Question

1. Pressure ulcer of left heel, stage

1
Document the details of all the steps you took
to arrive at the final codes in each encoder.
Use the matrix below to evaluate each encoder as follows:
1) Record

Answer 1

The question is about coding a stage 1 pressure ulcer of the left heel using the ICD-10-CM system. It involves identifying the main term, referencing the index for the correct code, determining the stage, and noting any additional required codes.

Step-by-step explanation:

The question relates to the coding of a medical diagnosis, specifically a pressure ulcer of the left heel at stage 1. To accurately code this condition, one would refer to the ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) system. The steps involved in this process include:

• Identifying the main term in the diagnosis which is 'Pressure Ulcer'.
• Referencing the ICD-10-CM index to find the appropriate code that corresponds to a pressure ulcer located on the heel.
• Determining the specific stage of the pressure ulcer, which in this case is stage 1.
• Noting any additional codes that might be required to fully capture the clinical picture, such as laterality, which refers to the ulcer being on the left heel.

An example of the final ICD-10-CM code for a stage 1 pressure ulcer of the left heel might be L89.622 (Pressure ulcer of left heel, stage 1), though actual codes should always be verified in the most current coding manual or with an updated electronic coding tool.