Find comprehensive information on Stage 4 Sacral Ulcer diagnosis, including clinical documentation, pressure injury staging, wound care coding, and treatment guidelines. Learn about ICD-10 codes for pressure ulcers, sacral pressure ulcer treatment, and preventative measures for pressure injuries. This resource offers guidance for healthcare professionals on accurate medical coding and effective clinical documentation for Stage 4 Sacral Ulcers. Explore resources for wound assessment, pressure ulcer management, and optimizing patient care.
Also known as
Pressure ulcer of other sites
Includes pressure ulcers of the sacrum, not elsewhere classified.
Encounter for fitting and adjustment of other devices
May be used for encounters related to pressure-relieving devices for stage 4 ulcers.
Other and unspecified peripheral circulatory disorders
Relevant if circulatory complications contribute to the stage 4 sacral ulcer.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the stage 4 sacral ulcer documented?
Yes
Is there necrosis present?
No
Insufficient documentation to code a stage 4 sacral ulcer. Query physician.
When to use each related code
| Description |
|---|
| Stage 4 Sacral Ulcer |
| Stage 3 Sacral Ulcer |
| Unstageable Sacral Ulcer |
Coding Stage 4 without specifying if its pressure, stasis, or neuropathic ulcer leads to inaccurate DRG assignment and reimbursement.
Insufficient documentation of ulcer characteristics (size, depth, location) can cause coding errors and compliance issues.
Failing to code coexisting conditions like diabetes or peripheral vascular disease impacts risk adjustment and quality reporting.
Patient presents with a Stage 4 sacral pressure ulcer, confirmed by visual assessment revealing full-thickness tissue loss with exposed bone, tendon, or muscle. The ulcer bed contains significant necrotic tissue and slough. Undermining and tunneling are present, dimensions measured at [length] x [width] x [depth] cm. Surrounding peri-wound skin exhibits signs of maceration and erythema. Patient reports [presenting symptoms, e.g., pain level using a validated pain scale, odor, drainage]. Comorbidities contributing to ulcer development include [e.g., diabetes, limited mobility, malnutrition]. Current wound care regimen consists of [e.g., debridement frequency and method, type of dressing, offloading measures]. Patient education provided regarding pressure ulcer prevention strategies, including repositioning techniques, nutritional optimization, and skin care. Plan includes continued wound care management, monitoring for signs of infection, and consultation with [relevant specialists, e.g., wound care nurse, dietitian, physical therapist]. Differential diagnosis considered included Stage 3 pressure ulcer, but ruled out due to exposed deep tissue. ICD-10 code L89.154 (Pressure ulcer of sacral region, stage 4) assigned. Treatment plan aims to promote wound healing, manage pain, and prevent complications such as osteomyelitis and sepsis. Patient's overall functional status and mobility will be assessed and addressed.