Find comprehensive information on skin ulcer diagnosis, including clinical documentation, pressure ulcer stages, arterial ulcers, venous ulcers, diabetic foot ulcers, and ICD-10 codes for skin ulcers. Learn about proper wound assessment, treatment options, and healthcare coding guidelines for accurate medical record keeping. This resource offers valuable insights for healthcare professionals, clinicians, and medical coders seeking information on skin ulcer management and documentation.
Also known as
Ulcer of lower limb, not elsewhere classified
Non-pressure, non-arterial, non-venous lower limb ulcers.
Non-pressure chronic ulcer of lower limb
Chronic ulcers of the lower limb excluding pressure ulcers.
Other disorders of skin and subcutaneous tissue
Includes other specified skin and subcutaneous tissue disorders.
Varicose veins of lower extremities
Varicose veins can lead to skin ulceration.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the ulcer due to pressure?
Yes
Stage of pressure ulcer?
No
Is the ulcer due to diabetes?
When to use each related code
| Description |
|---|
| Skin Ulcer |
| Pressure Ulcer |
| Venous Stasis Ulcer |
Coding skin ulcers without specifying the location (e.g., ankle, heel) leads to inaccurate coding and reimbursement issues.
Incorrect staging of pressure ulcers, like misclassifying stage 3 as stage 2, impacts severity documentation and quality metrics.
Failing to document the cause of the ulcer (e.g., pressure, diabetic, venous) affects accurate code assignment and treatment plans.
Patient presents with a skin ulcer, diagnosed as a [Specify ulcer type, e.g., pressure ulcer, venous stasis ulcer, arterial ulcer, diabetic foot ulcer]. Location of the ulcer is documented as [Specific anatomical location, e.g., sacral region, medial malleolus, lateral foot, plantar surface]. Ulcer dimensions are measured as [Length] x [Width] x [Depth] cm. Wound bed appearance is described as [e.g., granulating, sloughy, necrotic, fibrinous] with [Percentage] of each tissue type present. Surrounding skin is characterized as [e.g., intact, erythematous, macerated, indurated, edematous] with signs of [e.g., infection, inflammation, cellulitis] noted if present. Pain assessment reveals [Pain level, e.g., no pain, mild, moderate, severe] described as [Pain characteristics, e.g., throbbing, aching, burning, sharp]. Patient's current wound care regimen includes [e.g., daily dressing changes with [Dressing type], debridement [Type of debridement], compression therapy]. Assessment indicates [Current stage of ulcer if applicable, e.g., Stage I, II, III, IV pressure ulcer] and risk factors assessed include [e.g., immobility, diabetes, peripheral vascular disease, malnutrition, smoking]. Plan of care includes [e.g., continued wound care, nutritional support, pressure relief measures, vascular assessment, offloading]. Patient education provided on [e.g., wound care instructions, signs of infection, importance of follow-up]. Differential diagnosis considered [List relevant differential diagnoses]. ICD-10 code [Appropriate ICD-10 code] and CPT codes [Relevant CPT codes for procedures performed] documented. Follow-up scheduled for [Date/Time] to monitor ulcer healing progress and adjust treatment plan as needed.