Pressure Ulcer and Non-Pressure Ulcer ICD-10 Coding

Pressure Ulcer and Non-Pressure Ulcer ICD-10 Coding

Pressure ulcer and non-pressure chronic ulcer diagnostic codes are located in ICD-10-CM chapter 12, Disease of the skin and subcutaneous tissue. The concept of laterality (e.g., left or right) is pertinant, and should be included in the clinical documentation for skin ulcers.

ICD-10-CM codes for Pressure ulcers, located in Category L89, are combination codes that identify the site, stage, and (in most cases) the laterality of the ulcer. Possible stages are 1-4 and unstageable.

Stage 1: Skin changes limited to persistent focal edema

Stage 2: An abrasion, blister, and partial thickness skin loss involving the dermis and epidermis

Stage 3: Full thickness skin loss involving damage and necrosis of subcutaneous tissue

Stage 4: Necrosis of soft tissues through the underlying muscle, tendon, or bone

Unstageable: Based on clinical documentation the stage cannot be determined clinically (e.g., the wound is covered with eschar) or for ulcers documented as deep tissue injury without evidence of trauma.

An instructional note in ICD-10 states to code also any associated gangrene (I96).

Non-pressure chronic ulcers are similar to pressure ulcers in that they require documentation of the site, severity, and laterality. Category L97 and L98 are for Non-pressure ulcers, and have an instructional note to code first any associated underlying condition, such as:

Associated gangrene

Atherosclerosis of the lower extremities

Chronic venous hypertension

Diabetic ulcers

Postphlebetic syndrome

Postthrombotic syndrome

Varicose ulcers

The severity of the ulcers is described as:

Limited to breakdown of skin

With fat layer exposed

With necrosis of muscle

With necrosis of bone

Example: A type 1 diabetic patient is seen in the clinic. Upon examination of her feet, she is noted to have a left heel ulcer with the breakdown of skin into the dermis, but not full thickness. The physician documents a diagnosis of diabetic heel ulcer.

E10.621 Type 1 diabetes mellitus with foot ulcer

L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin

Following the instructional notes under category L97, the code for the underlying condition—here, diabetes mellitus—is listed first.

Codes for healing pressure ulcers are assigned based on documentation of current stage. Assign as many codes as necessary to identify all pressure ulcers for the patient.

Case 1: A patient presents on referral for diabetic right great toe ulcer with gangrene. Upon exam, there was swelling, discoloration, and malodor, with necrosis into the bone. Patient will be admitted to the hospital for IV antibiotics and surgical intervention. The patient is a type 2 diabetic.

Documentation supports Type 2 diabetes, right great toe ulcer with gangrene. The documentation parameters are met with site of the great toe, laterality of right, and severity of necrosis of bone. Following the guidelines the codes for the underlying condition and the gangrene are reported first, followed by the code from category L97.

E11.621 Type II diabetes with foot ulcer

I96 Gangrene, not elsewhere classified

L97.514 Non-pressure chronic ulcer of other part of right foot with necrosis of bone

Case 2: A patient is seen for bilateral pressure ulcers to the buttocks and elbows. The pressure ulcers on the elbows are documented as partial thickness skin loss into the dermis. The pressure ulcers on the buttocks are documented as full thickness skin loss with necrosis into the subcutaneous tissue.

L89.313 Pressure ulcer of right buttock, stage 3

L89.323 Pressure ulcer of left buttock, stage 3

L89.012 Pressure ulcer of right elbow, stage 2

L89.022 Pressure ulcer of left elbow, stage 2

Stage 3 describes healing or full thickness skin loss involving damage or necrosis of subcutaneous tissue, which matches the physician documentation. Following the guidelines, these ulcers would be coded as stage 3.

The pressure ulcers on the elbows are documented as partial thickness into the dermis, which supports stage 2 (stated to be healing or abrasion, blister, partial thickness skin loss involving epidermis and/or dermis)—which again matches the physician documentation. Following the guidelines, these ulcers are coded as stage 2. No bilateral codes are available; therefore, each pressure ulcer is assigned a separate code.

Peggy Stilley

Peggy Stilley

Peggy Stilley, CPC, CPMA, CPC-I, CPB, COBGC is Revenue Integrity Auditor at Oklahoma Sports and Orthopedic Institute in Norman, Oklahoma. She was previously a member of AAPC’s ICD-10 Training and Education team, and Director of Audit Services for AAPC Client Services. Peggy has more than 30 years of experience in the healthcare industry and has worked in a variety of positions. Her knowledge is enhanced by experience in multiple specialties including OB-Gyn, Maternal Fetal Medicine, General Practice, General Surgery, and Neurology. Peggy is a national speaker for AAPC. She has authored several articles on billing, coding, and practice management, and currently a member of the Oklahoma City chapter.
Peggy Stilley

About Has 3 Posts

Peggy Stilley, CPC, CPMA, CPC-I, CPB, COBGC is Revenue Integrity Auditor at Oklahoma Sports and Orthopedic Institute in Norman, Oklahoma. She was previously a member of AAPC’s ICD-10 Training and Education team, and Director of Audit Services for AAPC Client Services. Peggy has more than 30 years of experience in the healthcare industry and has worked in a variety of positions. Her knowledge is enhanced by experience in multiple specialties including OB-Gyn, Maternal Fetal Medicine, General Practice, General Surgery, and Neurology. Peggy is a national speaker for AAPC. She has authored several articles on billing, coding, and practice management, and currently a member of the Oklahoma City chapter.

2 Responses to “Pressure Ulcer and Non-Pressure Ulcer ICD-10 Coding”

  1. nikole dalimonte says:

    what do you do when there is no gangrene documented w/ the pressure ulcer or the patient just does not have gangrene?

  2. Melissa says:

    I would like to hear more about the Venous Hypertension Ulcers in detail. When coding Venous Hypertension Ulcers for Wound Clinic has proven to be difficult. These are always being denied. They aren’t listed on the LCD. This makes no sense, why is Venous Insufficiency listed but not Venous Hypertension Ulcers. I believe Venous Insufficiency to be part of the disease process of Venous Hypertension. Therefore wouldn’t be coded. I that statement isn’t true, please publish an article explaining this in detail.

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