The Dilemma of Coding and Reporting Deep-Tissue Pressure Injuries

The release of the 2020 Official Guidelines for Coding and Reporting (OCG) has resulted in confusion and apprehension surrounding the intent of the new guideline related to the new ICD-10-CM codes for pressure-induced deep-tissue damage, or deep-tissue pressure injury (L89.-6).

The ambiguity stems from what appears to be conflicting advice found within the coding guidelines (I.C.12.a) regarding pressure ulcer stage codes.

To provide history on the introduction of the new ICD-10-CM codes, we can reference the September 2018 Coordination and Maintenance Committee meeting. During this meeting, the following three points were discussed, based upon the request by the Centers for Medicare & Medicaid Services (CMS) for Healthcare Research and Quality (AHRQ) for new codes in order to identify and track deep-tissue injuries (DTIs) for surveillance and quality improvement purposes. The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education, and research. In 2016, the NPUAP adopted several changes to pressure ulcer staging, based on recent clinical literature and expert consensus, which introduced minor inconsistencies with ICD-10-CM.

• 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.

From a quality reporting perspective, a Stage 3, Stage 4, or unstageable ulcer will trigger a patient safety indicator (PSI), specifically PSI 3, pressure ulcer rate, which is also part of the PSI-90 composite. The PSI global exclusion of present on admission (POA) does apply; therefore, if the pressure ulcer is documented as present on admission, the pressure ulcer would be excluded from PSI reporting. A Stage 3 or 4 pressure ulcer not present on admission is also classified as a hospital-acquired condition (HAC). For these reasons, hospitals find it imperative to correctly report the ICD-10-CM codes and POA status for all documented pressure ulcers.

The question plaguing 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?

If we review our options for coding and reporting, there are three basic choices to consider for a patient whose clinical picture supports a deep-tissue pressure-induced injury that is present on admission and later evolves into a Stage 3 or 4 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

Interestingly, each of these options has rationale to support the choice that could be used to defend the ICD-10-CM code(s) and POA status reported – and yet, each option raises additional questions or concerns.

• The decision to report a single code that is meant to capture the DTPI along with the staged ulcer could be supported with the new guideline, which tells us specifically for pressure-induced deep-tissue damage or deep-tissue pressure injury, assign only the appropriate code for pressure-induced deep-tissue damage (L89.–6). In our example above, the DTPI is documented as present on admission, which indicates a POA status of yes. This option allows for the capture of the DTPI while not penalizing a hospital for progression to an open “non-intact” DTPI, which can occur based on the clinical nature of a deep-tissue pressure injury even when optimal care is provided to the patient. From a severity-of-illness (SOI) perspective, this option does not allow us to capture and report the severity of a progression to a Stage 3 or Stage 4 wound, which can significantly impact patient care for an extended period of time in subsequent encounters and care settings.

• The decision to report two codes, one for the DTPI and one for the staged ulcer, could be supported with the established guideline that tells us 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. American Hospital Association (AHA) Coding Clinic guidance published for the fourth quarter of 2017 provides advice regarding an unstageable ulcer present on admission, in which the eschar was removed during the stay to reveal a Stage 3 or 4 pressure ulcer. The advice states to code only the staged ulcer and to use the POA status of yes. This is not exactly the same scenario as our DTPI that evolves into a Stage 3 or 4 ulcer; however, it does indicate that perhaps it is acceptable to code both conditions with a POA status of yes, since it could be considered one deep-tissue pressure-induced injury that was present on admission. This option would not trigger a PSI or HAC because the Stage 3 or Stage 4 ulcer is noted to be present on admission. Therefore, allowing for the capture of the DTPI while not penalizing a hospital for progression to an open “non-intact” DTPI, which, again, can occur based on the clinical nature of a deep-tissue pressure injury even with optimal care provided to the patient. From a SOI perspective, this reporting option also allows us to capture the severity of a progression to a Stage 3 or Stage 4 wound, which can significantly impact patient care for an extended period of time in subsequent encounters and care settings. However, this option makes a clear clinical distinction between a DTPI and a Stage 3 or 4 pressure injury, and begs the question, is this the true intent, or were the new ICD-10-CM codes created to specifically identify a deep-tissue pressure-induced injury as just that, regardless of intact or non-intact presentation and/or progression? Also, what then is the relevance of the new Pressure-Induced Deep-Tissue Injury Guideline?

• The decision to report two codes, one for the DTPI and one for the staged ulcer, could be supported with the rationale provided above. However, one could cite the AHA Coding Clinic published in the fourth quarter of 2016 regarding the POA status. This Coding Clinic advises that if a pressure ulcer is documented at time of admission at one stage and evolves to a higher stage during the admission, the POA status would be yes for the stage at time of admission and no for the higher stage that evolved. This option would potentially trigger a reportable PSI, as well as the HAC. Is this option fair to healthcare organizations that provide optimal care to patients, but cannot prevent a deep-tissue pressure injury from evolving due to its clinical nature? We have to consider if this is perhaps the reason that AHRQ wanted to create distinct ICD-10-CM codes, in order to separately identify and track deep-tissue pressure-induced injuries.

The ambiguity surrounding the new guideline and new ICD-10-CM codes is definitely an unintended consequence by the cooperating parties; however, it does leave hospitals in a position to determine which option for reporting is going to most appropriately reflect their patients’ clinical situations while remaining compliant with coding and reporting. This is a decision that must be considered and discussed by a collaborative team, including wound care clinicians, physicians, and quality, clinical documentation integrity, and coding professionals within our healthcare organizations – until the cooperating parties provide additional definitive guidance. Hopefully, that official guidance will come sooner rather than later, to ensure consistency in coding and reporting practices, allowing for reliable data for clinical research and quality improvement efforts for our patients.

The guidelines referenced in this article are as follows:

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.–6).

Programming Note: Listen to Lis Baris report this story live today during Talk Ten Tuesdays, 10-10:30 a.m. EST.