Pressure Ulcers (aka decubitus ulcers) are one of the most common reasons for home healthcare services. Coding for a pressure ulcer requires two codes: A code to identify the location of the pressure ulcer (707.0x) and a code to identify the stage of the pressure ulcer (707.2x).
Pressure ulcer stages are based on severity, which is designated by stage I-IV and unstageable. Ulcer staging should be based on the ulcer’s deepest visible anatomical level. Review the history of each pressure ulcer in the medical record. If the pressure ulcer has ever been classified at a deeper stage than what is observed now, it should continue to be classified at the deeper stage.
When a pressure ulcer is covered with slough, eschar, or a non-removable dressing, these ulcers are coded as unstageable (707.25). The following ulcers are also coded as unstageable:
- pressure ulcers treated with a skin graft
- pressure ulcers treated with a muscle graft
- DTI (deep tissue injury) not due to trauma
If a pressure ulcer is treated with a muscle graft Aftercare Skin Surgery is coded followed by the location of the pressure ulcer (707.0x) preceded by unstageable pressure ulcer code (707.25).
If a patient is reported to have bilateral pressure ulcers of the same site and both ulcers are documented to be the same stage, only one code for the site and one code for the stage should be assigned.
However, if a patient is reported to have bilateral pressure ulcers of the same site but with different stages, one code is assigned for the site and one code for each stage should be assigned. The highest stage should be listed first.
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