Jeanie Heck, BBA, CCS, CPC, CRC Education Consultant, e4health

Decubitus and pressure ulcer coding is an area where the details really matter. Many coding and auditing errors stem not from misunderstanding the condition, but from missing key elements of specificity. A few important reminders:

• Staging must be coded when documented, since it affects both severity and reimbursement.
• Code all pressure ulcers that are present. Patients may have multiple ulcers, which often requires assigning more than one code.
• Assign additional codes when applicable to reflect associated conditions such as cellulitis, osteomyelitis, or gangrene, if documented.

The double-sided tip sheet below covers the common errors we see from both a coding and auditing perspective. Keep it handy as a quick reference alongside the ICD-10-CM Guidelines.

Download the pressure ulcer coding tip sheet