707.2x Pressure Ulcer Coding

[ZanatosAPNP]

Hello all,
Can anyone help guide me in the use of this coding set? Specifically, when you have a truly "unstageable" pressure ulcer, clinically speaking, I know this is AT LEAST a Stage III ulceration of the skin, per NPUAP guidelines. However, in ICD-9 CM, there is no severity assigned to this code (707.25), unlike 707.23 (III) and 707.24 (IV). Our coding department has told me that only one code from 707.2x may be assigned for an ulcer location, however clinically I think it is reasonable to assign both 707.25 & 707.23 to capture the resources, nursing staff, wound care consult, etc. being utilized. Why does there seem to be this gap between Stage III/IV pressure ulcers and an unstageable pressure ulcer when coding? And are these codes excluded from being used at the same time? I've reviewed our nursing education materials at my hospital, the NPUAP guidelines, the ICD9-CM index, and the 4Q 2008 Coding Clinic to find anything pointing me in one direction or the other. What am I missing?

Brian, RN

DISCLAIMER: The views and/or opinions expressed above are mine and not necessarily those of my employer.

[Randy Wagner BSN RN CCS]

Hi Brian,
I'm wondering if pehaps the "unstageable" is being mis-applied. To be unstageable, the ulcer stage would be obscured, such as by eschar. The concept of unstageable is similar to "unspecified" except the provider is unable to determine the depth due to the ulcer not being open to view. Because the level of severity is not able to be determined there is no severity weight attached to the code. Yes, you may not assign two levels of severity codes to the same ulcer because one ulcer can not have two different levels of severity. If, however, there are two or more different ulcers, a level of severity code would be assigned for each.

Randy, BSN, RN, CCS

[DrGold]

Brian - be on the lookout, in cases in which treatment is provided to the unstageable pressure ulcer, that it may be able to be staged after treatment, whether surgical debridement or any of the nonsurgical means. As we know from all coding rules, if it's unknown at the beginning and, after workup, the diagnosis becomes known, code the diagnosis - in this case, the stage. Some unstageable pressure sores may be merely "deep tissue injury" and may have no necrosis at all. That's why there can be no severity assigned.

Keep up the good fight!