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Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99)
ICD-10-CM Guidelines with Comprehensive Examples
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Section A
Pressure Ulcer Stage Codes
Codes in category L89, Pressure ulcer, identify the site and stage of the pressure ulcer. The ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, deep tissue pressure injury, unspecified stage, and unstageable.
Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable. See Section I.B.14. for pressure ulcer stage documentation by clinicians other than patient's provider.
Understanding Unstageable Pressure Ulcers
Code Assignment
Assignment of the code for unstageable pressure ulcer (L89.--0) should be based on the clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft).
Important Distinction
This code should not be confused with the codes for unspecified stage (L89.--9). When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.--9).
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Documented Pressure Ulcer Stage Assignment
01
Review Clinical Documentation
Assignment of the pressure ulcer stage code should be guided by clinical documentation of the stage or documentation of the terms found in the Alphabetic Index.
02
Check Alphabetic Index
For clinical terms describing the stage that are not found in the Alphabetic Index, and there is no documentation of the stage, the provider should be queried.
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Healed and Healing Pressure Ulcers
1
Patients Admitted with Healed Pressure Ulcers
No code is assigned if the documentation states that the pressure ulcer is completely healed at the time of admission.
2
Pressure Ulcers Documented as Healing
Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage.
3
Query When Unclear
If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.
4
Ulcers Present on Admission
For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.
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Pressure Ulcer Evolving During Admission
If a patient is admitted to an inpatient hospital with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned:
1
Code 1
One code for the site and stage of the ulcer on admission
2
Code 2
A second code for the same ulcer site and the highest stage reported during the stay
Pressure-Induced Deep Tissue Damage
For pressure-induced deep tissue damage or deep tissue pressure injury, assign only the appropriate code for pressure-induced deep tissue damage (L89.--6).
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Section B
Non-Pressure Chronic Ulcers
Healed Non-Pressure Ulcers
No code is assigned if the documentation states that the non-pressure ulcer is completely healed at the time of admission.
Healing Non-Pressure Ulcers
Non-pressure ulcers described as healing should be assigned the appropriate non-pressure ulcer code based on the documentation in the medical record.
Unspecified Severity
If the documentation does not provide information about the severity of the healing non-pressure ulcer, assign the appropriate code for unspecified severity.
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Non-Pressure Ulcer Documentation Guidelines
Query Requirements
If the documentation is unclear as to whether the patient has a current (new) non-pressure ulcer or if the patient is being treated for a healing non-pressure ulcer, query the provider.
Admission to Discharge Coding
For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and severity of the non-pressure ulcer at the time of admission.
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Non-Pressure Ulcer Progression During Admission
If a patient is admitted to an inpatient hospital with a non-pressure ulcer at one severity level and it progresses to a higher severity level, two separate codes should be assigned:
Initial Code
One code for the site and severity level of the ulcer on admission
Progressive Code
A second code for the same ulcer site and the highest severity level reported during the stay
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Scenario Examples for ICD-10-CM Chapter 12
1
Scenario 1: Stage Progression
A patient is admitted with a Stage 2 pressure ulcer on the right heel. During the hospital stay, the ulcer progresses to Stage 3.
Coding: Assign two codes - one for Stage 2 at admission and one for Stage 3 as the highest stage during stay.
2
Scenario 2: Unstageable Ulcer
A patient presents with a pressure ulcer on the sacrum covered with eschar, making staging impossible.
Coding: Assign L89.--0 for unstageable pressure ulcer. If eschar is debrided and Stage 3 is revealed, code only Stage 3.
3
Scenario 3: Healing Ulcer
A patient is admitted with a healing Stage 4 pressure ulcer on the left buttock, documented as improving but still Stage 4.
Coding: Assign the Stage 4 pressure ulcer code based on current documentation, even though it is healing.
4
Scenario 4: Completely Healed
A patient is admitted for surgery. Documentation notes a pressure ulcer on the coccyx that is completely healed.
Coding: No code is assigned for the healed pressure ulcer.
5
Scenario 5: Deep Tissue Injury
A patient develops pressure-induced deep tissue damage on the right hip during hospitalization.
Coding: Assign L89.--6 for pressure-induced deep tissue damage at the appropriate site.
6
Scenario 6: Non-Pressure Ulcer
A diabetic patient is admitted with a foot ulcer that progresses from limited thickness skin loss to full thickness skin loss during stay.
Coding: Assign two codes - one for initial severity and one for highest severity level during admission.
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