Perfect Your Coding for Pressure Ulcer Diagnoses With These Documentation Tips

Mon, Oct 15, 2018 --

ICD-10, Skill Sharpener

know who can document pressure ulcer stage

ICD-10-CM has a lot of codes (more than 150!) for pressure ulcers, and that means your clinicians’ documentation game has got to be on point for your to get the most accurate code for the case. These three steps should help you get the job done.

1. Know Where to Look for Pressure Ulcer Stage Documentation

For pressure ulcers, a nurse is often the one who documents stage. So it’s good news you can base code assignment for pressure ulcer stage on medical record documentation by someone other than the “physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis,” according to ICD-10-CM 2019 Official Guidelines.

Ulcer diagnosis is different: Don’t stretch the rules. The provider (like the physician) must document the pressure ulcer diagnosis.

Resolve conflict: If the medical records conflict, ask the patient’s attending provider for clarification.

Source (and an off-topic tidbit): In the FY 2019 ICD-10-CM Official Guidelines for Coding and Reporting (OGs), you’ll find this documentation rule in Section I.B.14, which was renamed in this latest version to “Documentation by Clinicians Other than the Patient’s Provider.” Those of you who enjoy the nitty gritty of coding may be interested to know that in 2018, the subsection had the more diagnosis-specific name “Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale.” The new name allows for the addition of more diagnoses to the subsection without having to extend the header name each time. For instance, the FY2019 OGs add text based on a 2018 clarification that you may base coding for social determinants of health (such as Z55-Z65) on documentation from clinicians other than the patient’s provider.

2. Go to L89.- When You’re Ready to Code Pressure Ulcers

Coding from L89.- (Pressure ulcer) requires digging through several layers of details. At the four-character level, the coding seems simple enough. You need to know the general site, such as the hip or ankle. But after that, things get more specific by site and stage, until you’re left choosing from codes like L89.114 (Pressure ulcer of right upper back, stage 4).

When you’re making the final code selection based on stage, keep in mind that there are separate codes for unstageable and unspecified because those two terms are not synonyms. “Unstageable” means that the clinician documents that he is unable to determine the stage, such as when the clinician opts to not disturb the eschar to assist with healing in a specific case. “Unspecified” means there is no documentation of stage (and no note about the ulcer being unstageable).

Remember this: For all of the codes in L89.-, ICD-10-CM instructions state that you should “code first any associated gangrene (I96).”

3. Use the Index and Notes to Confirm Pressure Ulcer Code Choice

To ensure you’ve got the correct code based on the documentation, familiarize yourself with the wording in the ICD-10-CM Index and the notes with the codes.

As an example, you may not be sure what to do when documentation records pre-ulcer skin changes on the right elbow. So it’s a huge help to see the note “pressure pre-ulcer skin changes limited to persistent focal edema, right elbow” under L89.011 in the ICD-10-CM Tabular. Similarly, if you look up ulcer, pressure, stage 1 in the ICD-10-CM Index, you’ll see “pre-ulcer skin changes limited to persistent focal edema” listed.

What About You?

Do you find that coding options line up well with the pressure ulcer documentation you see?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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1 Comments For This Post

  1. Cristina Boudreau Says:

    Thank you so much for this article about pressure ulcers documentation.
    If the physician documents “pressure ulcer” can we pick up the location from Wound care team notes (besides the stage)?

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