other part of right foot with fat layer exposed. The subcutaneous tissue includes the fat layer. In the outpatient setting, codes are assigned to the highest degree of certainty for that encounter/visit, which is similar to coding the post-operative diagnosis.
Excisional debridement is typically done layer-by-layer to excise all devitalized tissue until all non-viable tissue has been removed. Therefore, following debridement, the true depth of the ulcer can appear deeper, as its full extent will be uncovered. This is not the same as ulcer progression and does not indicate the ulcer has progressed or worsened.
The guideline requiring two codes for ulcers that progress to another severity does not apply to the outpatient setting. The guideline was intended for inpatient hospital reporting to allow the most accurate reporting of the present on admission (POA) indicator in order to track the change in severity during an inpatient admission.