Success Codes— Integumentary Edition


Time for another edition of my wildly popular “Success Codes” series. If you haven’t already, you may want to review my world-class, yet humbly simple (yes, really) explanation of RAF scoring—it’ll help you understand some of the shorthand terminologies below. It’s the only one on the web written by a PCP who’s been in the trenches blocking and tackling since Medicare Advantage first arrived on the scene 20+ years ago—and done so with incredible results.


That’s probably why it’s so good—and so good for you!


Now let’s get started.


Skin ulcers are a common comorbidity associated with later stages of most chronic illnesses. Their presence not only tips you off to the debilitated status of your patients but also will provide you with essential additional revenue to help offset the cost of these chronic diseases as they enter into their later, more expensive stages.


Of all the codes we’ve discussed, this category has the greatest variation in capitation.


Some wounds have no capitation at all, some almost triple your monthly amount.


In general, the deeper the wound, the more likely there will be an effect on your monthly compensation and the greater the effect will be.


But don’t worry about specifics.


The best-practice tactic is to simply diagnose and code every chronic skin wound, pressure-related or not.



And then do your best to get them to heal.





Pressure Ulcers. L 89.xx RAF 1.5-2.5 based on the stage

  • Usually only stage 3 and 4 carry risk.
  • For certain beneficiaries, like those enrolled in Medicaid PACE programs (check with your insurer) and those with ESRD, all depths affect capitation.



Gangrene I96 RAF 1.5—Different codes for gangrene depending on underlying causes.

  • Document the fact of tissue death and debridement plan.



Non-Pressure Ulcer  I97.xx, I98.xx RAF 0.6 —Any stage associated with risk

  • Definition- it’s simple and subjective, document based on that definition and you’re home free:  A wound that’s taking longer to heal than would usually be expected
    • Usually due to
      • Inciting factor-e.g. radiation, infection
      • Lack of resource needed to heal—e.g. nutrition










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