Q&A: Skin failure due to hypoperfusion
Q: We recently had a patient who presented with a stage 2 pressure ulcer. Due to hypoperfusion, the pressure ulcer progressed. The physicians are now documenting progression due to “skin failure” due to hypoperfusion. Can you have skin failure at the same site of a pressure ulcer, or is it progression of the pressure ulcer to stage 3 or 4?
A: A pressure injury is described as localized damage to skin and/or underlying soft tissue, typically over a bony prominence that is a result of pressure.
Skin failure is a loss of normal temperature control with an inability to maintain core body temperature; failure to prevent percutaneous loss of fluid, electrolytes, and protein with resulting imbalance; and failure of the mechanical barrier to prevent penetration of foreign materials.
Acute skin failure describes the cause of integumentary loss in association with hemodynamic instability and/or organ system compromise in critically ill patients. Current research show that we may be inaccurately classifying pressure injuries when skin failure is the likely cause.
So, clinically, can a patient have both a pressure injury and skin failure? Yes, they can. The documentation does need to specifically state the pressure ulcer worsened “due to hypoperfusion,” not due to pressure. Currently, there is no specific code for skin failure, so the advice out there is to use code L98.9. You can code both, stage 2 pressure injury POA-Y did not evolve to a higher stage related to pressure and other disorders of the skin, and L98.9 POA-N for the skin failure. These are two different diagnoses.
The skin failure would not be considered a worsening of a pressure injury (like acute respiratory failure worsening to acute respiratory distress syndrome or acute kidney injury worsening to acute tubular necrosis). As long as the documentation is specific as to the cause, which in this case is hypoperfusion, it is acceptable to document and capture the diagnoses.
We also see issues related to Kennedy Terminal Ulcers (KTU). These are ulcers develop quickly due to the dying process. There are no specific codes for a KTU and Coding Clinic Second Quarter 2018, page 21, advises (bold added):
Assign the appropriate code from category L89, Pressure ulcer, for a Kennedy ulcer. A Kennedy ulcer is a type of pressure ulcer that occurs at the end of life and is related to multiorgan failure. Because of its pathophysiology, this type of pressure ulcer does not typically respond to standard treatment. In view of the implications of a Kennedy ulcer for prognosis, and the differences in response from other pressure ulcers, a proposal for creation of a separate code for Kennedy ulcer may be taken to a future ICD-10 Coordination and Maintenance Meeting.
More recent studies have shown that a KTU is likely skin failure as a result of ischemia from the dying process. This is not to say that there KTUs are strictly due to hypoperfusion, as there may be an element of pressure causing the injury. The focus for CDI work is understanding the etiology of the injury, pulling the clinical indicators together to specify the cause of the skin breakdown.
Documentation of a Kennedy ulcer without further specification will be coded as a pressure injury POA-N, which is a well-known HAC and PSI. Is this an accurate representation of the etiology of the skin injury? In certain circumstances it may be accurate and in other circumstances it may not. This is an area where CDI professionals can work with providers, wound care specialists, coders, and quality professionals to provide the necessary education so we are all capturing these specific diagnoses appropriately and accurately.
Editor’s note: Kim Conner, BSN, CCDS, CCDS-O, CDI education specialist for ACDIS/HCPro based in Middleton, Massachusetts, answered this question. Contact her at firstname.lastname@example.org.