ICD-10 Coding for Stage 2 Pressure Ulcer, Coccyx(L89.152)
Complete ICD-10-CM coding and documentation guide for Stage 2 Pressure Ulcer, Coccyx. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Stage 2 Pressure Ulcer, Coccyx
L89.1-L89.15Primary Range
Pressure ulcer of sacral region
This range includes codes for pressure ulcers located in the sacral region, which encompasses the coccyx.
Key Information: ICD-10 code for stage 2 pressure ulcer coccyx
Essential facts and insights about Stage 2 Pressure Ulcer, Coccyx
Primary ICD-10-CM Code for stage 2 pressure ulcer coccyx
Decision Criteria
clinical Criteria
- Partial-thickness skin loss with red/pink wound bed
documentation Criteria
- Documentation must specify 'stage 2' and 'coccyx' location
Applicable To
- Stage 2 pressure ulcer of coccyx
Excludes
- Stage 3 or higher pressure ulcers
- Unstageable pressure ulcers
Clinical Validation Requirements
- Partial-thickness skin loss involving epidermis and/or dermis
- Red/pink wound bed without slough or eschar
Code-Specific Risks
- Misclassification if granulation tissue is present, indicating a deeper stage.
Coding Notes
- Ensure documentation specifies 'stage 2' and describes the wound bed accurately to avoid misclassification.
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 Stage 2 Pressure Ulcer, Coccyx to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code L89.152.
Impact
Clinical: Leads to inadequate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Educate providers on the importance of staging., Use templates to ensure all required elements are documented.
Impact
Reimbursement: Incorrect staging can lead to improper DRG assignment., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data affecting patient care and research.
Mitigation Strategy
Query the provider to confirm the correct stage if granulation tissue is documented.
Impact
Reimbursement: Incorrect POA can affect HAC penalties., Compliance: Non-compliance with CMS guidelines., Data Quality: Inaccurate hospital-acquired condition reporting.
Mitigation Strategy
Use POA: Y for the original stage and POA: N for the progressed stage.
Impact
Incorrect POA indicators for ulcers that progress during admission.
Mitigation Strategy
Educate coding staff on updated guidelines and conduct regular audits.
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 Stage 2 Pressure Ulcer, Coccyx, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Stage 2 Pressure Ulcer, Coccyx
Use these documentation templates to ensure complete and accurate documentation for Stage 2 Pressure Ulcer, Coccyx. These templates include all required elements for proper coding and billing.
Documenting a stage 2 pressure ulcer on the coccyx
Specialty: Wound CareRequired Elements
- Location: Coccyx
- Stage: 2
- Size: __ cm x __ cm
- Tissue: Partial thickness, red/pink bed
- Exudate: Serous/serosanguineous
- Edges: Attached, no undermining
- Surrounding Skin: Erythema present/absent
- Treatment: Offloading, hydrogel dressing q24h
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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