Pressure Ulcer (Pressure Injury) ICD-10-CM codes

Every L89 code carries site, laterality and stage. The 4th character is the site (elbow, back, hip, buttock, contiguous back-buttock-hip, ankle, heel, head or other), the 5th character is the specific part or side, and the 6th character is the stage: 0 unstageable, 1 through 4 for stages 1 to 4, 6 for pressure-induced deep tissue damage, and 9 for unspecified stage. A stage 3 sacral ulcer is L89.153; a stage 2 ulcer of the right heel is L89.612. Assign one code for each ulcer site documented.

Stage assignment follows the clinical documentation of the stage or of the ulcer depth (skin loss, exposed fat, exposed muscle or bone). Per the official guidelines, the stage may be taken from documentation by clinicians other than the patient's provider, such as wound-care nurses, as long as the provider has documented the ulcer diagnosis. Unstageable (6th character 0) is reserved for ulcers whose base is obscured by eschar or slough or that have been covered by a graft. Do not use it when the stage is simply missing from the record; that is unspecified stage (9), and it is a query opportunity.

If an ulcer worsens during an inpatient stay, report two codes for that site: one for the stage on admission and one for the highest stage reached. A healed pressure ulcer is not coded. A healing ulcer is coded to the stage documented, and a documented deep tissue pressure injury uses the 6th character 6 codes. When gangrene is present, sequence I96 first as instructed by the code-first note on L89.