Q&A: Diagnosis coding for a healing pressure ulcer

Q: Would a pressure ulcer be considered healing when the patient comes back to the outpatient setting?

A: Ask yourself, “Has it completely healed or is it still healing?” The physician can certainly say it’s a healing ulcer under active treatment. A healed ulcer, on the other hand, does not need a code because it is an event that happened in the past, not a current event. Knowing where the treatment is for the ulcer will help you to determine if an ICD-10-CM code is needed or if you need more specificity on the ulcer’s stage.

Remember pressure ulcers can sometimes present with complications that warrant further treatment. Infection is a potential complication of the pressure ulcer that can rapidly progress to become a life-threatening condition. Any complications addressed during the hospital stay should be coded as additional diagnoses. Some complications to watch for when coding include sepsis, cellulitis, osteomyelitis, gangrene, and sepsis arthritis.

Editor’s Note: This article originally appeared in JustCoding. Sarah Humbert, RHIA, corporate coding and compliance manager for KIWI-TEK, and Temeka Davis, RHIT, coding manager for KIWI-TEK, answered this question during the HCPro webinar, “Pressure Ulcer Coding: Strategies for ICD-10-CM Coding Accuracy.”