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L89.152
ICD-10-CM
Stage 2 Pressure Ulcer, Coccyx

Find information on stage 2 pressure ulcer coccyx diagnosis, including clinical documentation, treatment, and prevention strategies. Learn about pressure injury staging, wound assessment, and appropriate medical coding for a stage 2 pressure ulcer on the coccyx. This resource covers healthcare guidelines, pressure ulcer treatment, and documentation best practices for accurate medical coding and improved patient care. Explore pressure sore prevention and management specifically targeted to the coccyx region.

Also known as

Stage II Decubitus Ulcer, Coccyx
Partial Thickness Pressure Injury, Coccyx

Diagnosis Snapshot

Key Facts
  • Definition : Partial-thickness skin loss involving epidermis andor dermis. Presents as a shallow open ulcer or intact blister.
  • Clinical Signs : Pink or red wound bed, may appear as an abrasion, blister, or shallow crater. No visible fat or deeper tissue.
  • Common Settings : Hospital, nursing home, or home care. Occurs over bony prominences like the coccyx due to prolonged pressure.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC L89.152 Coding
L89

Pressure ulcer

Classifies pressure ulcers by stage, site, and other characteristics.

Z74

Other contact with health services

May be used to indicate aftercare for pressure ulcers.

B95-B98

Bacterial, viral and other infectious agents

Relevant if the pressure ulcer is infected.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the pressure ulcer Stage 2?

  • Yes

    Location: Coccyx?

  • No

    Specify the stage.

Code Comparison

Related Codes Comparison

When to use each related code

Description
Stage 2 Pressure Ulcer, Coccyx
Stage 1 Pressure Ulcer, Sacrum/Coccyx
Stage 3 Pressure Ulcer, Coccyx

Documentation Best Practices

Documentation Checklist
  • Stage 2 pressure ulcer coccyx documentation
  • Location: Coccyx specified
  • Partial-thickness skin loss
  • Intact or ruptured serum-filled blister
  • No granulation, slough, eschar present
  • ICD-10 code L89.152 documented

Mitigation Tips

Best Practices
  • Relieve pressure: Offload coccyx with pillows, cushions, or specialized mattresses.
  • Wound care: Cleanse with saline, apply appropriate dressing per MD order. Document thoroughly.
  • Nutrition support: Optimize protein intake for tissue repair. Consult registered dietitian.
  • Debridement: Consider enzymatic or autolytic debridement if indicated per MD order. Monitor progress.
  • Reposition: Turn and reposition patient every 2 hours. Document repositioning frequency and technique.

Clinical Decision Support

Checklist
  • Partial-thickness skin loss, coccyx. Observe/document exposed dermis.
  • Intact or ruptured serum-filled blister, coccyx. ICD-10 L89.152
  • No granulation tissue/slough, coccyx. Assess/document wound bed.
  • Rule out deep tissue injury. SNOMED CT 707685008

Reimbursement and Quality Metrics

Impact Summary
  • Diagnosis: Stage 2 Pressure Ulcer, Coccyx
  • ICD-10: L89.152, Coding accuracy impacts MS-DRG assignment.
  • Reimbursement: Accurate coding affects pressure ulcer stage payment.
  • Quality Metrics: Impacts hospitalacquired pressure ulcer reporting.
  • Hospital Reporting: Affects quality measures and valuebased purchasing.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code L89.152
  • Document partial-thickness skin loss
  • Specify coccyx location
  • Avoid unspecified codes
  • Consider staging documentation

Documentation Templates

Patient presents with a stage 2 pressure ulcer located on the coccyx.  Examination reveals partial-thickness skin loss involving the epidermis and dermis, presenting as a shallow open ulcer with a red-pink wound bed, without slough.  The wound edges are defined and intact, without undermining or tunneling.  Surrounding skin is intact with no signs of maceration or erythema.  The ulcer measures 2 cm x 3 cm.  Patient reports mild pain at the site with palpation.  No purulent drainage or foul odor noted.  The pressure ulcer is attributed to prolonged sitting and immobility related to recent hip surgery.  Diagnosis of stage 2 pressure ulcer, coccyx confirmed.  Plan of care includes pressure redistribution measures using a pressure-relieving cushion, regular turning and repositioning every two hours, wound care with saline cleansing and application of a hydrocolloid dressing, and ongoing assessment of wound healing.  Nutritional assessment and optimization will be addressed.  Patient education provided on pressure ulcer prevention and care.  Follow-up appointment scheduled in one week to monitor wound progress and adjust treatment plan as needed.  ICD-10 code L89.152, Pressure ulcer of sacral region, stage 2, assigned.
Stage 2 Pressure Ulcer, Coccyx - AI-Powered ICD-10 Documentation