Ease the Pressure of Coding Decubitus Ulcers
ICD-10 coding relies on documenting stage, location, and sometimes laterality.
Decubitus ulcers — also known as bedsores or pressure ulcers — develop as a result of compromised circulation to tissues of the skin. For example, when a patient stays in one position too long, the weight of the bones against the skin inhibits circulation and causes ulceration. This usually occurs at the heaviest bones, such as the buttocks, hips, and heels.
Appropriate coding of a pressure ulcer requires documentation of the location (site), laterality (if applicable), and stage of the ulcer. ICD-10-CM pressure ulcer codes are combination codes that identify the location (site) of the ulcer, as well as the stage.
Pressure ulcer stage is classified based on the severity: stages 1-4, unspecified stage, and unstageable.
Stage 1: Redness that does not turn pale when pressed and released with a fingertip (persistent focal erythema).
Stage 2: Partial thickness skin loss involving epidermis, dermis, or both.
Stage 3: Full thickness ulceration into subcutaneous fat, which may extend up to, but not through, deep fascia.
Stage 4: Necrosis of the soft tissue extending to muscle, tendons, joints, and/or bone.
Unspecified stage: There is no provider documentation specifying the stage of the ulcer.
Unstageable ulcer: The provider cannot clinically determine the depth of the ulcer, due to eschar or slough covering the ulcer.
When multiple ulcer sites are documented, code for each anatomic site and stage. Sequencing is based on the pressure ulcer being treated. If all the pressure ulcers are treated, sequence the code for the most severe pressure ulcer first. ICD-10 includes a note with category L89 Pressure ulcer to “code first any associated gangrene (I96).”
For example, the physician documents an unstageable pressure ulcer on the right hip covered in eschar. The appropriate coding is L89.210 Pressure ulcer of right hip, unstageable.
In a second example, a patient is diagnosed with a stage 3 pressure ulcer of the left heel. Proper coding is L89.623 Pressure ulcer of left heel, stage 3.
2016 ICD-10-CM Expert for Physicians
Oby Egbunike, CPC, COC, CPC-I, CCS-P, is a licensed ICD-10-CM instructor for AAPC. She has a Bachelor of Arts in Business Administration with concentration in Health Information Management from Northeastern University Boston. Egbunike has more than 10 years of experience in healthcare management, coding, billing, and revenue cycle. She is associate director of professional coding and education at Lahey Health. Egbunike is a member of the Boston, Mass., local chapter.