With the arrival of the Patient-Driven Payment Model (PDPM) and consequent replacement of RUG-IV, ICD-10 diagnosis coding has become a pivotal learning opportunity in the skilled nursing facility (SNF) realm of healthcare. Nurse assessment coordinators (NACs) are frequently acting as ICD-10 sleuths, figuring out how a resident’s diagnosis should be portrayed in the Minimum Data Set (MDS) and beyond. Now’s the time to learn the ins and outs of coding top diagnoses you’ll see in your facility.
If you code for a SNF, you know that residents who spend a lot of time confined to a wheelchair, chair, or a bed, can develop pressure injuries, also known as pressure ulcers, pressure sores, decubitus ulcers, and bed sores.
Pressure ulcers are complicated diagnoses, and figuring out the correct ICD-10 code, in addition to everything you’re already worried about documenting per the MDS Resident Assessment Instrument (RAI) 3.0 User’s Manual, can be challenging. And while Section M (Skin Conditions) of the manual references many of the same criteria, such as site and severity, that you use to code pressure ulcers under ICD-10, it does not address issues such as sequencing and terminology that you need to master before entering the correct ICD-10 codes into Section I (Active Diagnoses) of the MDS.
Fortunately, there’s a simple, four-step process that you can use to find the correct ICD-10 pressure ulcer code quickly and correctly.
If your provider’s notes indicate the resident has gangrene, you’ll need to code that first before you dig into the L89 codes. ICD-10 directs you to code the condition with I96 (Gangrene, not elsewhere classified) and sequence it before the specified pressure ulcer.
ICD-10 breaks down pressure ulcer sites in the following way:
• L89.0- — Elbow
• L89.1- — Back
• L89.15- — Sacral region
• L89.2- — Hip
• L89.3- — Buttock
• L89.4- — Contiguous [touching, or next to] site of back, buttock and hip
• L89.5- — Ankle
• L89.6- — Heel
• L89.8- — Other site
• L89.81- — Head
• L89.9- — Unspecified site.
Very often, residents will present with pressure ulcers in multiple sites, which can result in a sequencing issue. When that occurs, go back through the doctor’s notes to see, first, if all the ulcers are being treated. If there’s only one, then that’s all you’ll need to code; if there are more, you would sequence them by severity, putting the most severe first.
More on that in a minute.
While the site categories are pretty self-explanatory, two of them can present problems unless you know what the ICD-10 terms “other” and “unspecified” mean. You would use an “other” code, such as L89.89- (Pressure ulcer of other site), if the provider has indicated where the ulcer is, but there is no specific code under L89.- that specifies the site documented.
Code L89.9- (Pressure ulcer of unspecified site), on the other hand, means that the provider has not documented where the ulcer is at all. You would rarely use this code, though you might see it in your provider’s documentation as it can be a default code choice in electronic health records (EHRs). If that is the case, you may want to query the physician and ask for a more definitive site choice for your documentation.
The L89 codes are broken down further by laterality, which means that you can choose between right, left, and unspecified anatomic areas of most sites using a fifth digit. There are no bilateral codes in the L89 section of ICD-10, however, which means that pressure ulcers that equally affect both sides of regions such as the hips and buttocks have to be coded separately using the codes for right and left.
Finally, pressure ulcers are categorized by degrees of severity, known as stages, that correlate to the depth of the tissue damage. Following the classification established by the National Pressure Ulcer Staging System (which is the same as the classification found in Section M of the RAI), they range from stage one, where the skin is merely inflamed and red, through to stage four, where there is bone-deep tissue loss along with necrosis. ICD-10 follows the same classification system, assigning sixth digits one through four for each corresponding stage.
When classifying severity using ICD-10 codes, however, you might also be confused by the words “unspecified” and “unstageable.” In these cases, unspecified takes on the same meaning as it did before, meaning that the physician did not document the severity of the wound, while unstageable simply means that the stage of the wound cannot be determined as slough and/or eschar are covering the would bed. As both of these things enable the wound to heal, a physician won’t remove them to determine the stage and could classify the severity of the wound as unstageable.
However, classifying a pressure ulcer’s severity as unspecified or unstageable is a rare occurrence.
Putting it All Together
Your physician treats a resident with a stage two pressure ulcer of the right buttock and a stage three pressure ulcer of the right hip. The doctor’s notes indicate that the wounds are not contiguous, so you would code
L89.213 (Pressure ulcer of right hip, stage 3)
L89.312 (Pressure ulcer of right buttock, stage 2).
Per the sequencing guidelines mentioned earlier, you would sequence the most severe pressure ulcer — the stage three ulcer of the right hip — first.
Contributing editor: Rachel Dorrell
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