ICD-10 Coding for Sacral Pressure Ulcer(L89.150, L89.151, L89.152, L89.153, L89.154, L89.159)
Complete ICD-10-CM coding and documentation guide for Sacral Pressure Ulcer. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Sacral Pressure Ulcer
L89.15-L89.159Primary Range
Pressure ulcer of sacral region
This range includes codes for pressure ulcers specifically located in the sacral region, detailing laterality and stage.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| L89.150 | Pressure ulcer of sacral region, unspecified stage | Use when the stage of the sacral pressure ulcer is not documented. |
|
| L89.151 | Pressure ulcer of sacral region, stage 1 | Use for sacral ulcers with intact skin and non-blanchable redness. |
|
| L89.152 | Pressure ulcer of sacral region, stage 2 | Use for sacral ulcers with partial thickness skin loss. |
|
| L89.153 | Pressure ulcer of sacral region, stage 3 | Use for sacral ulcers with full thickness skin loss. |
|
| L89.154 | Pressure ulcer of sacral region, stage 4 | Use for sacral ulcers with exposed bone, tendon, or muscle. |
|
| L89.159 | Pressure ulcer of sacral region, unspecified stage | Use when the stage of the sacral pressure ulcer is not documented. |
|
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 sacral pressure ulcer
Essential facts and insights about Sacral Pressure Ulcer
Primary ICD-10-CM Codes for sacral pressure ulcer
Decision Criteria
documentation Criteria
- Stage of ulcer is not documented
Applicable To
- Sacral pressure ulcer, unspecified stage
Excludes
- Pressure ulcer of other sites
Clinical Validation Requirements
- Documentation of sacral location
- Absence of stage specification
Code-Specific Risks
- Risk of under-documentation leading to unspecified coding.
Coding Notes
- Ensure documentation specifies sacral location even if stage is unspecified.
L89.151 - Pressure ulcer of sacral region, stage 1
Use for sacral ulcers with intact skin and non-blanchable redness.
Applicable To
- Sacral pressure ulcer, stage 1
Excludes
- Pressure ulcer of other sites
Clinical Validation Requirements
- Documentation of sacral location
- Stage 1 description: non-blanchable erythema
Coding Notes
Ensure clear documentation of non-blanchable erythema.
L89.152 - Pressure ulcer of sacral region, stage 2
Use for sacral ulcers with partial thickness skin loss.
Applicable To
- Sacral pressure ulcer, stage 2
Excludes
- Pressure ulcer of other sites
Clinical Validation Requirements
- Documentation of sacral location
- Stage 2 description: partial thickness skin loss
Coding Notes
Document partial thickness loss clearly.
L89.153 - Pressure ulcer of sacral region, stage 3
Use for sacral ulcers with full thickness skin loss.
Applicable To
- Sacral pressure ulcer, stage 3
Excludes
- Pressure ulcer of other sites
Clinical Validation Requirements
- Documentation of sacral location
- Stage 3 description: full thickness skin loss
Coding Notes
Ensure documentation of full thickness loss.
L89.154 - Pressure ulcer of sacral region, stage 4
Use for sacral ulcers with exposed bone, tendon, or muscle.
Applicable To
- Sacral pressure ulcer, stage 4
Excludes
- Pressure ulcer of other sites
Clinical Validation Requirements
- Documentation of sacral location
- Stage 4 description: full thickness tissue loss with exposed bone
Coding Notes
Document exposed structures clearly.
L89.159 - Pressure ulcer of sacral region, unspecified stage
Use when the stage of the sacral pressure ulcer is not documented.
Applicable To
- Sacral pressure ulcer, unspecified stage
Excludes
- Pressure ulcer of other sites
Clinical Validation Requirements
- Documentation of sacral location
- Absence of stage specification
Coding Notes
Ensure documentation specifies sacral location even if stage is unspecified.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Sacral Pressure Ulcer to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code L89.150.
Impact
Clinical: Inadequate treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use standardized templates., Regular staff training on documentation.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data reporting.
Mitigation Strategy
Ensure documentation specifies if the ulcer is covered by slough/eschar (unstageable) or if the stage is simply not documented (unspecified).
Impact
Reimbursement: Potential loss of reimbursement for additional ulcers., Compliance: Failure to meet coding specificity requirements., Data Quality: Incomplete clinical data.
Mitigation Strategy
Document and code each ulcer site and stage separately.
Impact
Inadequate documentation of ulcer stage can lead to audit findings.
Mitigation Strategy
Implement regular documentation audits and staff training.
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 Sacral Pressure Ulcer, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Sacral Pressure Ulcer
Use these documentation templates to ensure complete and accurate documentation for Sacral Pressure Ulcer. These templates include all required elements for proper coding and billing.
Wound Care Progress Note
Specialty: Wound CareRequired Elements
- Location
- Stage
- Measurements
- Undermining
- Exudate
- Odor
- Edges
- Surrounding Skin
- Bone Visible
- Treatment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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