“I am using for example a pressure ulcer right forefoot, 5th mpj area stage 1 as L89.811, but my biller is telling me it is an invalid code for pressure ulcer of MPJ stage 1. Any insight on how I should go forward since my understanding that a fourth character 6 is heel and 8 is other site of foot and 9 is unspecified site which is not recommended to use?”
Pressure Ulcer Staging
Effective January 1, 2009, the term “decubitus ulcer” was changed to “pressure ulcer.” A six-part staging system for pressure ulcers was put into effect on January 1, 2009, as well. This is what ICD-10 has incorporated to base the series of L89- upon. Classification systems, whether Wagner, University of Texas, etc. for ulcer grading do not apply to pressure ulcers.
Unspecified Stage
Stage I
- An observable pressure related alteration of intact skin whose
indicators as compared to the adjacent or opposite area on the body
may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues
- It is inappropriate to bill for the debridement of a Stage I Pressure Ulcer
Stage II
- Partial thickness skin loss involving epidermis, dermis, or both.
The ulcer is superficial and presents clinically as an abrasion,
blister or shallow crater
- It is inappropriate to bill for the debridement of a Stage II Pressure Ulcer
Stage III
- Full thickness skin loss involving damage to, or necrosis of,
subcutaneous tissue that may extend down to, but not through,
underlying fascia. The ulcer presents clinically as a deep crater
with or without undermining of adjacent tissue.
Stage IV
- Full thickness skin loss with extensive destruction, tissue
necrosis, or damage to muscle, bone, or supporting
structures (e.g. tendon, joint capsule). Undermining and
sinus tracts also may be associated with Stage IV pressure
ulcers.
Unstageable
- Eschar – Thick dry black necrotic tissue
L89.xxx Coding
- 4th Character Options
- 0 – Elbow
- 1 – Back
- 2 – Hip
- 3 – Buttock
- 4 - Contiguous site of back, buttock and hip
- 5 – Ankle
- 6 – Heel
- 8 – Other site
- 9 - Unspecified site
- 5th Character Options
- 0 – Unspecified
- 1 – Right
- 2 – Left
The 6th character relates to the stage of the ulcer based upon the list above ranging from Unspecified – Unstageable (1-5).
With respect to the code that you presented me with, L89.811 is actually the best ICD-10-CM code for a pressure ulcer of the metatarsal head, Stage 1. Your biller was unfortunately incorrect in her/his assessment. The correct ICD-10-CM code for a Stage 1 pressure ulcer beneath the head of the 5th metatarsal on the right foot is the following: L89.811.
While the question specifies the metatarsal head, the “other site” is the correct 4th character to use.
Taking it one step further:
The ICD-10-CM pressure ulcer category (L89) contains specific codes for common anatomic sites such as the sacrum, heel, ankle, hip, buttock, elbow, and back. However, there is no specific ICD-10-CM code for the plantar aspect of the foot or the metatarsal heads. Therefore, a pressure ulcer located beneath the 5th metatarsal head is classified as an "other site."
This is my opinion.
Michael G. Warshaw, DPM, CPC
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