Cracking the Code

Pressure Ulcers

According to the Mayo Clinic, bedsores, also called pressure and decubitus ulcers are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. These develop most often on the skin that covers bony areas of the body like the heels, ankles, hips, and tailbone.


The coding for these pressure ulcers is as follows. If the pressure ulcer is completely healed, then a code would not be reported for the pressure ulcer. In some cases, the pressure ulcer will get worse during the admission. As an example, a patient is seen for treatment of a stage 2 ulcer that ultimately progresses to stage 3. In this case, two codes would be reported. First, the code for the site and stage of the ulcer upon admission. Secondly, the code for the highest stage for that site during that stay. It is important to note for ulcers that were present on admission but healed at the time of discharge, the code for the site and stage of the pressure ulcer at the time of admission is only reported.


There are stages of pressure ulcers that identify the extent of the tissue damage. Stage one is persistent focal edema. Stage two is partial thickness skin loss involving the epidermis, dermis, or both. Stage three is full-thickness skin loss involving damage or necrosis of subcutaneous tissue. Stage four would be necrosis of soft tissue extending to the underlying muscle, tendon, or bone.


The code selection for these pressure ulcers is based on the location of the ulcer, the laterality (if applicable), along with the stage of the ulcer. For each location, there is an option for stages one through four, deep tissue pressure injury, unspecified stage, and unstageable. An unstageable ulcer is defined as when the base of the ulcer is covered in eschar or slough so much that it cannot be determined how deep the ulcer is. We always must remember this diagnosis is determined based on the documentation. This code should not be used if the stage is not documented. Now in this instance, we would report the unspecified code for that location or query the provider. If during an encounter, the stage of an unstageable pressure ulcer is revealed after debridement, assign only the code for the stage revealed following debridement.

Q: A 63-year-old male patient is diagnosed with pressure ulcers on each heel. Each heel displays bone involvement with evidence of necrosis and is identified as stage 4. What ICD-10-CM code(s) is/are reported for this encounter?
A: L89.614, L89.624 Rationale: For this case, the patient is diagnosed with pressure ulcers on each heel which is stage 4. We are going to look in our ICD-10-CM Alphabetic Index under Ulcer/pressure/stage 4/heel L89.6-. As always as we verify in the Tabular List, we see that a 5th character is required for laterality and a 6th character is required for the stage. We will report L89.614 for the right and L89.624 for the left as per the documentation.
Reference: 2024 ICD-10-CM codebook & Mayo Clinic
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