Decubitus (pressure) ulcer, Stage II (to fascia, just under skin)
| ICD10 Diagnosis | |
| Dx: | Decubitus (pressure) ulcer, Stage II (to fascia, just under skin) |
| ICD10 code: | L89.1 |
| Pre-ICD10 counterpart: | Ulcers - Decubitus only |
| Charlson/ALERT Scale: | none |
| APACHE Como Component: | none |
| APACHE Acute Component: | none |
| Start Date: | |
| Stop Date: | |
| External ICD10 Documentation | |
This diagnosis is a part of ICD10 collection.
Additional Info
- Stage 2 - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
- involves dermis and epidermis
- May also present as an intact or ruptured serum filled blister
Excludes
- excoriation from skin irritation, shearing or skin tears, unless they progress to a documented Stage II pressure ulcer, this can be difficult to know when this happens, so use best clinical judgment based on documentation.
Coding multiple ulcers
- If there are pressure ulcers on DIFFERENT body parts (e.g. left heel, right heel, coccyx) then code them separately -- even though they will not be readily distinguishable as the code doesn't include body location.
- If there are multiple pressure ulcers close to each other on the same body part (e.g. coccyx area) then only code the one of the highest/worst stage.
Coding Progression of Ulcers
- Progression of Ulcers should be coded following our guidelines for Acquired Diagnosis combine each stage progression with the date and time it was noted in the chart.
If there are multiple pressure ulcers follow the above guidelines -- even though they will not be readily distinguishable as the code doesn't include body location.
- Julie will report on the worst stage from Acquired Diagnosis
- NOTE: As per our TASK meeting , there was a significant rise in the number of acquired stage 1 and 2 decubitus ulcers at the GGH ICU, beginning Jan 2022.
A sample of charts from the timeframe of concern was audited, and we collaborated with the GGH educator and manager and we were unable to determine a reason for this rise. Going forward, a recommendation will be forwarded to the OIT committee, and education about proper documentation of stages of decubitus ulcers will be reinforced across all sites. This will begin in March 2024. Up until March 2024 the data re. acquired decubitus ulcers is not reliable, as it often required the collector to subjectively interpret documentation on the stage of the decubitus ulcer.
Alternate ICD10s to consider coding instead or in addition
| Decubitus ulcer codes: |
Or:
Candidate Combined ICD10 codes
Related CCI Codes
- code Debridement if applicable
Data Integrity Checks (automatic list)
none found
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