The prevalence of pressure injury and/or pressure ulcers has continued across healthcare, with some estimates and studies saying that in the last 10 years they have increased by 63%. The proper ICD-10-CM coding of these takes clinical knowledge, comprehension and proficiency of documentation and the coding conventions and guidelines.
Deep tissue-pressure injury or DTPI, are also known as pressure ulcers are caused by pressure breaking down the skin and underlying soft tissue(s). Clinically, the skin pressure usually comes from constant or repeated force, even repeated friction, that causes the skin to initially turn red. When the pressure continues, it damages the skin and the underlying tissue resulting in an open ulcer or wound.
The extra or repeated pressure to the skin and soft tissue affects the blood flow to the skin. This results in depriving blood supply, oxygen and nutrients from reaching the affected area of skin and/or tissue, leading to the formation of an opening and/or an ulcer. In addition, as a result of pressure, or pressure in combination with shear and/or friction the ulcer heals very slowly or does not heal at all. Pressure injuries/ulcers are thus chronic wounds with physiologically impaired healing. As they form into deep tissues, the injuries may not be visible until they reach a more advanced stage.
Several years ago, it was estimated that 15% of acute care patients have pressure ulcers stage IV with a notable increase in pressure ulcer incidence by 63% since approximately 2004. Individuals who are most at risk for this condition are those confined to a bed for long periods of time due to a health condition that makes movement difficult or in the same anatomic position over a body prominence that then rubs or puts pressure repeatedly. The bony prominences of the body that are the most frequently affected sites include the shoulders, back of the head, elbows, sacrum (buttock), hip, thighs, knees, heels and toes. Conditions that affect the flow of blood through the body, such as type 2 diabetes, also put a person at risk for pressure injuries/ulcers.
When we think about the ICD-10-CM (diagnosis) coding we need to look back to FY2020, as there were new ICD-10-CM codes for the reporting of pressure-induced deep tissue damage (injury). This included a sixth character of “6” to specifically indicate “pressure-induced deep tissue damage.”
Look under ICD-10-CM you will find within Chapter 12 Diseases of the Skin and Subcutaneous Tissue category L89 Pressure ulcer. A sixth character is required on these pressure injury/ulcer code stems to complete the code, and the options are:
0 – Unstageable
1 – Stage 1
2 – Stage 2
3 – Stage 3
4 – Stage 4
6 – Pressure-induced Deep tissue pressure injury
9 – Unspecified stage
Coding professionals and Clinical Documentation Integrity (CDI) specialists should understand that unstageable pressure ulcers are diagnosed when the physician or clinician is not able to assign a stage due to the ulcer being covered by eschar or possibly even a skin graft. If a patient with an “Unstageable pressure ulcer” has a debridement and the stage of the ulcer is then revealed and documented, only assign the code for the stage revealed and not unstageable. While the “Unspecified pressure ulcers” are coded and reported when there is a lack of documentation regarding the pressure ulcer stage, this should be rare and there should be a query process in place to obtain documentation specificity.
Remember the official guidelines tell us that “if a patient is admitted to an inpatient hospital 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 second code for the same ulcer site and the highest stage reported during the stay. In addition, for pressure-induced deep-tissue damage or deep-tissue pressure injury, assign only the appropriate code for pressure-induced deep-tissue damage (L89.–6).”
Also remember that the tabular instruction for category L89 states to “code first any associated gangrene”. It should be noted that clinically the stage of the pressure injury or ulcer change quickly, so review the documentation carefully. Documentation is always the foundation for the accurate assignment of clinical codes (ICD-10-PCS, CPT), so work with your provider to ensure that complete, detailed and specific information on the type, occurrence (i.e., POA), site and stage of the pressure injury or pressure ulcer is in the health record.
It has been estimated that about 1 million pressure injuries occur in the United States every year. You can see these pressure ulcer/injuries in either the outpatient or in the inpatient (hospital) setting. In addition, a research study (found in the National Library of Medicine) of Stage IV pressure ulcers calculated the associated costs over a 29-month period and found that the average cost of hospital treatment associated with stage IV pressure ulcers and related complications was $129,248 for hospital-acquired ulcers during one admission. For community-acquired ulcers over an average of 4 admissions, the average cost was $124,327. If you are interested in reading more about the cost of these conditions, I’ve included the study link in the references.
The Centers for Medicare and Medicaid Services has developed a nice pocket guide regarding pressure ulcer and injury definitions and stages developed specifically for the Skilled Nursing Facility Quality Reporting Program (QRP). This guide it is available at: https://www.cms.gov/files/document/pocket-guidepressure-ulcers-and-injuries-stages-and-definitions.pdf
As always, the documentation must support the code(s) and the code(s) must be supported by the documentation.