Pressure Ulcer Stages
Codes from ICD-10-CM category L89 are combination codes that identify the site of the pressure ulcer and the stage of the ulcer.
ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, unspecified stage and unstageable.
Assign as many codes from category L89 as needed to report all the pressure ulcers the patient has.
Unstageable Pressure Ulcers
Assignment of the ICD-10 CM codes for unstageable pressure ulcer (L89.--0) is based on documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined perhaps because the ulcer is covered by eschar or for some other reason and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma.
Do not confuse "unstageable" pressure ulcer with "unspecified stage" when there is no documentation regarding the stage of the pressure ulcer.
Documented Pressure Ulcer Stage
Assignment of the ICD-10-CM pressure ulcer stage code is based on documentation of the stage or documentation of the terms found in the Alphabetic Index.
For clinical terms describing the stage that are not found in the Alphabetic Index, and there is no documentation of the stage, the provider should be queried.
Healed Pressure Ulcers
No ICD-10-CM code is assigned if the documentation states that the pressure ulcer is completely healed.
Healing Pressure Ulcers
Pressure ulcers documented as healing should be assigned the pressure ulcer stage code based on the documentation in the medical record.
If the documentation does not state the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage.
If the documentation is unclear as to whether there is a current (new) pressure ulcer or if there is a healing pressure ulcer, query the provider.
Pressure Ulcer Evolving
If a pressure ulcer at one stage progresses to a higher stage, then report the code for the highest stage for that site.
ICD-10-CM Official Guidelines for Coding and Reporting
