Primary Care Coding Alert

Question: We recently had a patient visit our office who was suffering from pressure ulcers on their thighs. I’m relatively new to coding and am having a hard time understanding how to code different stages of pressure ulcers. How do I code the different stages of pressure ulcers for this patient’s thighs?

AAPC Forum Participant

Answer: Luckily, ICD-10-CM makes coding the different stages of pressure ulcers relatively easy for coders. Each of the stages of pressure ulcer represents the different healing stages of the wound. Thighs are one area that are not specifically noted in the code book, however. You would look under L89.4 (Pressure ulcer of contiguous site of back, buttock and hip) to find the appropriate code.

Make note: In the ICD-10-CM Official Guidelines for Coding and Reporting, the guidelines for Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99) go into greater detail on how to code the stages of pressure ulcers appropriately.

When coding for pressure ulcers of the back, buttock and hip, always remember to code to the 5^th character as shown:

• L89.40 (Pressure ulcer of contiguous site of back, buttock and hip, unspecified stage): Use this diagnosis code when the stage of the pressure ulcer is undetermined.
• L89.41 (… stage 1): Use this diagnosis code for “pressure pre-ulcer skin changes limited to persistent focal edema,” according to ICD-10-CM.
• L89.42 (… stage 2): Use this diagnosis code for “pressure ulcer with abrasion, blister, partial thickness skin loss involving epidermis and/or dermis,” according to ICD-10-CM.
• L89.43 (… stage 3): Use this diagnosis code for “pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue,” according to ICD-10-CM.
• L89.44 (… stage 4): Use this diagnosis code for a “pressure ulcer with necrosis of soft tissues through to underlying muscle, tendon, or bone,” according to ICD-10-CM.
• L89.45 (…unstageable): Use this diagnosis code when the base of the ulcer is covered by slough (normally yellow, gray, green, tan or brown material) or eschar (tan, brown, or black material) and the depth of the wound or stage cannot be determined.
• L89.46 (Pressure-induced deep tissue damage of contiguous site of back, buttock and hip): Use this diagnosis code when there is a blood-filled blister or discolored intact skin with damage to the underlying tissue. The wound area may also be painful and have a different temperature than surrounding tissue.

Remember: add modifiers LT (Left) and RT (Right) to tell the payer which thigh each code pertains to on your claim.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC