“Two codes are needed to completely describe a pressure ulcer: A code from subcategory 707.0, Pressure ulcer, to identify the site of the pressure ulcer and a code from subcategory 707.2, Pressure ulcer stages.
A healed ulcer, on the other hand, does not need a code because it is an event that happened in the past, not a current event. Knowing where the treatment is for the ulcer will help you to determine if an ICD-10-CM code is needed or if you need more specificity on the ulcer's stage.
As of October 1, 2016, the ICD-10-CM Official Guidelines for Coding and Reporting have been revised to indicate that if a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a ...
When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89. 009).
Pressure ulcer/injury codes are all located in category L89 of the ICD-10-CM code book.
A scab is evidence of wound healing. A pressure ulcer that was staged as a 2 and now has a scab indicates it is a healing stage 2, and therefore, staging should not change. Eschar characteristics and the level of damage it causes to tissues is what makes it easy to distinguish from a scab.
Possible stages are 1-4 and unstageable. Unstageable: Based on clinical documentation the stage cannot be determined clinically (e.g., the wound is covered with eschar) or for ulcers documented as deep tissue injury without evidence of trauma.
Chronic ulcers or non-healing ulcers are defined as spontaneous or traumatic lesions, typically in lower extremities that are unresponsive to initial therapy or that persist despite appropriate care and do not proceed towards healing in a defined time period with an underlying etiology that may be related to systemic ...