tci Part B Insider - 2012 Issue 10

Reader Question: 707.21 May Describe Complete Pressure Ulcer Dx

Question: An established elderly patient reported to our physician for inspection of sores on her back. The doctor diagnosed a stage I pressure ulcer on her lower back. How should I report this diagnosis?Answer: You should submit a pair of codes; one to represent the stage of the pressure ulcer, and another for the ulcer itself. On the claim, report the following:99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical...

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