Pressure Ulcers: ICD-10-CM Coding
Pressure ulcers also are known as bedsores or decubitus ulcers. Pressure ulcers are areas of damaged skin and tissue developing as a result of compromised circulation. When a patient stays in one position without movement, the weight of the bones against the skin inhibits circulation and causes an ulceration of the tissue. Pressure ulcers usually form near the heaviest bones (buttocks, hips, and heels).
There are stages of pressure ulcers that identify the extent of the tissue damage.
Stage 1—Persistent focal erythema
Stage 2—Partial thickness skin loss involving epidermis, dermis, or both
Stage 3—Full thickness skin loss extending through subcutaneous tissue
Stage 4—Necrosis of soft tissue extending to muscle and bone
ICD-10-CM code selection is based on the location of the ulcer, laterality (if applicable), and the stage of the ulcer. For each location, there is an option to identify an unstageable ulcer. An unstageable ulcer is when the base of the ulcer is covered in eschar or slough so much that it cannot be determined how deep the ulcer is. This diagnosis is determined based on the clinical documentation. This code should not be used if the stage is not documented. In that instance, report the unspecified code for that location.
The category of codes for pressure ulcers (L89) has a note to code first any associated gangrene from category I96.
Tip: Because there are several pages of ICD-10-CM codes for pressure ulcers, make a note at the top of each page of your ICD-10-CM manual to remind you to code associated gangrene first, if applicable.
When multiple sites are documented, select a code for each anatomic site and stage. The sequence depends on the pressure ulcer being treated. If all the pressure ulcers are being treated, sequence the code for the most severe pressure ulcer first.
Example: A patient with a stage 3 pressure ulcer on her left heel and a stage 2 pressure ulcer of her left hip is scheduled for debridement. The correct codes and sequence are:
L89.623 Pressure ulcer of left heel, stage 3
L89.222 Pressure ulcer of left hip, stage 2
If the pressure ulcer is healed completely, a code is not reported for the pressure ulcer. There are some cases where the pressure ulcer will get worse during the course of the admission. For example, the patient is admitted for treatment of a stage 2 ulcer that progresses to stage 3. Report the code for the highest stage.