Find comprehensive information on sacral pressure ulcers, including staging (stage 1, stage 2, stage 3, stage 4, unstageable), treatment, prevention, and documentation. Learn about pressure injury risk assessment, Braden Scale, Norton Scale, and proper wound care. Explore medical coding guidelines for pressure ulcers, ICD-10 codes (e.g., L89), and clinical documentation improvement for accurate reimbursement. This resource provides essential information for healthcare professionals, wound care specialists, and medical coders dealing with sacral pressure sores.
Also known as
Pressure ulcer
Classifies pressure ulcers based on location and stage.
Bed confinement
Indicates confinement to bed, a risk factor for pressure sores.
Other circulatory disorders
Covers circulatory issues that can contribute to pressure ulcer development.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the sacral pressure ulcer documented?
Yes
Is the stage documented?
No
Do not code a pressure ulcer
When to use each related code
| Description |
|---|
| Sacral Pressure Ulcer |
| Trochanteric Pressure Ulcer |
| Ischial Pressure Ulcer |
Coding sacral pressure ulcers requires precise documentation of stage (I-IV, unstageable, deep tissue injury) to avoid upcoding/downcoding risks impacting reimbursement.
Insufficient documentation linking the pressure sore to underlying conditions or external factors can lead to coding errors and compliance issues.
Accurate POA indicator for the pressure ulcer is crucial for proper reimbursement and quality reporting, impacting hospital-acquired condition penalties.
Patient presents with a sacral pressure ulcer, also known as a sacral decubitus ulcer or sacral bedsore. Assessment reveals a stage [Insert Stage I-IV] pressure injury located over the sacrum. The wound bed presents as [Describe wound bed: e.g., granulating, necrotic, sloughy] with [Describe exudate: e.g., serous, serosanguinous, purulent] drainage. Surrounding skin is [Describe surrounding skin: e.g., intact, erythematous, indurated, macerated]. Patient reports [Describe patient's pain level and quality: e.g., no pain, mild tenderness, moderate throbbing pain]. Measurements of the ulcer are [Length] x [Width] x [Depth] cm. Risk factors assessed include immobility, impaired mobility, nutritional status, moisture, shear, and friction. The Braden Scale score is [Insert Braden Scale Score], indicating a [Risk level: e.g., mild, moderate, high] risk for pressure injury development. Diagnosis of pressure ulcer is confirmed based on clinical presentation and assessment findings. Plan of care includes [Specify treatment plan: e.g., wound care with [Type of dressing], debridement [If applicable: e.g., sharp, enzymatic, autolytic], pressure redistribution using [Specify pressure redistribution surface: e.g., alternating pressure mattress, foam mattress overlay], nutritional consultation, pain management]. Patient education provided on pressure injury prevention strategies, including frequent repositioning, skin care, and proper nutrition. Follow-up scheduled for [Frequency] to monitor wound healing and adjust treatment as needed. ICD-10 code L89.150 assigned.