Name of the Condition

• Personal History of Diabetic Foot Ulcer (ICD Code: Z86.31)

Summary

• This condition refers to a medical history of having a diabetic foot ulcer, which is a common complication in people with diabetes. It implies that the individual previously experienced an ulcer on the foot due to underlying diabetes-related complications but is not currently experiencing it.

Causes

• Diabetic foot ulcers are primarily caused by prolonged high blood sugar levels, which lead to nerve damage (neuropathy) and poor circulation in the feet, making them susceptible to injury and slow healing.

Risk Factors

• Poorly managed diabetes, peripheral neuropathy, poor blood circulation, history of foot injuries, use of tobacco, obesity, and advanced age can all increase the risk of developing foot ulcers.

Symptoms

• While the condition itself is historical, past symptoms may have included open sores on the feet, swelling, redness, or drainage. Numbness or tingling in the foot could have also been present.

Diagnosis

• Confirmation of a past diabetic foot ulcer is often based on patient history, physical examination of any residual scars, and review of medical records.

Treatment Options

• Although treatment would have occurred when the ulcer was active, it typically involves wound care, infection control, glycemic management, and sometimes surgery. Past treatments focus on healing the ulcer and preventing recurrence.

Prognosis and Follow-Up

• A personal history of a diabetic foot ulcer signifies a higher risk of recurrence. Regular foot exams, good glycemic control, and appropriate foot care are essential for a favorable long-term outlook.

Complications

• If not properly managed in the past, diabetic foot ulcers could have led to severe infections, cellulitis, or potentially amputation.

Lifestyle & Prevention

• Management of blood sugar levels, regular foot examinations, maintaining good hygiene, wearing appropriate footwear, and avoiding tobacco use are critical measures to prevent the recurrence of foot ulcers.

When to Seek Professional Help

• Immediate medical assistance should be sought for new foot wounds, persistent swelling, redness, or warmth in the foot, or signs of infection such as fever.

Additional Resources

• American Diabetes Association (ADA): diabetes.org
• Wound Healing Society: woundheal.org

Tips for Medical Coders

• Ensure the code Z86.31 is used to indicate a past history of a diabetic foot ulcer, not an active condition.
• Verify documentation confirming the ulcer is healed and that treatment history supports this coding to avoid errors.