Shirley Posted Sun 12th of April, 2015 21:52:21 PM
Clinical History: Left ischial ulcer. Specimen received: Ischial tissue- Left. Gross description: Received in a container labeled "left ischial tissue" is an irregularly shaped fragment of soft tissue with a small portion containing an ellipse of skin. On sectioning diffuse fibrosis extends through the area. MICROSOPIC DESCRIPTION: Soft tissue of left ischial region demonstrates extensive diffuse fibrosis with mild infiltrates of mononuclear inflammatory cells. A significant portion of the soft tissue is covered with granular fibrin containing sheets of neutrophils that rest upon a granulation tissue base. The adjacent epidermis shows pseudoepitheliomatous hyperplasia and normal maturation pattern. DIAGNOSIS: Skin and soft tissue of left ischial region , excision: Granulation tissue, extensive, with diffuse fibrosis and mild chronic inflammation. Ulcer with mild to moderate acute inflammation.
SuperCoder Answered Mon 13th of April, 2015 08:49:24 AM
Ischial ulcer- ICD9 is 707.05 and use additional code to identify ulcer stage from series 707.20 to 707.25.
ICD10 code series- L89.320 to L89.329, use the code according to ulcer stage.