The Pressure is On!

The Anatomy and Pathophysiology spotlight this month is pressure ulcers. The Integumentary system is the largest organ of the body and is composed of the skin and accessory tissues. There are three layers of skin; the epidermis is the outer layer of skin, which protects the body. The dermis layer contains hair follicles, glands, blood and lymphatic vessels, and nervous tissue found deeper in the dermis. The final layer is the hypodermis, which contains the dermal appendages (nails, hair, sebaceous, and sweat glands). When there is an injury to the skin and underlying tissue, a pressure ulcer may result.

Pressure ulcers, also called decubitus ulcers or bedsores, are often seen in patients with diabetes, vascular disease, urinary or bowel incontinence, malnourishment, or a debilitating disease such as multiple sclerosis. Patients who are bed ridden or confined to a wheelchair are more prone to pressure ulcers in areas such as the back, hip, shoulder, back of head, ankle, and heel. Continual pressure or contact against the skin reduces blood flow and a lack of oxygen in the tissue. Subsequently, the skin begins to break down and eventually will die.

Pressure ulcers are categorized in stages based severity:

  • Stage 1 – Begins as a reddened area that does not turn white when pressed.
  • Stage 2 – Appears as a blister or open sore and involves the epidermis and dermis.
  • Stage 3 – The ulcer appears as an open sore referred to as a crater. Damage is to the subcutaneous and underlying fascia.
  • Stage 4 – Has progressed to a deep level with necrosis to the muscle and bone; there may also be involvement of tendons or joints.
  • The stage of a pressure ulcer is based on clinical documentation; when it cannot be clinically determined it is coded unstageable.

The Official Coding Guidelines contain instructions to code pressure ulcers. There are changes from the current guidelines in ICD-9-CM; ICD-10-CM contains many combination codes which will reduce the number of codes required to accurately report the condition. An instructional “code first” note for associated gangrene applies to all pressure ulcer codes. Codes are located in L89 (Pressure Ulcer) and in order are categorized by site (elbow, back, hip, buttocks, ankle, heel), laterality, and severity which is identified by stages (I-IV). For example, a stage 2 pressure ulcer on a patient’s right elbow would be reported with L89.012 Pressure ulcer of right elbow, stage 2. Providers should be queried when documentation lacks the stage of the ulcer, location, or laterality.

Stay tuned for more A&P articles in the coming months.


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