Find Clarity in Wound Care Coding
Here’s what you need to know regarding diagnosis documentation and reporting for wound care. Coding wound care is complex for several reasons, including the fact that nonphysician healthcare personnel are often the ones providing the actual care. And chronic wounds are a big deal: 7 million individuals currently live with chronic wounds, including venous ulcers and diabetic ulcers, with a care cost of $50 billion annually. Gena Cornett, CPC, CPB, CPCO, CRCR, RCMS, CPB-1, offered some tips for coders to gain confidence in diagnosis coding in her presentation “From Wounds to Wins: Expert Tips for Accurate Coding” at AAPC’s HEALTHCON Regional 2025. Find more information next month regarding coding wound care procedures. Understand Key Diagnosis Coding Principles Wounds are considered acute or chronic, with the latter often stalling in one of the phases of healing and thus requiring special management. Acute wounds are usually caused by trauma like a burn or injury, whereas chronic wounds, like pressure injuries and nonpressure chronic ulcers, are often impacted by comorbidities or are the result of another or underlying condition, Cornett said. Note: The phrases pressure injury and pressure ulcer are still used interchangeably, but some healthcare industry stakeholders prefer “pressure injury” because the condition can manifest without an open wound. Coders can find diagnosis codes for nonpressure chronic injuries in the ICD-10-CM L97- (Non-pressure chronic ulcer) code series and pressure injuries in the L89- (Pressure ulcer) series. Coders may need to use two codes for ulcers/injuries when they result from an underlying condition, in which case coders should code the underlying condition first. “It’s very important that our providers are documenting the location, the laterality, and the severity … you’ve probably heard it over and over: Avoid unspecified codes,” Cornett said. “We really have to work with them to understand why we’re not using unspecified codes. Those probably aren’t going to get paid on the claim.” From a payer’s perspective, an unspecified code can suggest that a provider doesn’t know the severity of the wound. It’s crucial to code to the highest level of specificity. Beware These ICD-10-CM Idiosyncrasies and Coding Issues Reporting nonpressure ulcers correctly requires provider documentation of the location, laterality, and severity, including whether: Pressure injury documentation should also include site and severity, but for these wounds, severity is categorized by stage, including stage 1, stage 2, stage 3, stage 4, unstageable, and deep tissue injury. The ICD-10-CM codes in the L89 series include an unspecified code like L89.--9 (Pressure ulcer … unspecified), and some providers may go for the unspecified code if they cannot see the base of a pressure injury because it’s covered in eschar, but the correct code family would actually be L89.--0 ( … Unstageable), Cornett said. Additionally, as pressure injuries heal, they do not change categories. For example, if a patient has a stage 4 pressure injury that is healing, it should not be documented as stage 3 but, instead, a healing stage 4, she said. However, if a stage 3 injury gets worse, it may meet the criteria for stage 4 categorization. Coding tip: Code first any associated gangrene via the I96 (Gangrene, not elsewhere classified ) code family, which may happen for stage 4 pressure injuries. Rely On These Documentation Strategies Providers need to be diligent in keeping their pressure injury documentation — and diagnoses — up to date, because the stage categories correlate with treatment. If a coder submits a claim reporting a physician documenting a patient having a stage 1 pressure injury and debridement of subcutaneous tissue, a payer’s going to deny the claim because a stage 1 wound isn’t open —there’s no subcutaneous tissue accessible to debride, Cornett said. “Providers really need to be careful about documenting for each date of service which stage is this pressure ulcer that they’re debriding,” she said. Cornett said the documentation process can be especially complicated because whoever is providing direct care may be recording information about the staging of a patient’s pressure injury. In such cases, the nurse and physician aren’t necessarily talking about the wound together in the room — they need to discuss and look together, and make sure that any nurse-provided documentation that gets pulled into the physician’s documentation reflects what the physician is seeing. Deep tissue injury is another diagnosis code category for wounds that aren’t open but have damaged tissues beneath the skin; coders should be careful that they aren’t reporting debridement of deep pressure injuries, as there isn’t an open wound to debride, she said. Check back next month for more information on coding wound care, including reporting instructions for procedure codes. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
