Pressure ulcers or pressure-induced deep-tissue damage occurs due to pressure breaking down the skin and underlying tissue. The ICD-10 updates in 2020 include the addition of new codes for the reporting of pressure-induced deep-tissue damage. The new codes are of special interest to podiatry medical billing service providers as the heels and ankles are common sites for pressure ulcers. Other areas where pressure ulcers develop include the hips, tailbone, head, shoulders, elbows, and other places where the skin covers bone.

Also known as deep-tissue pressure injury (DTPI), these ulcers are common among patients hospitalized in acute- and chronic-care facilities. It is estimated that about 1 million pressure injuries occur in the United States every year.

How Pressure Ulcers develop

As the term implies, ‘a pressure ulcer results when an area of the skin comes under pressure, breaking down the skin and underlying tissue. Pressure ulcers tend to affect people who are confined to a bed for long periods of time due to a health condition that makes movement difficult.

The extra pressure to the skin and soft tissue affects the flow of blood through the skin. Deprived of blood supply, oxygen and nutrients fail to reach the affected area, and it begins to break down, leading to the formation of an ulcer. Conditions that affect the flow of blood through the body, such as type 2 diabetes, also put a person at risk of pressure ulcers. As they form in deep tissue, the injuries may not be visible until they reach an advanced stage.

Symptoms

Early symptoms of a pressure ulcer include skin discoloration that persists even when the skin is pressed, skin that feels warm, spongy or hard, pain or itchiness in the affected area. A pressure ulcer at this stage may be referred to as a category one pressure ulcer.

Symptoms of a pressure ulcer can progress to broken skin and an open wound or blister (a category two ulcer), and a deep wound that may reach the muscle and bone (a category four ulcer).

As they form in deep tissue, these ulcers may not be visible until they reach an advanced stage.

ICD-10 Code Changes for Deep Tissue Pressure Ulcers in 2020

The FY 2020 ICD-10-CM Official Guidelines for Coding and Reporting provide greater clarity on reporting healed/healing pressure ulcers and pressure-induced deep tissue damage. There are new ICD-10 codes under category L89 Pressure ulcer as well as new guidelines on assigning these codes in 2020. The ICD-10 changes and guidelines for pressure ulcers that came into effect on Oct 1, 2019 are as follows:

Addition of a new fifth or sixth character option for the L89-series of codes: An article in Podiatry Today explains that when coding for lower extremity skin changes that result from prolonged pressure, coding will start with the following code stems –

  • L89.51 – Pressure ulcer of right ankle
  • L89.52 – Pressure ulcer of left ankle
  • L89.61 – Pressure ulcer of right heel
  • L89.62 – Pressure ulcer of left heel
  • L89.89 – Pressure ulcer of other site

A sixth character is required on these code stems to complete the code, and the options are:

0 – Unstageable
1 – Stage 1
2 – Stage 2
3 – Stage 3
4 – Stage 4
9 – Unspecified stage

While these character options continue to be used, the 2020 update introduces a new fifth or sixth character of “6” to specifically indicate “pressure-induced deep tissue damage.” For example:

  • L89.016 Deep tissue pressure injury of right elbow
  • L89.626 Pressure-induced deep tissue damage of left heel

Coding deep tissue injuries: The new ICD-10 codes for deep pressure-induced tissue damage that came into effect Oct. 1, 2019 are as follows:

  • L89.116 – Pressure-induced deep tissue damage of right upper back
  • L89.126 – Pressure-induced deep tissue damage of left upper back
  • L89.136 – Pressure-induced deep tissue damage of right lower back
  • L89.146 – Pressure-induced deep tissue damage of left lower back
  • L89.156 – Pressure-induced deep tissue damage of sacral region
  • L89.206 – Pressure-induced deep tissue damage of unspecified hip
  • L89.216 – Pressure-induced deep tissue damage of right hip
  • L89.226 – Pressure-induced deep tissue damage of left hip
  • L89.306 – Pressure-induced deep tissue damage of unspecified buttock
  • L89.316 – Pressure-induced deep tissue damage of right buttock
  • L89.326 – Pressure-induced deep tissue damage of left buttock
  • L89.46 – Pressure-induced deep tissue damage of contiguous site of back, buttock and hip
  • L89.506 – Pressure-induced deep tissue damage of unspecified ankle
  • L89.516 – Pressure-induced deep tissue damage of right ankle
  • L89.526 – Pressure-induced deep tissue damage of left ankle
  • L89.606 – Pressure-induced deep tissue damage of unspecified heel
  • L89.616 – Pressure-induced deep tissue damage of right heel
  • L89.626 – Pressure-induced deep tissue damage of left heel
  • L89.816 – Pressure-induced deep tissue damage of head
  • L89.896 – Pressure-induced deep tissue damage of other site
  • L89.96 – Pressure-induced deep tissue damage of unspecified site

Distinction between healed/healing pressure ulcers and pressure-induced deep tissue damage: The 2020 ICD-10 guidelines also provide additional clarity on patients admitted with pressure ulcers documented as healed and add the phrase “at the time of admission”. Revenue Cycle Advisor highlights the following points with regard to reporting pressure ulcer stages:

  • If the pressure ulcer was to the bone (stage 4) but improves during the hospital stay to only include the depth of the subcutaneous tissue (stage 3), the pressure ulcer is to be reported as a stage 4 pressure ulcer, not a stage 3.
  • If a pressure ulcer was present on admission and is healed at the time of discharge, the site and stage of the pressure ulcer at the time of admission should be reported.
  • If a pressure ulcer present on admission is at one stage and advances to another stage during the patient’s hospital stay, two codes should be assigned: the first code is for the site and stage of the pressure ulcer at the time of admission, and the second code should indicate the same ulcer site but the highest stage documented during the stay.
  • A pressure ulcer/non-pressure ulcer is not reported is when it is healed at the time of admission.

These coding and reporting changes are aimed at helping clinicians better identify and track deep pressure-induced tissue damage in their patients for surveillance and quality improvement purposes. Coders in companies providing physician billing services are knowledgeable about ICD-10 and CPT code changes, state and national regulations, and payer guidelines, which allows them to help providers report diagnosis and treatment correctly for accurate billing and optimal reimbursement.