New Codes for Deep Tissue Pressure Injury/ Pressure-induced Deep Tissue DamageOctober 2, 2019
The addition of a new sixth character option to code category L89, Pressure Ulcer, was approved at the September 2018 Coordination and Maintenance (C&M) Committee meeting. This sixth character resulted in the addition of 25 new codes, effective for FY2020. The sixth character, which happens to be “6,” is used to denote “pressure-induced deep tissue damage,” aka “deep tissue pressure injury” (DTPI). As you read our blog, keep in mind that DPTI, although classified with pressure ulcers in code category L89 Pressure Ulcer, DPTI are not pressure ulcers.
Prior to the addition of these 25 new codes, DPTI was classified as an “unstageable” pressure ulcer. The need for new codes to distinguish DTPI from unstageable ulcers was explained in great detail by the National Pressure Ulcer Advisory Panel (NPUAP). The NPUAP has long served as the “authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education and research.” The NPUAP has been collaborating with CMS since 2007, going all the way back to ICD-9-CM, providing recommendations for staging of pressure ulcers. Research over the years has demonstrated significant clinical differences and treatment protocols between “unstageable ulcers” and “deep tissue injuries,” aka DTPI. For example, an unstageable wound or ulcer is normally debrided in order to determine the extent and stage. DTPI is not normally debrided. Finally and obviously, the inability to track and distinguish DTPI cases from unstageable ulcer cases was not possible prior to the addition of this new character and resulting new codes.
The new character option and new codes was requested by the Agency for Healthcare Research and Quality (AHRQ) to identify and track these conditions for surveillance and quality improvement purposes. The AHRQ is a U.S. government agency that functions as a part of the Department of Health & Human Services (HHS) to support research to help improve the quality of health care. It was a sure bet that the new character option and new codes would be approved.
Current NPUAP Definition of Deep Tissue Pressure Injury
Deep Tissue Pressure Injury (DTPI) is now defined as “intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This condition results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.”
NPUAP further explained “Deep tissue injury” is currently indexed to “ulcer, pressure, unstageable, by site.” However, unstageable ulcers can ONLY be Stage 3 or 4, by definition (“full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed”). By contrast, deep tissue injury may resolve without tissue loss and often have a combined etiology involving both ischemia and pressure.
Let’s take a moment to review and define some terms:
- Unstageable pressure ulcer: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth cannot be determined, but it will be either a Category III or IV pressure ulcer. Stable (dry, adherent, intact, without erythema or fluctuance) eschar on the heels serves as a natural (biological) cover and should not be removed.
- Eschar: Black or brown necrotic, devitalized tissue. The tissue can be loose or firmly adherent and hard, soft, or somewhat soggy
- Slough: Soft, moist, devitalized (non-viable) tissue. It may be white, yellow, tan, or green, and it may be loose or firmly adherent
Source: WOCN. Wound Ostomy and Continence Nurses Society. Guideline for the Prevention and Management of Pressure Ulcers. Mount Laurel, NJ: Wound Ostomy and Continence Nurses Society; 2010.
Deep Tissue Pressure Injury Image and Comments
Below is an image and comment concerning this image of a DPTI from the website Skilled Wound Care (SWC). The comment provides insight from a nursing perspective. Overall, the SWC website provides information about wound care and pressure ulcers for clinicians, primarily nurses, physician specialists and physician assistants. https://www.skilledwoundcare.com/pressure-injury
SWC CLINICAL PEARL: “In our time presenting the picture above to nursing staff strong arguments have occurred calling the wound above Unstageable or Stage 4, but it is a Deep Tissue Pressure Injury. The greatest area of confusion in this wound is that the skin is lifting in the central part of this wound. In a Deep Tissue Pressure Injury, the skin may or may not be intact per the NPUAP definition. These wounds are most commonly left intact and dry, with careful offloading at all times. If you must position the patient on this wound use direct foam padding dressings.”
Code Category L89 Expansion
Category L89 includes all of the new FY2020 25 codes in all subcategories by anatomical site or unspecified site that denote Deep Tissue Pressure Injury (DTPI). Every subcategory in code category L89 now includes a code with the character option 6, for DTPI. Below is an example of the codes for pressure ulcer of the right heel. The new code in this subcategory is L89.616 Pressure-induced deep tissue damage of right heel.
- The 25 new codes have a severity status of Complication/Comorbidity (CC).
See the code descriptor for L89.616. The term “damage” is used, not “injury,” as we have been discussing all along, however deep tissue “damage” and deep tissue “injury” are synonymous terms and refer to the same condition or diagnosis. Your providers may use either or both terms.
When assigning and reporting a code for “deep tissue pressure injury” or “pressure-induced deep tissue damage,” your code assignment will be the same code and should end with the sixth character “6.” If you are using an Encoder, be sure that the pathway selected takes you to a code that ends with the sixth character “6.”
Note: The National Center for Health Statistics (NCHS) has been notified of issues in the Index concerning terms and subterms. At the time this blog was written the Index issues have not been revised. We recommend keeping a close eye out for anticipated corrections/revisions, and in the meantime, again, be sure that your code for “deep tissue pressure injury” or “pressure-induced deep tissue damage” ends with the sixth character “6.”
For FY2020 the “Official Guidelines for Coding and Reporting” (OCG) Section II.C. Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99) two additions provide guidance for assigning and reporting codes for “pressure induced deep tissue damage, as follows:
- Section II.C.12.a.1) now includes mention of “deep tissue pressure injury” and also reminds the coder to identify the site and stage of a pressure ulcer (1-4) of the pressure ulcer, and includes mention of “deep tissue pressure injury, and reads
Pressure ulcer stages
Codes in category L89, Pressure ulcer, identify the site and stage of the pressure ulcer.
The ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, deep tissue pressure injury, unspecified stage, and unstageable. Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable.
- Section II.C.12.a.7), which appears self-explanatory, reads
“For pressure-induced deep tissue damage or deep tissue pressure injury, assign only the appropriate code for pressure-induced deep tissue damage (L89.–6).”
Note that while we are accustomed to assigning and reporting the site and stage of pressure ulcers, deep tissue pressure injuries are not classified by stage; they are classified by site only. One code and only one code is assigned and reported for deep tissue pressure injuries/deep tissue pressure damage.
The addition of a new sixth character option to code category L89, Pressure Ulcer, was approved at the September 2018 Coordination and Maintenance (C&M) Committee meeting. This sixth character, used to denote DPTI/pressure induced deep tissue damage, resulted in the addition of 25 new codes, effective for FY2020.
Prior to the addition of these 25 new codes, DPTI was classified as an “unstageable” pressure ulcer.
DPTI, although classified with pressure ulcers in code category L89 Pressure Ulcer, DPTI are not pressure ulcers.
Category L89 includes all of the new FY2020 25 codes in all subcategories by anatomical site or unspecified site that denote Deep Tissue Pressure Injury (DTPI). Every code subcategory in category L89, now includes a code with the character option 6, for DTPI.
The OCG Section II.C. Chapter 12: Diseases of the Skin and Subcutaneous Tissue (L00-L99) has added terminology for FY2020 advising coders to assign and report a code from category L89 that identifies both the site and the stage. DTPI/deep tissue damage is not staged. One code is assigned for DPTI/deep tissue damage. These codes always end with the sixth character “6.”
There is an extensive amount of information with regard to pressure ulcers and wound care. We recommend a review of the link to the C&M meeting materials of September 2018, and these websites.
Follow this link for detailed information about the September, 2018 C&M meeting: https://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/ICD-9-CM-C-and-M-Meeting-Materials-Items/2018-09-11-MeetingMaterials.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=descending
We highly recommend visiting the NPUAP website, https://npuap.org/. Here you will find an extensive list of resources that includes information about pressure injury stages, including photos and other education material available for viewing or purchase.
The Joint Commission published an informative and concise article about “Preventing Pressure Injuries” in 2016. https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_25_July_20161.PDF
NJPR blogs are for educational purposes and are accurate at the time of publishing. Learn more.