Pressure ulcer, bedsore or decubitus ulcer
The other names for Pressure ulcers are bedsores or decubitus ulcers.Pressure ulcers are areas of damaged skin and tissue developing as a result of compromised circulation. The weight of the bones against the skin inhibits circulation and causes an ulceration of the tissue, when a patient stays in one position without movement. Pressure ulcers usually form near the heaviest bones for eg buttocks, hips, and heels
There are stages of pressure ulcers that identify the extent of the tissue damage.
- Persistent focal erythema – Stage 1.
- Partial thickness skin loss involving epidermis, dermis, or both – Stage 2.
- Full thickness skin loss extending through subcutaneous tissue – Stage 3.
- Necrosis of soft tissue extending to muscle and bone – Stage 4.
The ICD-10-CM code is selected based on the location of the :
- Ulcer,
- Laterality and
- The stage of the ulcer.
For each location, there is an option to identify an unstageable ulcer. An unstageable ulcer is defined when the base of the ulcer is covered in eschar or slough so much that it cannot be determined how deep the ulcer is.This diagnosis can be determined based on the clinical documentation. If the stage is not documented, this code should not be used. In such a situation the unspecified code should be reported for that location.
There is a note available in the category of codes for pressure ulcers (L89) to code first any associated gangrene from category I96.
Because there are several pages of ICD-10-CM codes for pressure ulcers, make a note at the top of each page of your ICD-10-CM manual to remind you to code associated gangrene first, if applicable.
A code must be selected for each anatomic site and stage, when multiple sites are documented. The sequence depends on the pressure ulcer being treated.The code for the most severe pressure ulcer must be sequenced first, if all the pressure ulcers are being treated.
Here ia an example for explaining how to code pressure ulcers in ICD-10-CM:
Example: A physician attends a patient with a stage 3 pressure ulcer on her left heel and a stage 2 pressure ulcer of her left hip for debridement. The correct codes and sequence are:
Pressure ulcer of left heel, stage 3 – L89.623.
Pressure ulcer of left hip, stage 2 – L89.222.
A code is not reported for the pressure ulcer, if the pressure ulcer is healed completely. There may be some cases where the pressure ulcer will get worse during the course of the admission. In cases when the patient is admitted for treatment of a stage 2 ulcer that progresses to stage 3, the code for the highest stage should be reported.