Understanding Stage 3 Pressure Ulcer diagnosis, treatment, and prevention is crucial for healthcare professionals. This resource provides information on Stage 3 pressure injury staging, clinical documentation requirements, ICD-10 codes for pressure ulcers, and appropriate wound care management. Learn about the pathophysiology of Stage 3 pressure sores, risk assessment, and effective prevention strategies for optimal patient care. Find details on deep tissue injury, necrotic tissue, undermining, and accurate wound measurement for proper medical coding and reimbursement.
Also known as
Pressure ulcer
Covers all stages of pressure ulcers, including stage 3.
Stage 3 pressure ulcer
Specifically designates a stage 3 pressure ulcer.
Encounter for attention to surgical dressings
May be used for aftercare related to a stage 3 pressure ulcer.
Follow this step-by-step guide to choose the correct ICD-10 code.
Full-thickness skin loss?
Yes
Subcutaneous fat visible?
No
Not a Stage 3 Pressure Ulcer. Review documentation for alternative diagnosis.
When to use each related code
| Description |
|---|
| Stage 3 Pressure Ulcer |
| Stage 2 Pressure Ulcer |
| Stage 4 Pressure Ulcer |
Missing or unspecified anatomical location of the Stage 3 pressure ulcer impacts accurate code assignment and reimbursement.
Insufficient documentation of undermining, tunneling, or necrosis can lead to undercoding and lost revenue.
Lack of clear clinical evidence supporting Stage 3 assignment poses audit risk and potential coding errors.
Patient presents with a full-thickness skin loss pressure ulcer, consistent with a Stage 3 pressure injury. The wound bed depth extends through the dermis and into the subcutaneous tissue, without exposed bone, tendon, or muscle. Undermining or tunneling may be present. Slough andor eschar may be visible but does not obscure the depth of tissue loss. The pressure ulcer location is documented as (insert location, e.g., sacrum, heel). Surrounding skin may exhibit signs of inflammation, including erythema, edema, induration, or warmth. Pain assessment reveals (insert pain level and description, e.g., moderate, constant aching pain). Patient's nutritional status has been assessed, and a nutritional consult has been ordered to optimize wound healing. Wound care plan includes (insert specific interventions, e.g., debridement, moist wound dressings, pressure redistribution measures). The etiology of this pressure ulcer is likely related to (insert contributing factors, e.g., immobility, impaired perfusion, shear forces). Differential diagnoses considered included deep tissue injury and Stage 4 pressure ulcer, but were ruled out based on clinical presentation. Patient education provided regarding pressure ulcer prevention strategies, including repositioning techniques, skin hygiene, and nutritional optimization. Plan to reassess wound in (insert timeframe, e.g., 72 hours, 1 week) and adjust treatment plan as needed. ICD-10 code L89 is documented for this Stage 3 pressure ulcer. This documentation supports medical necessity for pressure ulcer treatment and appropriate healthcare resource utilization.