August 01, 2015
Area(s) of Interest: Patient Care Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from Peggy Silley, the Director of ICD-10 Development and Training for AAPC, a training and credentialing association for the business side of health care.   

Codes for pressure ulcers and non-pressure chronic ulcers are located in ICD-10-CM chapter 12, “Disease of the skin and subcutaneous tissue.” The concept of laterality (e.g., left or right) is introduced, and should be included in the clinical documentation for skin ulcers.

ICD-10-CM codes for pressure ulcers, located in Category L89, are combination codes that identify the site, stage and (in most cases) the laterality of the ulcer. Possible stages are 1-4 and unstageable.

• Stage 1: Skin changes limited to persistent focal edema
• Stage 2: An abrasion, blister and partial thickness skin loss involving the dermis and epidermis
• Stage 3: Full thickness skin loss involving damage and necrosis of subcutaneous tissue
• Stage 4: Necrosis of soft tissues through the underlying muscle, tendon or bone
• 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.

An instructional note in ICD-10 states to also code any associated gangrene (I96).

Non-pressure chronic ulcers are similar to pressure ulcers in that they require documentation of the site, severity and laterality. Category L97 and L98 are for non-pressure ulcers, and have an instructional note to code first any associated underlying condition, such as:

• Associated gangrene
• Atherosclerosis of the lower extremities
• Chronic venous hypertension
• Diabetic ulcers
• Postphlebetic syndrome
• Postthrombotic syndrome
• Varicose ulcers

The severity of the ulcers is described as:

• Limited to breakdown of skin
• With fat layer exposed
• With necrosis of muscle
• With necrosis of bone

Example 1: A type 1 diabetic patient is seen in the clinic. Upon examination of her feet, she is noted to have a left heel ulcer with the breakdown of skin into the dermis, but not full thickness. The physician documents a diagnosis of diabetic heel ulcer.

• E10.621 Type 1 diabetes mellitus with foot ulcer
• L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin

Following the instructional notes under category L97, the code for the underlying condition—here, diabetes mellitus—is listed first.

Codes for healing pressure ulcers are assigned based on documentation of current stage. Assign as many codes as necessary to identify all pressure ulcers for the patient.

Example 2: A patient presents on referral for diabetic right great toe ulcer with gangrene. Upon exam, there was swelling, discoloration and malodor, with necrosis into the bone. Patient will be admitted to the hospital for IV antibiotics and surgical intervention. The patient is a type 2 diabetic.

Documentation supports type 2 diabetes, right great toe ulcer with gangrene. The documentation parameters are met with site of the great toe, laterality of right and severity of necrosis of bone. Following the guidelines the codes for the underlying condition and the gangrene are reported first, followed by the code from category L97.

• E11.621 Type II diabetes with foot ulcer
• I96 Gangrene, not elsewhere classified
• L97.514 Non-pressure chronic ulcer of other part of right foot with necrosis of bone

Example 3: A patient is seen for bilateral pressure ulcers to the buttocks and elbows. The pressure ulcers on the elbows are documented as partial thickness skin loss into the dermis. The pressure ulcers on the buttocks are documented as full thickness skin loss with necrosis into the subcutaneous tissue.

• L89.313 Pressure ulcer of right buttock, stage 3
• L89.323 Pressure ulcer of left buttock, stage 3
• L89.012 Pressure ulcer of right elbow, stage 2
• L89.022 Pressure ulcer of left elbow, stage 2

Stage 3 describes healing or full thickness skin loss involving damage or necrosis of subcutaneous tissue, which matches the physician documentation. Following the guidelines, these ulcers would be coded as stage 3.

The pressure ulcers on the elbows are documented as partial thickness into the dermis, which supports stage 2 (stated to be healing or abrasion, blister, partial thickness skin loss involving epidermis and/or dermis)—which again matches the physician documentation. Following the guidelines, these ulcers are coded as stage 2. No bilateral codes are available; therefore, each pressure ulcer is assigned a separate code. 

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