Tip: Navigating the 2017 pressure ulcer coding changes

by Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP

As if coders and CDI specialists aren’t under enough pressure as it is, the advent of the 2017 ICD-10-CM Official Guidelines for Coding and Reporting brings to the table new documentation requirements for pressure ulcer coding.

Considering that these conditions have an effect on length of stay, require additional monitoring and nursing care, and ultimately affect reimbursement for facilities, it’s no wonder auditors scrutinize coding for these conditions. However, a solid understanding of these types of ulcers and the coding requirements can alleviate the “confusion of ulcer codes.

In April, the National Pressure Ulcer Advisory Panel (NPUAP) revised the pressure injury staging system. Since then, the NPUAP has received positive feedback regarding the system, and in August, the Joint Commission adopted the new terminology.

The definitions for each type of pressure injury are now:

Stage 1 pressure injury: Non-blanchable erythema of intact skin: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (e.g., skin tears, burns, abrasions).

Stage 3 pressure injury: Full-thickness skin loss: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury.

Stage 4 pressure Injury: Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury.

Unstageable pressure injury: Obscured full-thickness skin and tissue loss: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema, or fluctuance) on an ischemic limb or the heel(s) should not be removed.

Deep tissue pressure injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (i.e., unstageable, stage 3, or stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

The new staging system identifies the stages of pressure ulcers as 1 through 4 as well as an unstageable ulcer. These are similar to the codes from the L89 category in ICD-10-CM, however the system introduces new terms in an attempt to more accurately describe the stages and descriptions of such injuries.

The NPUAP no longer uses the term “pressure ulcer,” and has replaced it with “pressure injury,” since stage 1 and deep tissue injuries describe intact skin, not open ulcers. The system also introduced the new term DTPI with this update.

Editor’s note: This is an excerpt of an article originally published by JustCoding. Click here to access the full article.