The Dilemma of Coding of Deep Tissue Pressure Injury as an Unstable Pressure Sores

The ICD-10 has expanded to include codes for Deep Tissue Pressure Injury (DTPI) as of October 1, 2019. Prior to this change, DTPI was coded as an unstable pressure injury.  However, the common approach to unstable wounds is to debride them in order to determine the extent and stage them once the wound can be seen or probed.  DTPI in its early stages is usually not debrided; hence the code for unstageable wounds did not denote the problem.

According to an article by wound billing expert, Lisa Baris, RHIT, CCS, CCDS on ICD10Monitor.com,

• In the previous staging system, Stage 1 and Deep Tissue Injury described injured intact skin, while the other stages described open ulcers. This led to confusion because the definitions for each of the stages referred to the injuries as “pressure ulcers.” A pressure injury is now described as “localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or another device.” The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by “microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue.”

• Deep Tissue Pressure Injury (DTPI) is now defined as “intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, (or) purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This condition results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may “evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.”

• “Deep tissue injury” is currently indexed to “ulcer, pressure, unstageable, by the site.” However, unstageable ulcers can only be Stage 3 or 4, by definition (“full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed”). By contrast, a deep-tissue injury may resolve without tissue loss. In addition, deep-tissue injuries often have a combined etiology involving both ischemia and pressure.

The question troubling quality, clinical documentation integrity, and coding professionals since the updated coding guidelines were published and new codes released is this:

how do we assign a code for a deep-tissue pressure injury (DTPI) that presents as intact skin, but evolves rapidly to an open wound with tissue loss that is then staged as a 3 or 4 pressure ulcer, remembering that this can occur even with optimal care and treatment?

There are three basic choices to consider for a patient whose clinical picture supports a deep-tissue pressure-induced injury that is present on initial admission and later evolved into a Stage III or IV pressure ulcer.

• Assign only one code to report the DTPI, with a POA status of yes
• Assign a code to report the DTPI with POA status of yes, and assign a code for the Stage 3 or Stage 4 ulcer with a POA status of yes
• Assign a code to report the DTPI with POA status of yes, and assign a code for the Stage 3 or Stage 4 ulcer with a POA status of no

In Patient admitted with pressure ulcer evolving into another stage during the admission:

• If a patient is admitted to an inpatient hospital with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.

Pressure-induced deep tissue damage:

• For pressure-induced deep-tissue damage or deep-tissue pressure injury, assign only the appropriate code for pressure-induced deep-tissue damage (L89.XX6).

Medical Billing Expert can help with reviewing of wound management codes for your Pressure Injury case to identify any discrepancies within medical records about the wound or staging of the wound.  Our Medical Billing experts are ready to assist with your next case.  Contact us for a free case consultation.