Venous Leg Ulcer Formation
Venous leg ulcers develop as a result of abnormal vein function. When venous blood is not returned to the heart as it should be, it can accumulate in leg veins and cause pressure to the overlying skin. This can lead to a decrease in oxygen and nutrient delivery to this area of the skin, which can lead to skin break down and ulcer formation.
Chronic Venous Hypertension
Chronic venous hypertension, sometimes referred to as chronic venous insufficiency, is a result of blood pooling in the legs when venous return is not sufficient. This can cause swelling of the lower extremity, the feeling of tightness, itching, pain with activity, and brown-colored skin, particularly near the ankles.
Varicose Veins
Varicose veins are twisted, enlarged, and typically a darker color than a healthy vein. They often appear to be “bulging.” Varicose veins can cause the feeling of heaviness of the legs, burning, itching, throbbing, and changes in the color of the skin surrounding and overlying the varicosity.
Coding
Venous leg ulcers are often found in the presence of chronic venous hypertension or varicose veins. When a venous leg ulcer occurs in the presence of chronic venous hypertension, ICD-10-CM codes to consider include:
- I87.311 Chronic venous hypertension (idiopathic) with ulcer of right lower extremity
- I87.312 Chronic venous hypertension (idiopathic) with ulcer of left lower extremity
- I87.313 Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity
- I87.331 Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity
- I87.332 Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity
- I87.333 Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity
When a venous leg ulcer occurs in the presence of varicose veins, ICD-10-CM codes to consider include:
- I83.012 Varicose veins of right lower extremity with ulcer of calf
- I83.013 Varicose veins of right lower extremity with ulcer of ankle
- I83.022 Varicose veins of left lower extremity with ulcer of calf
- I83.023 Varicose veins of left lower extremity with ulcer of ankle
- I83.212 Varicose veins of right lower extremity with both ulcer of calf and inflammation
- I83.213 Varicose veins of right lower extremity with both ulcer of ankle and inflammation
- I83.222 Varicose veins of left lower extremity with both ulcer of calf and inflammation
- I83.223 Varicose veins of left lower extremity with both ulcer of ankle and inflammation
References
DISCLAIMER: The information provided here is intended to educate health care providers regarding compliance with ICD, CPT, and HCPCS coding. The information provided does not guarantee reimbursement and is accurate to the best of our knowledge at the time of this publication. Coding guidelines can change and we encourage you to stay up to date. The existence of a code does not guarantee payment.
Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Dr. Lehrman is a podiatrist practicing in Fort Collins, CO and operates Lehrman Consulting, LLC which provides consultation services regarding coding, compliance and documentation. Dr. Lehrman is a Certified Professional Coder and Certified Professional Medical Auditor. He serves as a staff liaison at the AMA CPT® Editorial Panel meetings where CPT codes are created, edited, and deleted. He is a Diplomate of the American Board of Foot and Ankle Surgery, Fellow of the American Society of Podiatric Surgeons, and is recognized as a “Master” by the American Professional Wound Care Association. Dr Lehrman is a Fellow of the American Academy of Podiatric Practice Management, Past Director of the American Professional Wound Care Association Board of Directors, and is a Past Chairman of the Board of the American Society of Podiatric Surgeons. Dr. Lehrman is also on the editorial advisory board of the journal WOUNDS.
