ICD-10 Coding of Decubitus Pressure Ulcers
ICD-10 coding relies on:
- Documenting stage
- Location
- Laterality
Decubitus pressure ulcers , also known as bedsores or pressure ulcers develop as a result of compromised circulation to tissues of the skin.
Appropriate coding of a pressure ulcer requires documentation of each the following
- Location (site)
- Laterality (if applicable)
- Stage of the ulcer
ICD-10-CM pressure ulcer codes are combination codes that identify the location (site) of the ulcer, as well as the stage.
Pressure ulcer stage is classified based on the severity: stages 1-4, unspecified stage, and unstageable.
- Stage 1:Redness that does not turn pale when pressed and released with a fingertip (persistent focal erythema).
- Stage 2:Partial thickness skin loss involving epidermis, dermis, or both.
- Stage 3:Full thickness ulceration into subcutaneous fat, which may extend up to, but not through, deep fascia.
- Stage 4:Necrosis of the soft tissue extending to muscle, tendons, joints, and/or bone.
- Unspecified stage:There is no provider documentation specifying the stage of the ulcer.
- Unstageable ulcer:The provider cannot clinically determine the depth of the ulcer, due to eschar or slough covering the ulcer.
When multiple ulcer sites are documented, code for each anatomic site and stage.
Sequencing is based on the pressure ulcer being treated.
If all the pressure ulcers are treated, sequence the code for the most severe pressure ulcer first.
ICD-10 includes a note with category L89 Pressure ulcer to ?code first any associated gangrene (I96).?