You need to break down pressure ulcers/injuries coding to get it just right. Always remember to code based on the diagnoses stated by the provider and include the laterality and the stage.
Look for chapter-specific guidelines
Find codes for pressure ulcers/injuries in the L89 category classified by site and the stage. Some of these also include laterality, including the elbow, back, hip, buttock, ankle, and heel.
The guidelines state that you may use as many codes as necessary to describe the patient’s condition.
NOTE: You must code each site of a pressure ulcer/injury and stage.
How to code the stage
For pressure ulcers/injuries that are documented as healed, you do not code the pressure ulcer/injury, per chapter-specific guidelines. On the other hand, you do code a pressure ulcer/injury documented as healing. If the documentation is not clear whether the pressure ulcer/injury is healed or in the healing phase, be sure to query.
Do not code unspecified stage for a pressure ulcer/injury, as you should know the stage (or unstageable) of the ulcer/injury. Under PDGM, unspecified is not an acceptable diagnosis for the primary grouping or comorbidity adjustment.
An unstageable pressure ulcer, per coding guidelines, is a pressure ulcer/injury whose stage cannot be clinically determined. This may be the result of the ulcer being covered by eschar or treated with a graft.
NOTE: Keep in mind, that it is the provider who must document the diagnosis of the pressure ulcer/injury, but the clinician may provide the stage. This was updated in October 1, 2018 coding guideline and states that the patient’s provider establishes the diagnosis, but the clinician may provide the BMI, depth of non-pressure ulcers/injuries, pressure ulcer/injury staging, and the NIH stroke scale.
Find the right code
As with all coding, begin in the alpha index. When looking up a code for a pressure ulcer/injury, first go to injury and find the subentry of pressure with a further entry of injury. This instructs you to see Ulcer, pressure, by site.
The “see” convention tells you to go to the term referenced to locate the correct code. Go to Ulcer with the indentation of pressure and then by site.
You can see, in the alpha, the dash which tells you that it is not a complete code. An example of this would be Ulcer…pressure…buttock…L89.3-.
Look up L89.3- in the tabular for and see that you also need to know the laterality and the stage.
Go back to move forward
You must go backwards in the coding manual. What that means is once you are at the code, go back to the category at L89, where you will find additional instructional notes. Here you will see some of the terminology of what is included, such as decubitus ulcer, pressure area, or pressure sore.
At L89, you also find a code first note for any associated gangrene. This means if the patient has associated gangrene, you will code the gangrene and then follow it with the pressure ulcer/injury code.
L89 also has an excludes 2 note. The excludes 2 convention means that it is not coded here, unless they are unrelated. For example, a diabetic ulcer would not be assigned a code from the L89 category.
Continue to go back and look at the full categories for L80 through L99 to see if there are any further instructions, and in this case there are not.
Then, you also must go back to the beginning of the chapter and see if there are any additional instructions.
NOTE: A new guideline added October 1, 2019 for the 7th character of 6 directs you to use this character for pressure-induced deep tissue damage or deep tissue injury. Previously, deep tissue damage/injuries had been coded to unstageable.