ICD 10 Coding Alert

Question: What’s the difference between an unstageable pressure ulcer and a pressure ulcer with an unspecified stage?

New Jersey Subscriber

Answer: The ICD-10-CM manual addresses this very issue. To code a specified pressure ulcer as unstageable, the clinical documentation must state as much. Specifically, the ICD-10-CM manual states that unstageable pressure ulcer 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) and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma.”

On the other hand, you will code a pressure ulcer under an unspecified stage code if there is no clinical documentation that allows for a code of greater specificity. The ICD-10-CM manual advises that, when the provider does not offer documentation specifying the stage of the ulcer, code the stage as unspecified. However, if documentation exists that specifically explains the reason why the provider cannot identify the ulcer’s stage, code as unstageable.