Cracking the Code
Coding Pressure Ulcers
Pressure ulcers, also known as bedsores or decubitus ulcers, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin, according to the Mayo Clinic. Pressure Ulcers occur on the skin that covers bony areas such as heels, ankles, hips, and the tailbone. Patients with limited mobility and who spend a considerable amount of time in a wheelchair or bed are at a higher risk of developing a pressure ulcer. These ulcers can develop over hours and days. Treatment of an ulcer can range from simple to more complex depending on the severity. In more severe cases, pressure ulcers may never heal completely.
Code selection of pressure ulcers is based on the locations of the ulcer laterality (if applicable), and the stage of the ulcer. For each area, there is a selection for stages 1-4, deep tissue pressure injury, unspecified stage, and unstageable. Unstageable occurs when the base of the ulcer is covered in too much slough (dead tissue) to even determine the depth. We always must remember that the diagnosis is determined based on the provider’s documentation. When multiple sites are documented, select a code for each anatomic site and stage. If all ulcers are being treated at the time of the encounter, you would code the most severe ulcer first.
As a resource, the ICD-10-CM code book contains chapter-specific coding guidelines to help assist the coder or auditor while navigating code selection for pressure ulcers.
Q: A patient has developed a pressure ulcer on his right hip. The base of the ulcer is covered in slough and the provider documents that the stage of the ulcer cannot be determined. What is the correct ICD-10-CM code?
A: L89.210. Rationale: The documentation states that the ulcer is covered in slough at the base and the stage cannot be ascertained. This would be determined as unstageable. In the ICD-10-CM Alphabetic Index, we look at Ulcer, ulcerated, ulcerating, ulceration, ulcerative/pressure (pressure area)/unstageable/hip which directs us to L89.2-. In the Tabular List, the 5th character 1 determines the right hip, and the 6th character 0 points to unstageable.
Reference: FY 2023 ICD-10-CM code book, Mayo Clinic.