ICD 10 Coding Alert

Question: How should I code a patient who has two stage-two pressure ulcers on the right buttock? Should I use the same code twice as the guidelines for the Diseases of the Skin and Subcutaneous Tissue chapter direct me to, or should I only use the same code once as it could look like an accidental code duplication?

New Mexico Subscriber

Answer: While you are correct in saying ICD-10 guidelines require you to “assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable” (1.C.12.a.1), in this case, doing so could create unnecessary confusion and, quite possibly, a claim submission error.

Had the ulcers been in separate locations, or of different stages, two codes would have been needed, and you would put the most severe first, assuming your provider was treating both at the same time. However, in this encounter, both ulcers are of the same severity and location, so you would use L89.312 (Pressure ulcer of right buttock, stage 2) only once to document this patient’s condition.

If the two ulcers each necessitate treatment that will result in separate line items on a claim or multiple units of the same service, you can distinguish them by appending an appropriate modifier to the CPT^® code reported for the service. For example, you might append modifier 59 (Distinct procedural service) to the second service to indicate it was done at a different site (i.e. the second pressure ulcer), even though both line items will have the same diagnosis code attached.