ICD-10 Coding for Decubitus Ulcer Stage 2(L89.1, L89.22x)
Complete ICD-10-CM coding and documentation guide for Decubitus Ulcer Stage 2. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Decubitus Ulcer Stage 2
L89.1-L89.9Primary Range
Pressure ulcer codes by site and stage
This range includes all pressure ulcer stages and sites, with specific codes for stage 2 ulcers.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| L89.1 | Pressure ulcer of sacral region, stage 2 | Use when documenting a stage 2 ulcer in the sacral region with appropriate clinical findings. |
|
| L89.22x | Pressure ulcer of hip, stage 2 | Use for stage 2 ulcers on the hip with appropriate clinical documentation. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for stage 2 decubitus ulcer
Essential facts and insights about Decubitus Ulcer Stage 2
Primary ICD-10-CM Codes for decubitus ulcer stage 2
Decision Criteria
clinical Criteria
- Presence of partial thickness loss and red/pink wound bed
Applicable To
- Stage 2 sacral pressure ulcer
Clinical Validation Requirements
- Partial thickness loss of dermis
- Shallow open ulcer with red/pink wound bed
- No slough or eschar
Code-Specific Risks
- Confusing with unstageable ulcers
- Incorrectly documenting as stage 3
Coding Notes
- Ensure documentation specifies 'stage 2' and includes clinical indicators.
L89.22x - Pressure ulcer of hip, stage 2
Use for stage 2 ulcers on the hip with appropriate clinical documentation.
Applicable To
- Stage 2 hip pressure ulcer
Excludes
- Diabetic ulcers (E08-E13 with .62x)
- Non-pressure chronic ulcers (L97.-)
Clinical Validation Requirements
- Partial thickness loss of dermis
- Shallow open ulcer with red/pink wound bed
- No slough or eschar
Coding Notes
Document the ulcer's stage and location precisely.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Decubitus Ulcer Stage 2 to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code L89.1.
Impact
Clinical: Leads to inadequate treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential loss of reimbursement.
Mitigation Strategy
Use checklists for wound documentation, Regular staff training on documentation standards
Impact
Reimbursement: Incorrect coding may lead to improper DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure no slough or eschar covers the wound bed before coding as stage 2.
Impact
Missing details about ulcer stage and characteristics.
Mitigation Strategy
Implement regular audits and feedback loops.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Decubitus Ulcer Stage 2, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Decubitus Ulcer Stage 2
Use these documentation templates to ensure complete and accurate documentation for Decubitus Ulcer Stage 2. These templates include all required elements for proper coding and billing.
Documenting a stage 2 ulcer on the hip
Specialty: Wound CareRequired Elements
- Location
- Stage
- Size
- Wound bed description
- Exudate type
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Decubitus Ulcer Stage 2? Ask your questions below.