ICD-10 Coding for Deep Tissue Injury(L89.-6)
Complete ICD-10-CM coding and documentation guide for Deep Tissue Injury. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Deep Tissue Injury
L89.-6Primary Range
Pressure-induced deep tissue damage
This range is used for coding deep tissue injuries due to pressure, regardless of progression to open ulcer.
Key Information: ICD-10 code for deep tissue injury
Essential facts and insights about Deep Tissue Injury
Primary ICD-10-CM Code for deep tissue injury
Decision Criteria
clinical Criteria
- Presence of intact skin with purple/maroon discoloration
documentation Criteria
- Documented tenderness, temperature change, or tissue firmness/bogginess
Applicable To
- Intact skin with purple/maroon discoloration
- Blood-filled blister
Excludes
- Open ulcers of the same site
Clinical Validation Requirements
- Intact skin with purple/maroon discoloration
- Tenderness, temperature change, or tissue firmness/bogginess
Code-Specific Risks
- Incorrectly coding as an open ulcer
- Missing documentation of intact skin
Coding Notes
- Always code L89.-6 as primary when DTPI is present, even if ulceration occurs later.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Risk factors such as paralysis or malnutrition
Z91.41-Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Pressure ulcer stages 1-4
L89.00-L89.4Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Deep Tissue Injury to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code L89.-6.
Impact
Clinical: Misdiagnosis risk., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Use specific descriptors for skin condition., Include patient-reported symptoms.
Impact
Reimbursement: Incorrect staging can lead to reimbursement errors., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Code DTPI as L89.-6 only, do not stage.
Impact
Coding DTPI as POA=No when present on admission.
Mitigation Strategy
Ensure thorough admission assessments and documentation.
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 Deep Tissue Injury, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Deep Tissue Injury
Use these documentation templates to ensure complete and accurate documentation for Deep Tissue Injury. These templates include all required elements for proper coding and billing.
Acute Care H&P
Specialty: Wound CareRequired Elements
- Location and size of discoloration
- Skin integrity
- Tenderness and temperature changes
- Plan for pressure offloading
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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