Outpatient Facility Coding Alert

You Be the Coder:

Factor Pressure Ulcer Stage Into Coding Determination

Published on Fri Feb 14, 2020

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Question: I am looking for the code(s) to report for the debridement of an infected stage IV decubitus ulcer of the left heel. The wound size is 32 square centimeters.

Kansas Subscriber

Answer: A decubitus ulcer, also known as a pressure ulcer, is an open wound of the skin that’s the result of prolonged pressure to a localized site. In order to determine the correct code, you need to factor in the stage, or level, of the decubitus ulcer. For decubitus ulcers ranging from stages I to III, you’ll report codes 11042 (Debridement, subcutaneous tissue (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less) or +11045 (… each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)), depending on the size of the wound.

In this patient’s case, you’ll code a debridement of a stage IV infected decubitus ulcer of the heel as 11043 (Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less) and +11046 (Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)). By definition, a stage IV ulcer extends to the muscle, which qualifies the procedure as a debridement of muscle and the fascial tissue that precedes it.

As for the diagnosis coding, you’ll code the decubitus ulcer of the heel as L89.624 (Pressure ulcer of left heel, stage 4). You may also code the infection of the ulcer as a secondary diagnosis using L08.9 (Local infection of the skin and subcutaneous tissue, unspecified).