Chapter 12
DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE
Introduction
Diseases of the skin and subcutaneous tissue include diseases affecting the epidermis, dermis, and hypodermis, subcutaneous tissue, nails, sebaceous glands, sweat glands, and hair and hair follicles. Common conditions of the skin and subcutaneous tissue include boils, cellulitis, abscess, pressure ulcers, lymphadenitis, and pilonidal cysts.
Codes for diseases of the skin and subcutaneous tissue are located in
Chapter 12. Integumentary system diseases span nine code blocks in ICD-10-CM with most code categories expanded to the fourth- or fifth-character level.
Chapter 12 in ICD-10-CM classifies conditions into related disease groups.
Integumentary system codes include additional detail and specificity about various conditions of skin and subcutaneous tissue such as laterality and site designation, or type and cause. Codes for pressure ulcers, for example, are combination codes that include site, laterality, and severity in the code description. These codes classify the four stages of pressure ulcers as well as unstageable pressure ulcers. The laterality of the affected site is also specified in the codes for carbuncle, furuncle, abscess, cellulitis, and non-pressure ulcers.
ICD-10-CM captures a level of specificity for disease coding that requires precise clinical information documented in the medical record. Contact dermatitis for example, is specified as allergic or irritant and the substance causing the condition must also be specifically identified.
In addition to more specificity, updated and standardized terminology is used in ICD-10-CM. For example, dermatitis and eczema are common conditions coded to this chapter. ICD-10-CM includes a note indicating that the terms dermatitis and eczema are used synonymously and interchangeably.
Other clinical terms are commonly used interchangeably in medical record documentation. Various terms are used to describe pressure ulcers, and instructional notes are provided to clarify that codes for pressure ulcers include diagnoses documented as:
•Bed sore
•Decubitus ulcer
•Plaster ulcer
•Pressure area
•Pressure sore
Understanding the coding and documentation requirements for diseases of the skin and subcutaneous tissue begins with a review of the code blocks in ICD-10-CM, which are displayed in the table below.
ICD-10-CM Blocks |
L00-L08 |
Infections of the Skin and Subcutaneous Tissue |
L10-L14 |
Bullous Disorders |
L20-L30 |
Dermatitis and Eczema |
L40-L45 |
Papulosquamous Disorders |
L49-L54 |
Urticaria and Erythema |
L55-L59 |
Radiation-Related Disorders of the Skin and Subcutaneous Tissue |
L60-L75 |
Disorders of Skin Appendages |
L76 |
Intraoperative and Postprocedural Complications of Skin and Subcutaneous Tissue |
L80-L99 |
Other Disorders of the Skin and Subcutaneous Tissue |
Diseases of the skin and subcutaneous tissue include:
•Infections of the skin and subcutaneous tissues
•Noninfectious inflammatory conditions of the skin classified in five code blocks:
–L10-L14Bullous Disorders
–L20-L30Dermatitis and Eczema
–L40-L45Papulosquamous Disorders
–L49-L54Urticaria and Erythema
–L55-L59Radiation-Related Disorders of the Skin and Subcutaneous Tissue
•Other diseases of the skin in two code blocks, one for other disorders of the skin and subcutaneous tissues and one for disorders of the skin appendages such as hair, nails and glands.
•Intraoperative and postprocedural complications of the skin and subcutaneous tissues in code block L76.
Exclusions
To assign the most specific code possible, close attention must be paid to the coding and sequencing instructions in the Tabular List and Alphabetic Index, particularly the exclusion notes. There are no Excludes 1 notes for
Chapter 12; however, there are multiple Excludes 2 notes which are listed in the table below.
Excludes1 |
Excludes2 |
None |
Certain conditions originating in the perinatal period (P04-P96)
Certain infectious and parasitic diseases (A00-B99)
Complications of pregnancy, childbirth and the puerperium (O00-O9A)
Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)
Endocrine, nutritional and metabolic diseases (E00-E88)
Lipomelanotic reticulosis (I89.8)
Neoplasms (C00-D49)
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
Systemic connective tissue disorders (M30-M36)
Viral warts (B07.-) |
Chapter Guidelines
The coding guidelines include the coding conventions, the general coding guidelines, and the chapter-specific coding guidelines. Coding and sequencing guidelines for integumentary diseases and complications due to the treatment of integumentary conditions are incorporated into the Alphabetic Index and the Tabular List.
The ICD-10-CM Official Guidelines for Coding and Reporting specifically address the need for consistent, complete documentation in the medical record, calling complete and accurate documentation “essential” for code assignment and reporting of diagnoses and procedures.
Chapter specific guidelines for Diseases of the Skin and Subcutaneous Tissue all relate to detailed instruction for pressure ulcers and non-pressure chronic ulcers.
ICD-10-CM Official Guidelines for Coding and Reporting
Pressure ulcer stage codes
•Pressure ulcer stages:
–Codes from category L89 Pressure ulcer are combination codes that identify the site of the pressure ulcer as well as the stage of the ulcer. The ICD-10-CM classifies pressure ulcer stages based on severity, which is designated by stages 1-4, unspecified stage, and unstageable. Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable.
•Unstageable pressure ulcers:
–Assignment of the code for unstageable pressure ulcer (L89.--0) should be based on the clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by slough or eschar or has been treated with a skin or muscle graft).
–These codes should not be confused with the codes for unspecified stage (L89.--9). When there is no documentation regarding the stage of the pressure ulcer, assign the appropriate code for unspecified stage (L89.--9).
•Documented pressure ulcer stage:
–Assignment of the pressure ulcer stage code should be guided by clinical documentation of the stage or documentation of the terms found in the Alphabetic Index.
–For clinical terms describing the stage that are not found in the Alphabetic Index, and when there is no documentation of the stage, the provider should be queried.
•Patients admitted with pressure ulcers documented as healed:
–No code is assigned if the documentation states that the pressure ulcer is completely healed.
•Patients admitted with pressure ulcers documented as healing:
–Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record. If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage.
–If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider.
•Patient admitted with pressure ulcer evolving into another stage during the admission:
–If a patient is admitted to an inpatient hospital with a pressure ulcer at one stage and it progresses to a higher stage, assign the code for the highest stage reported for that site.
Non-pressure chronic ulcers
•No code is assigned when documentation states the non-pressure chronic ulcer is healed
•Patient admitted with non-pressure ulcers documented as healing:
–Non-pressure ulcers described as healing should be assigned the appropriate non-pressure ulcer code based on the documentation in the medical record. If the documentation does not provide information about the severity of the healing non-pressure ulcer, assign the appropriate code for unspecified severity
–If the documentation is unclear as to whether the patient has a current (new) non-pressure ulcer or if the patient is being treated for a healing non-pressure ulcer, query the provider.
–For ulcers present on admission but healed at the time of discharge, assign the code for the site and severity of the non-pressure ulcer at the time of admission
•Patient admitted with non-pressure ulcer progressing into another severity level during the admission:
–If a patient is admitted to an inpatient hospital with a non-pressure ulcer at one severity level and it progresses to a higher severity level, two codes should be assigned: one for the site and severity of the ulcer on admission and a second one for the same ulcer site and the highest severity level reported during the stay.
General Documentation Requirements
Documentation requirements depend on the particular disease or disorder affecting the integumentary system. Some of the new general documentation requirements are discussed here, but greater detail for some of the more common integumentary system diseases will be provided in the next section.
In general, basic medical record documentation requirements include the severity or status of the disease (e.g., acute or chronic), as well as the site, etiology, and any secondary disease process. Physician documentation of the significance of any findings or confirmation of any diagnosis found in laboratory or other diagnostic test reports is necessary for code assignment. Provider documentation should also clearly specify any cause-and-effect relationship between medical treatment and an integumentary disorder.
Many of the codes in
Chapter 12 require site specificity for accurate and detailed code assignment. For example, the location of an abscess of the trunk must be identified as the chest wall, abdominal wall, umbilicus, back, groin, or perineum in order to code to the highest level of specificity available. Laterality must be documented for abscess as well as for cellulitis, carbuncle, furuncle, and pressure and non-pressure ulcers.
In addition to these general documentation requirements, there are specific diseases and disorders that require greater detail in documentation to ensure optimal code assignment.
Code-Specific Documentation Requirements
In this section, ICD-10-CM code categories, subcategories, and subclassifications for some of the more frequently reported integumentary diseases are reviewed. Although not all codes with significant documentation requirements are discussed, this section will provide a representative sample of the type of documentation needed for integumentary diseases. The section is organized alphabetically by the code category, subcategory, or subclassification.
Acne
Acne is an inflammatory eruption of the skin appearing most commonly on the face, neck, chest, back, and shoulders. Acne may also occur on the trunk, arms, legs, and buttocks. Acne occurs when hair follicles become clogged with oil and dead skin cells. Acne varioliformis is an infection involving the follicles and the production of pus occurring primarily on the forehead and temples. It is also referred to as acne necrotica miliaris.
Cystic acne (or acne vulgaris) is characterized by scaly red skin, blackheads and whiteheads (comedones), papules, and pustules. The “cysts,” that accompany cystic acne, can appear on the buttocks, groin, and armpit area where sweat collects in hair follicles. Codes for acne are categorized in
Chapter 12 under Disorders of skin appendages.
Coding and Documentation Requirements
Identify type:
•Acne conglobata
•Acné excoriée des jeunes filles, which includes:
–Picker’s acne
•Acne tropica
•Acne varioliformis, which includes:
–Acne necrotica miliaris
•Acne vulgaris
•Infantile acne
•Other specified acne
•Unspecified acne
Acne
ICD-10-CM Code/Documentation |
L70.0 |
Acne vulgaris |
L70.1 |
Acne conglobata |
L70.2 |
Acne varioliformis |
L70.3 |
Acne tropica |
L70.4 |
Infantile acne |
L70.5 |
Acné excoriée des jeunes filles |
L70.8 |
Other acne |
L70.9 |
Acne, unspecified |
Documentation and Coding Example
A 19-year-old female presents with complaints of acne on her chin and left temple locally, due to frequent cell phone use where the receiver rubs on her face. She indicates the problem is worsening.
Medications: Patient is currently taking oral contraceptives, started last year, prescribed by her gynecologist. Allergic to penicillin, results in difficulty breathing.
History: Menses onset 13 y.o., light flow, regular, no complications. Positive for birth control pill use. Vaccination status is current. History of childhood chickenpox. No previous surgeries. Family history is non-contributory. Patient reports good dietary habits, regular exercise. Patient consumes 3-5 servings of caffeine per day. Non-smoker, admits to social alcohol use. Denies STD history.
Review of Systems: Reddening of face, acne problems, no allergic or immunologic symptoms. Denies fever, headache, nausea, dizziness.
Physical Exam: Patient is a pleasant 19-year-old female, in no apparent distress, well-developed, well-nourished and with good attention to hygiene and body habitus. Skin: Examination of scalp shows no abnormalities. Hair growth and distribution is normal. Inspection of skin outside of affected area reveals no abnormalities. Palpation of skin shows no abnormalities. Inspection of eccrine and apocrine glands shows no evidence of hyperhidrosis, chromhidrosis or bromhidrosis. Face shows keratotic papule.
Impression/Plan: Acne vulgaris.
Recommended treatment is antibiotic therapy. Tetracycline 250 mg capsule, BID. Discussed with the patient the prescription for Tetracycline and gave her information regarding the side effects and the proper method of ingestion. Patient received extensive counseling about acne and literature regarding acne vulgaris. She understands the course of acne treatment is long-term. Patient to return for follow-up in 4 weeks.
Diagnosis: Acne vulgaris.
Diagnosis code(s)
Coding Note(s)
ICD-10-CM provides a specific code for acne vulgaris.
Alopecia
Alopecia is a skin disease characterized by loss of hair. The condition may be localized or there may be loss of hair on all hair bearing skin. One of the more common types of alopecia is alopecia areata. This is an acquired skin disease believed to be caused by an autoimmune disorder which causes the immune system to attack the hair follicles disrupting normal hair formation. Alopecia areata may occur on any part of the body, but most often hair loss is limited to patchy areas on the scalp. When the hair loss occurs in a band-like or wave-like pattern, usually on the temporal (side) and/or occipital (back) region of the scalp, and hair remains on the top of the scalp, it is referred to as ophiasis or ophiasis patterned alopecia areata. When hair loss occurs on the entire scalp, the condition is referred to as alopecia totalis. When there is total loss of body hair, the condition is referred to as alopecia universalis. Hair loss may resolve and hair may regrow without medical treatment or hair loss may be permanent. There are a variety of medical treatments but not all treatments work for all individuals.
Another form of hair loss is referred to as effluvium, which means outflowing, and these types are caused by changes in the hair growth cycle. Hair follicles in the scalp go through two phases, a growth phase and a resting phase. In a normal hair growth cycle, 80-90% of hair follicles are in the growth phase called anagen and 10-20% are in the rest phase called telogen. In telogen effluvium, there is a significant increase in the number of hair follicles that are in the dormant or resting phase during which no hair growth occurs. This results in general shedding and thinning of hair which is typically more pronounced on the top of the scalp. Shedding and thinning may occur only on the scalp or may also be present on other parts of the body. In anagen effluvium, the pattern of hair loss is typically the same occurring diffusely over the entire scalp, but the hair loss occurs much more quickly. Instead of hair being shed and increased numbers of hair follicles being in the telogen stage, in anagen effluvium hair is shed rapidly while still in the growth phase. Anagen effluvium typically occurs as a side effect of cytotoxic drugs used to treat cancer. Once the cytotoxic drugs are discontinued hair growth resumes.
A third classification of hair loss is androgenic alopecia, also called androgenetic alopecia. Even though the condition is sometimes referred to as male-pattern baldness, it affects both men and women. Androgenic alopecia is a genetically determined disorder of the hair follicles. It is believed that damage to the hair follicle occurs when testosterone is converted into dihydrotestosterone (DHT) by an enzyme in the oil gland of the hair follicle. DHT causes damage to the hair follicle resulting in the inability of the follicle to grow normal hair. Normal adult hair is replaced with vellus hair which is the thin, fine, short hair present on the hair bearing surfaces of the body before puberty.
In ICD-10-CM, alopecia codes capture specific types of hair loss. Codes for nonscarring hair loss are organized into three categories including L63 Alopecia areata, L64 Androgenic alopecia, and L65 Other nonscarring hair loss. There is a fourth category in the code set for cicatricial alopecia (L66), which contains codes for scarring types of hair loss and includes several specified conditions. Hair is considered a skin appendage. Codes for alopecia are categorized in
Chapter 12 under the section Disorders of skin appendages.
Coding and Documentation Requirements
Identify type of hair loss:
•Alopecia areata
–Ophiasis
–Totalis (capitis)
–Universalis
–Other specified type
–Unspecified
•Androgenic alopecia
–Drug-induced androgenic alopecia
–Other specified type of androgenic alopecia
–Unspecified
•Cicatricial alopecia (scarring type)
–Folliculitis decalvans
–Folliculitis ulerythematosa reticulata
–Lichen planopilaris (follicular lichen planus)
–Perifolliculitis capitis abscedens
–Pseudopelade
–Other cicatricial alopecia
–Unspecified
–Other nonscarring type:
–Alopecia mucinosa
–Anagen effluvium
–Telogen effluvium
–Other specified type of nonscarring hair loss
–Unspecified nonscarring type
•Alopecia
ICD-10-CM Code Category |
ICD-10-CM Code/Documentation |
Nonscarring hair loss |
L63.0 |
Alopecia (capitis) totalis |
L63.1 |
Alopecia universalis |
L63.2 |
Ophiasis |
L63.8 |
Other alopecia areata |
L63.9 |
Alopecia areata, unspecified |
L64.0 |
Drug-induced androgenic alopecia |
L64.8 |
Other androgenic alopecia |
L64.9 |
Androgenic alopecia, unspecified |
L65.0 |
Telogen effluvium |
L65.1 |
Anagen effluvium |
L65.2 |
Alopecia mucinosa |
L65.8 |
Other specified nonscarring hair loss |
L65.9 |
Nonscarring hair loss, unspecified |
Scarring hair loss |
L66.0 |
Pseudopelade |
L66.1 |
Lichen planopilaris |
L66.2 |
Folliculitis decalvans |
L66.3 |
Perifollicular capitis abscedens |
L66.4 |
Folliculitis ulerythematosa reticulata |
L66.8 |
Other cicatricial alopecia |
L66.9 |
Cicatricial alopecia unspecified |
Documentation and Coding Example
Follow-up visit for ophiasis. This 48-year-old female noted hair loss in the right temporal region approximately 6 months ago. Hair loss progressed and eventually extended around the occipital region and into the left temporal area in the typical wave pattern of ophiasis. She has undergone a regimen of cortisone shots into the bald regions. There is now fine, thin hair regrowth beginning in the regions of hair loss. New hair is completely white.
Impression: Resolving ophiasis.
Plan: Patient will monitor hair growth and examine scalp for any signs of new hair loss. If she notes that hair growth in the bald regions is not becoming thicker or not continuing or if she notes any new bald patches, she will return for re-evaluation.
Diagnosis Code(s)
Coding Note(s)
There is a specific code for ophiasis which is a form of alopecia areata.
Carbuncle/Furuncle
A furuncle, or boil, is an infection of a hair follicle. Individual furuncles may cluster together forming a carbuncle.
ICD-10-CM includes specific codes for furuncle, carbuncle, abscess, and cellulitis. Cutaneous abscess, furuncle, and carbuncle are found in category L02 while codes for cellulitis and acute lymphangitis are located in category L03. These codes further specify the affected site by identifying laterality, so it is essential that the medical record documentation fully describe the site. Coding and documentation requirements for carbuncle and furuncle are included here with the coding and documentation requirements and coding example for abscess and cellulitis to follow.
Coding and Documentation Requirements
Identify condition:
•Carbuncle
•Furuncle
Identify site:
•Buttock
•Face
•Foot
•Hand
•Limb (except hand/foot)
–Lower limb
–Upper limb
–Axilla
–Unspecified limb
•Neck
•Trunk
–Abdominal wall
–Back [any part, except buttocks]
–Chest wall
–Groin
–Perineum
–Umbilicus
–Unspecified site of trunk
•Other site
–Head (any part except face)
–Other specified site
•Unspecified site
For upper and lower limbs/hand/foot identify laterality:
•Right
•Left
•Unspecified
Use additional code to identify any infectious organism (B95-B96).
Carbuncle/Furuncle
ICD-10-CM Code/Documentation |
Furuncle |
Carbuncle |
L02.02 |
Furuncle of face |
L02.03 |
Carbuncle of face |
L02.12 |
Furuncle of neck |
L02.13 |
Carbuncle of neck |
L02.221 |
Furuncle of abdominal wall |
L02.231 |
Carbuncle of abdominal wall |
L02.222 |
Furuncle of back [any part, except buttock] |
L02.232 |
Carbuncle of back [any part, except buttock] |
L02.223 |
Furuncle of chest wall |
L02.233 |
Carbuncle of chest wall |
L02.224 |
Furuncle of groin |
L02.234 |
Carbuncle of groin |
L02.225 |
Furuncle of perineum |
L02.235 |
Carbuncle of perineum |
L02.226 |
Furuncle of umbilicus |
L02.236 |
Carbuncle of umbilicus |
L02.229 |
Furuncle of trunk, unspecified |
L02.239 |
Carbuncle of trunk, unspecified |
L02.421 |
Furuncle of right axilla |
L02.431 |
Carbuncle of right axilla |
L02.422 |
Furuncle of left axilla |
L02.432 |
Carbuncle of left axilla |
L02.423 |
Furuncle of right upper limb |
L02.433 |
Carbuncle of right upper limb |
L02.424 |
Furuncle of left upper limb |
L02.434 |
Carbuncle of left upper limb |
L02.521 |
Furuncle right hand |
L02.531 |
Carbuncle of right hand |
L02.522 |
Furuncle left hand |
L02.532 |
Carbuncle of left hand |
L02.529 |
Furuncle unspecified hand |
L02.539 |
Carbuncle of unspecified hand |
L02.32 |
Furuncle of buttock |
L02.33 |
Carbuncle of buttock |
L02.425 |
Furuncle of right lower limb |
L02.435 |
Carbuncle of right lower limb |
L02.426 |
Furuncle of left lower limb |
L02.436 |
Carbuncle of left lower limb |
L02.621 |
Furuncle of right foot |
L02.631 |
Carbuncle of right foot |
L02.622 |
Furuncle of left foot |
L02.632 |
Carbuncle of left foot |
L02.629 |
Furuncle of unspecified foot |
L02.639 |
Carbuncle of unspecified foot |
L02.821 |
Furuncle of head [any part, except face] |
L02.831 |
Carbuncle of head [any part, except face] |
L02.828 |
Furuncle of other sites |
L02.838 |
Carbuncle of other sites |
L02.92 |
Furuncle, unspecified |
L02.93 |
Carbuncle, unspecified |
Documentation and Coding Example
HPI: This is a 58-year-old obese white male who presents to the clinic with an area of tenderness, redness, and swelling in the neck area that has become pustular. It began ten days ago as a small red lump on the skin, then the surrounding skin became swollen and inflamed and painful with visible pus filling the center of the lump. Self-treatment with warm compresses brought some temporary relief.
ROS: Patient denies vertigo, syncope, convulsions or headaches. No muscle or joint pain. Denies fever, shortness of breath, dyspnea on exertion, chest pain, cough or hemoptysis. Denies nausea, melena, rectal bleeding, he has occasional indigestion. Genitourinary is normal. No other complaints. All other systems negative on review.
Medications: None. No known drug allergies. Patient is single, lives alone. Denies use of alcohol. Former smoker, one pack of cigarettes per day, quit over 5 years. Past medical history is significant for right knee ACL repair six years ago. Mother is alive and well. Father died of cancer.
Physical Examination: Well-developed, obese white male in no acute distress. Pleasant, alert and oriented x3. Pulse 72 regular rate and rhythm, respirations 18, blood pressure 122/88. Normocephalic and atraumatic. PERRLA. Extraocular movements are intact. Neck is supple, no thyromegaly or cervical adenopathy. Pharynx is clear. Tympanic membranes are normal. Chest is symmetrical with equal expansion. Lungs clear to percussion and auscultation. No cardiomegaly. No thrills or murmurs. Normal sinus rate and rhythm. No guarding or rebound tenderness in the abdomen; bowel sounds are normal. No peripheral edema, cyanosis or varicosities. Inguinal area is normal. Skin is normal color, turgor and temperature with no ulcerations or rashes noted except in the neck area on the left side under the chin line. On examination, there is a single hair follicle with pus, no multiple hair follicle involvement. Exudate sent to lab for culture to rule out inclusion cysts or deep fungal infection.
Impression/Plan: Solitary boil on neck. No oral antibiotics or incision and drainage necessary at this time. Patient instructed to keep the skin clean using an antiseptic soap for washing the infected areas, to wash his hands carefully before and after touching the boil, and avoid greasy creams. Patient counseled not to share washcloths or towels with others. Apply warm compresses for 15 minutes several times a day to help the boil come to a head and drain followed by application of topical clindamycin cream. If resolved, no follow-up necessary; however, patient instructed to return to the clinic if it worsens or fever develops.
Diagnosis: Single boil on neck.
Diagnosis Code(s)
Coding Note(s)
The Alphabetic Index entry for Boil directs the user to see Furuncle, by site. Boil and folliculitis of neck are listed as included conditions under code L02.12.
Cellulitis/Abscess/Acute Lymphangitis
Cellulitis is a diffuse inflammation of the connective tissue causing severe inflammation of deeper dermal and subcutaneous layers of the skin. Cellulitis is a common bacterial infection usually caused by streptococcus or staphylococcus. A cutaneous abscess is an accumulation of pus surrounded by inflamed tissue resulting from an infection of the skin and subcutaneous tissue. Acute lymphangitis is caused by an infection involving the lymphatic vessels. The lymphatic vessels become inflamed and painful and there are visible red streaks below the skin surface. Acute lymphangitis is a serious condition that can evolve into a systemic infection and sepsis if not treated promptly.
ICD-10-CM provides specific codes for cutaneous abscess and for cellulitis. Cellulitis may be complicated by acute lymphangitis—an inflammation of the lymphatic vessels. There are distinct codes for cellulitis, cutaneous abscess, and for acute lymphangitis, so provider documentation of the presence of lymphangitis in cellulitis cases is needed in order to assign the most accurate codes. The provider documentation in the medical record should clearly distinguish lymphangitis from lymphadenitis, which is an inflammation of a lymph node.
The site affected by cellulitis, abscess, or acute lymphangitis is further specified by identifying laterality, so the site must be fully described in the medical record documentation in order to assign the most accurate codes.
Coding and Documentation Requirements
Identify condition:
•Acute lymphangitis
•Cellulitis, which includes:
–Chronic
–Diffuse
–Phlegmonous
–Septic
–Suppurative
•Cutaneous abscess
Identify site:
•Abdominal wall
•Axilla
•Back (any part, except buttock)
•Buttock
•Chest wall
•Face
•Finger
•Foot (except toe)
•Groin
•Hand (except finger)
•Head (any part, except face)
•Lower limb
•Neck
•Perineum
•Toe
•Trunk, unspecified site
•Umbilicus
•Upper limb
•Other specified site
•Unspecified site
For abscess, cellulitis, or acute lymphangitis affecting the extremities, identify laterality:
•Right
•Left
•Unspecified
Cellulitis, Abscess, Acute Lymphangitis
ICD-10-CM Code/Documentation |
Cutaneous Abscess |
L02.01 |
Cutaneous abscess of face |
L02.11 |
Cutaneous abscess of neck |
L02.811 |
Cutaneous abscess of head [any part, except face] |
L02.211 |
Cutaneous abscess of abdominal wall |
L02.212 |
Cutaneous abscess of back [any part, except buttock] |
L02.213 |
Cutaneous abscess of chest wall |
L02.214 |
Cutaneous abscess of groin |
L02.215 |
Cutaneous abscess of perineum |
L02.216 |
Cutaneous abscess of umbilicus |
L02.219 |
Cutaneous abscess of trunk, unspecified |
L02.31 |
Cutaneous abscess of buttock |
L02.411 |
Cutaneous abscess of right axilla |
L02.412 |
Cutaneous abscess of left axilla |
L02.413 |
Cutaneous abscess of right upper limb |
L02.414 |
Cutaneous abscess of left upper limb |
L02.511 |
Cutaneous abscess of right hand |
L02.512 |
Cutaneous abscess of left hand |
L02.519 |
Cutaneous abscess of unspecified hand |
L02.415 |
Cutaneous abscess of right lower limb |
L02.416 |
Cutaneous abscess of left lower limb |
L02.419 |
Cutaneous abscess of limb, unspecified |
L02.611 |
Cutaneous abscess of right foot |
L02.612 |
Cutaneous abscess of left foot |
L02.619 |
Cutaneous abscess of unspecified foot |
L02.818 |
Cutaneous abscess of other sites |
L02.91 |
Cutaneous abscess, unspecified |
Cellulitis |
L03.211 |
Cellulitis of face |
L03.221 |
Cellulitis of neck |
L03.811 |
Cellulitis of head [any part, except face] |
L03.311 |
Cellulitis of abdominal wall |
L03.312 |
Cellulitis of back [any part except buttock] |
L03.313 |
Cellulitis of chest wall |
L03.314 |
Cellulitis of groin |
L03.315 |
Cellulitis of perineum |
L03.316 |
Cellulitis of umbilicus |
L03.319 |
Cellulitis of trunk, unspecified |
L03.317 |
Cellulitis of buttock |
L03.111 |
Cellulitis of right axilla |
L03.112 |
Cellulitis of left axilla |
L03.113 |
Cellulitis of right upper limb |
L03.114 |
Cellulitis of left upper limb |
L03.011 |
Cellulitis of right finger |
L03.012 |
Cellulitis of left finger |
L03.019 |
Cellulitis of unspecified finger |
L03.119 |
Cellulitis of unspecified part of limb |
L03.115 |
Cellulitis of right lower limb |
L03.116 |
Cellulitis of left lower limb |
L03.031 |
Cellulitis of right toe |
L03.032 |
Cellulitis of left toe |
L03.039 |
Cellulitis of unspecified toe |
L03.119 |
Cellulitis of unspecified part of limb |
L03.818 |
Cellulitis of other sites |
L03.90 |
Cellulitis, unspecified |
Lymphangitis |
L03.212 |
Acute lymphangitis of face |
L03.222 |
Acute lymphangitis of neck |
L03.891 |
Acute lymphangitis of head [any part, except face] |
L03.321 |
Acute lymphangitis of abdominal wall |
L03.322 |
Acute lymphangitis of back [any part except buttock] |
L03.323 |
Acute lymphangitis of chest wall |
L03.324 |
Acute lymphangitis of groin |
L03.325 |
Acute lymphangitis of perineum |
L03.326 |
Acute lymphangitis of umbilicus |
L03.329 |
Acute lymphangitis of trunk, unspecified |
L03.327 |
Acute lymphangitis of buttock |
L03.121 |
Acute lymphangitis of right axilla |
L03.122 |
Acute lymphangitis of left axilla |
L03.123 |
Acute lymphangitis of right upper limb |
L03.124 |
Acute lymphangitis of left upper limb |
L03.021 |
Acute lymphangitis of right finger |
L03.022 |
Acute lymphangitis of left finger |
L03.029 |
Acute lymphangitis of unspecified finger |
L03.125 |
Acute lymphangitis of right lower limb |
L03.126 |
Acute lymphangitis of left lower limb |
L03.129 |
Acute lymphangitis of unspecified part of limb |
L03.041 |
Acute lymphangitis of right toe |
L03.042 |
Acute lymphangitis of left toe |
L03.049 |
Acute lymphangitis of unspecified toe |
L03.898 |
Acute lymphangitis of other sites |
L03.91 |
Acute lymphangitis, unspecified |
Documentation and Coding Example
This 62-year-old male presents to the ED with complaints of pain and tenderness over the instep of his left foot. The patient is afebrile. On examination, the painful area is red and inflamed and there is fluctuance on palpation of the inflamed region.
Impression: Subcutaneous abscess
Treatment: The area was prepped and draped and a local anesthetic administered. A cruciate incision was made over the abscess site and the abscess drained. A sample of the fluid was sent to the lab for culture and sensitivity. The abscess cavity was flushed with sterile saline. The wound was left open to heal by secondary intention and a soft dressing was applied.
Plan: The patient was given instructions on care of the abscess site. Pros and cons of antibiotics were discussed and the patient elects not to take antibiotics at this time. Patient instructed to return for any increased pain, swelling, redness around or extending from the drainage site or for any fever, body aches or other symptoms that may suggest systemic infection.
Diagnosis Code(s)
L02.612 |
Cutaneous abscess of left foot |
Coding Note(s)
Abscess of the foot is classified to category L02 Cutaneous abscess, furuncle, and carbuncle. The code is specific to site and laterality.
Contact Dermatitis
Contact dermatitis results when skin comes in direct contact with a substance that causes inflammation of the skin. Skin inflammation may be due to an allergy to the substance or due to irritants in the substance.
Contact dermatitis is classified by type. Allergic contact dermatitis is coded differently from irritant contact dermatitis so the medical record documentation must clearly identify the type of contact dermatitis as well as the cause. If the documentation does not specify whether the contact dermatitis is allergic or irritant, an unspecified code must be assigned. When contact dermatitis is an adverse effect of a drug, the documentation must identify the specific drug for accurate code assignment.
Coding and Documentation Requirements
Identify type:
•Allergic contact dermatitis
•Irritant contact dermatitis
•Unspecified contact dermatitis
Identify contact dermatitis as due to:
•Animal (cat) (dog) dander
•Adhesives
•Cosmetics
•Drugs in contact with skin
•Dyes
•Food in contact with skin
•Metals
•Plants [except food]
•Other chemical products, which include:
–Cement
–Insecticide
–Plastic
–Rubber
•Other specified agents
•Unspecified cause
Identify irritant contact dermatitis as due to:
•Cosmetics
•Detergents
•Drugs in contact with skin
•Food in contact with skin
•Metals
•Plants [except food]
•Oils and greases
•Solvents
•Other chemical products, which include:
–Cement
–Insecticide
–Plastic
–Rubber
•Other specified agents
•Unspecified cause
Identify unspecified contact dermatitis as due to:
•Cosmetics
•Drugs and medicines in contact with skin
•Dyes
•Food in contact with skin
•Other chemical products, which include:
–Cement
–Insecticide
–Plastic
–Rubber
•Plants [except food]
•Other specified agents
•Unspecified cause
Contact Dermatitis
ICD-10-CM Code/Documentation |
L23.1 |
Allergic contact dermatitis due to adhesives |
L23.81 |
Allergic contact dermatitis due to animal (cat) (dog) dander |
L23.5 |
Allergic contact dermatitis due to other chemical products |
L24.5 |
Irritant contact dermatitis due to other chemical products |
L25.3 |
Unspecified contact dermatitis due to other chemical products |
L23.2 |
Allergic contact dermatitis due to cosmetics |
L24.3 |
Irritant contact dermatitis due to cosmetics |
L25.0 |
Unspecified contact dermatitis due to cosmetics |
L24.0 |
Irritant contact dermatitis due to detergents |
L23.3 |
Allergic contact dermatitis due to drugs in contact with skin |
L24.4 |
Irritant contact dermatitis due to drugs in contact with skin |
L25.1 |
Unspecified contact dermatitis due to drugs in contact with skin |
L23.4 |
Allergic contact dermatitis due to dyes |
L25.2 |
Unspecified contact dermatitis due to dyes |
L23.6 |
Allergic contact dermatitis due to food in contact with the skin |
L24.6 |
Irritant contact dermatitis due to food in contact with skin |
L25.4 |
Unspecified contact dermatitis due to food in contact with skin |
L24.1 |
Irritant contact dermatitis due to oils and greases |
L23.89 |
Allergic contact dermatitis due to other agents |
L24.89 |
Irritant contact dermatitis due to other agents |
L25.8 |
Unspecified contact dermatitis due to other agents |
L23.7 |
Allergic contact dermatitis due to plants, except food |
L24.7 |
Irritant contact dermatitis due to plants, except food |
L25.5 |
Unspecified contact dermatitis due to plants, except food |
L23.0 |
Allergic contact dermatitis due to metals |
L24.81 |
Irritant contact dermatitis due to metals |
L24.2 |
Irritant contact dermatitis due to solvents |
L23.9 |
Allergic contact dermatitis, unspecified cause |
L24.9 |
Irritant contact dermatitis, unspecified cause |
L25.9 |
Unspecified contact dermatitis, unspecified cause |
Documentation and Coding Example
A 27-year-old white female referred for dermatology consultation of eczema of her right hand. Patient was treated with Cetaphil cream and Cetaphil cleansing lotion with increased moisturizing cream. She was referred for evaluation because she is flaring. Her hands are very dry and cracked. She started using hot, soapy water to wash her hands because she states the Cetaphil cleansing lotion is causing burning and pain because of the fissures in her skin.
No history of dermatological problems. No bad sunburns or blood pressure problems in the past. No known drug allergies. Current medications include daily Multivitamin and Tums PRN. She is a nonsmoker.
Vital Signs: Temperature 98.4, pulse 72, respirations 20, and blood pressure is 118/76. Head is normocephalic. Pupils are equal and reactive. The nares are patent. Oropharynx is clear without lesions. Neck is supple without lymphadenopathy. Heart, regular rate and rhythm. Lungs, positive breath sounds at the bases. No crackles or wheezes are heard. Abdomen is soft, non-tender, nondistended, with positive bowel sounds heard. Neurologic intact. Extremities: Without cyanosis, clubbing or edema. Skin is warm and dry without any rash except for area of complaint. Examination reveals very dry, cracked hands bilaterally. Irritant contact dermatitis caused by over washing of the hands with harsh soap.
Impression: Irritant contact dermatitis of both hands from harsh soap.
Treatment: Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion. Aristocort ointment 0.1% and Polysporin ointment TID and PRN itch. Keflex 500 mg BID for two weeks with one refill. Return in one month if not better; otherwise, on a PRN basis. Consult letter sent to PCP.
Diagnosis: Bilateral irritant contact dermatitis of hands.
Diagnosis code(s)
L24.0 |
Irritant contact dermatitis due to detergents |
Coding Note(s)
Contact dermatitis is classified by type and cause, so the provider documentation must identify both. In this case, the documentation specifies the type of contact dermatitis as irritant and the associated cause as detergent. There is no subclassification for location or laterality.
Psoriasis
Psoriasis is a common skin disorder that manifests with thick silvery scales and dry, red, itchy patches that are often painful. Patients typically experience periodic flare ups and periods of remission. Outbreaks may be triggered by infection, injury, stress, cold, or medications. Psoriasis is a chronic condition that can also affect other tissues such as the joints causing psoriatic arthritis or arthropathy.
Complete, accurate coding requires documentation identifying the presence of arthritis, arthropathy, or spondylitis.
Coding and Documentation Requirements
Identify type of psoriasis:
•Acrodermatitis continua
•Arthropathic psoriasis
–Distal interphalangeal psoriatic arthropathy
–Psoriatic arthritis mutilans
–Psoriatic juvenile arthropathy
–Psoriatic spondylitis
–Other psoriatic arthropathy
–Unspecified arthropathic psoriasis
•Generalized pustular psoriasis, which includes:
–Impetigo herpetiformis
–Von Zumbusch’s disease
•Guttate psoriasis
•Psoriasis vulgaris
•Pustulosis palmaris et plantaris
•Other specified psoriasis, which includes:
–Flexural psoriasis
•Unspecified psoriasis
Psoriasis and Psoriatic arthropathy
ICD-10-CM Code Category |
ICD-10-CM Code/Documentation |
Psoriatic arthropathy |
L40.50 |
Arthropathic psoriasis, unspecified |
L40.51 |
Distal interphalangeal psoriatic arthropathy |
L40.52 |
Psoriatic arthritis mutilans |
L40.53 |
Psoriatic spondylitis |
L40.54 |
Psoriatic juvenile arthropathy |
L40.59 |
Other psoriatic arthropathy |
Psoriasis |
L40.0 |
Psoriasis vulgaris |
L40.1 |
Generalized pustular psoriasis |
L40.2 |
Acrodermatitis continua |
L40.3 |
Pustulosis palmaris et plantaris |
L40.4 |
Guttate psoriasis |
L40.8 |
Other psoriasis |
L40.9 |
Psoriasis, unspecified |
Documentation and Coding Example 1
Patient is a 12-year-old male suffering from Psoriasis on elbows, knees, and hands. His eruptions worsened in the past two weeks. He has erythematous eruptions with scaling and severe itching and burning. Itching is aggravated at night. There are many cracks with watery discharge and much bleeding. Patient also reports asymmetrical joint stiffness of the knees in the morning or after long periods of inactivity. At the onset of this severe aggravation, he was put on steroids and methotrexate by his dermatologist.
There is a strong family history of psoriasis; his father, his paternal uncle both suffer from psoriasis and his paternal grandfather also suffers from psoriatic arthritis. The patient’s psoriasis is aggravated in summer; he can’t tolerate heat and desires a fan in all seasons. He complains of gastric upset for the past week to ten days. No recent upper respiratory infections or other viral infections or stressful events. History is also negative for physical trauma, vaccination, or sunburn.
Vitals: 110/75, 72, 98.6. Well-nourished white male, NAD, alert and oriented to person, place, and time. AT/NC; oropharynx clear with moist mucous membranes; and normal dentition and gums. Anicteric sclerae, moist conjunctiva; PERRLA, fundi clear with sharp disc margins and normal posterior segments. Trachea midline; FROM, neck supple, no lymphadenopathy, thyromegaly or carotid bruits; no JVD. Lungs CTA in front with no rales or crackles; normal respiratory effort; no dullness to percussion. CV: RRR. Abdomen: Soft, non-tender; no masses or HSM, normal abdominal aorta without bruits. Appetite is normal with cravings for spicy foods with previously noted complaints of gastric upset for 7-10 days. He drinks approximately 1-2 liters/day; urine and stool are normal.
Skin: Normal temperature, turgor, and texture. He has erythematous eruptions with scaling and several cracks with watery discharge. Psoriasis papules are sharply demarcated, erythematous, scaly, and pruritic. No extremity lymphadenopathy; brisk and symmetric pedal pulses; no digital cyanosis however, there is evidence of dactylitis in the toes and the toenails appear pitted. There is stiffness, swelling, and tenderness of the knee joints and surrounding ligaments and tendons. He has psoriatic arthritis developing in both the knees. Concomitant joint and nail involvement reinforces the diagnosis. The patient was started on Carcinosin 200 and saw improvement with reduced scaling within two weeks. The pain in his knees was also improving. New eruptions were under control and his gastric upset also reduced significantly.
Diagnosis: Juvenile Psoriatic Arthritis.
Diagnosis code(s)
L40.54 |
Psoriatic juvenile arthropathy |
Coding Note(s)
Arthritic or arthropathic psoriasis is classified by type such as distal interphalangeal psoriatic arthropathy, psoriatic arthritis mutilans, psoriatic spondylitis and psoriatic juvenile arthropathy.
Documentation and Coding Example 2
This 26-year-old male presents today with complaints of psoriasis on his scalp. He has experienced periodic outbreaks since he was a child so he is familiar with the condition which typically flares when he is under stress. This flare started when he was finishing work on his master’s degree and preparing for public presentations of his master’s thesis. He has been using an over-the-counter medicated shampoo without relief of symptoms.
Examination: This is a well-developed, well-nourished, thin, athletic young man. Ht 5’10”, Wt 139, T 98.2, B/P 108/70, P 66 and regular, R 18. Skin of face, trunk, and arms is clear. There are several small crusty and inflamed patches noted around the knees bilaterally. These are consistent with psoriasis. Examination of the neck is normal. Thyroid normal. There are no enlarged lymph nodes noted in the neck region. The top and sides of the scalp are clear but there is a large contiguous area of crusting and inflamed skin from the level of the ear to the base of the hairline on the back of the scalp.
Impression: Plaque psoriasis flare.
Plan: Patient will continue to use medicated shampoo. He was given prescriptions for corticosteroid ointment for the psoriasis outbreak on his legs and for corticosteroid scalp solution to treat the outbreak on his scalp as these have worked well in the past. He is to return in 4 weeks for re-evaluation or sooner if there is any exacerbation of symptoms.
Diagnosis Code(s)
Coding Note(s)
Plaque psoriasis is synonymous with psoriasis vulgaris and is listed as an inclusion term under code L40.0. It can be found in the Alphabetic Index under psoriasis, plaque.
Skin Ulcer Chronic
A skin ulcer is a breakdown in the skin that may involve only the skin, extend into the subcutaneous tissue and fat layer, or even deeper into the muscle and bone. Classification of skin ulcers depends on whether the skin ulcer is documented as a pressure or non-pressure ulcer. In ICD-10-CM, skin ulcers that are caused by pressure are classified in category L89. Non-pressure ulcers are classified in category L97 and in subcategory L98.4. Precise documentation of the location, causation (pressure vs. chronic non-pressure) and severity of the chronic skin ulcer is imperative for proper code selection. Chronic ulcers documented as healing should be coded to the current stage of the ulcer. Both pressure and non-pressure ulcers will be reviewed with separate tables, documentation guidelines and documentation examples for each.
Pressure Ulcers
A pressure ulcer is an ulceration caused by prolonged pressure occurring most often over bony prominences of the body. The ulcer is caused by ischemia of the underlying structures of the skin, fat, and muscles as a result of the sustained and constant pressure. Documentation related to pressure ulcers is integral to coding, assessment, and measurement of quality of care. A pressure ulcer is sometimes documented as decubitus ulcer, bed sore, plaster ulcer, pressure area, or pressure sore.
In ICD-10-CM, a combination code that describes both the pressure ulcer site and the ulcer stage is defined for coding. Codes for decubitus ulcers also include laterality, and severity. These codes classify the four stages of pressure ulcers as well as unstageable and unspecified stage pressure ulcers. Pressure ulcer stages are classified based on severity and designated by stages I-IV (1-4) and unstageable.
A pressure ulcer coded as “unstageable” should not be confused with a pressure ulcer whose stage is unspecified. Assigning a code for an unstageable pressure ulcer must be based on the clinical documentation indicating that the pressure ulcer stage cannot be clinically determined. Unstageable pressure ulcers are advanced stage pressure ulcers that cannot have the extent of tissue damage confirmed due to being obscured by slough or eschar. After the slough or eschar is removed, either a stage 3 or stage 4 pressure ulcer is revealed. The code for unspecified pressure ulcer is assigned when there is no documentation regarding the stage of the pressure ulcer.
Deep tissue pressure injury (DTPI) is currently 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”. DTPIs often have both ischemic and pressure-induced etiologies, and arise from intense or prolonged pressure and shear forces at a bone and muscle interface. Unlike advanced pressure ulcers, deep tissue injury may resolve without tissue loss, or the wound may evolve to show the actual extent of tissue injury. These type of wounds are also reported in category L89 Pressure ulcer as pressure-induced deep tissue damage by site and laterality.
Coding and Documentation Requirements
Identify pressure ulcer or deep tissue pressure injury site:
•Ankle
•Back
–Upper
–Lower
–Unspecified part
•Buttock
•Contiguous site of back, buttock, hip
•Elbow
•Head (includes face)
•Heel
•Hip
•Sacral region, which includes:
–Coccyx
–Tailbone
•Other specified site
•Unspecified site
Identify laterality:
•Right
•Left
•Unspecified
Identify pressure ulcer stage: (based upon clinical documentation)
•Pressure ulcer stage 1
–Pre-ulcer skin changes with persistent focal edema
•Pressure ulcer stage 2
–Abrasion
–Blister
–Partial thickness skin loss involving epidermis and/or dermis
•Pressure ulcer stage 3
–Full thickness skin loss with damage or necrosis of subcutaneous tissue
•Pressure ulcer stage 4
–Necrosis through to underlying muscle, tendon or bone
•Unstageable
•Unspecified stage
Pressure Ulcer of Heel
ICD-10-CM Code/Documentation |
Unspecified Heel |
L89.600 |
Pressure ulcer of unspecified heel, unstageable |
L89.601 |
Pressure ulcer of unspecified heel, stage 1 |
L89.602 |
Pressure ulcer of unspecified heel, stage 2 |
L89.603 |
Pressure ulcer of unspecified heel, stage 3 |
L89.604 |
Pressure ulcer of unspecified heel, stage 4 |
L89.609 |
Pressure ulcer of unspecified heel, unspecified stage |
Right Heel |
L89.610 |
Pressure ulcer of right heel, unstageable |
L89.611 |
Pressure ulcer of right heel, stage 1 |
L89.612 |
Pressure ulcer of right heel, stage 2 |
L89.613 |
Pressure ulcer of right heel, stage 3 |
L89.614 |
Pressure ulcer of right heel, stage 4 |
L89.619 |
Pressure ulcer of right heel, unspecified stage |
Left Heel |
L89.620 |
Pressure ulcer of left heel, unstageable |
L89.621 |
Pressure ulcer of left heel, stage 1 |
L89.622 |
Pressure ulcer of left heel, stage 2 |
L89.623 |
Pressure ulcer of left heel, stage 3 |
L89.624 |
Pressure ulcer of left heel, stage 4 |
L89.629 |
Pressure ulcer of left heel, unspecified stage |
Documentation and Coding Example
An 83-year-old female presented with a chief concern of an ulcer on the posterior aspect of her left heel which has recently gotten worse. The patient denies any trauma to the foot. The ulceration developed following an extended period of bed rest. She has no known allergies. There is no history of fever, rash, respiratory infection, or gastrointestinal symptomatology. There is no history of diabetes, psoriasis, skin cancers, or dysplastic nevi. Her medical history is otherwise unremarkable.
Vital Signs: BP = 120/80. Pulse = 80 Resp =12. Patient is afebrile. The neck is supple. There is no jugular venous distension. The thyroid is non-tender. The lungs are clear to auscultation and percussion. There is a regular rhythm. S1 and S2 are normal. No abnormal heart sounds detected. Normal bowel sounds are present. The abdomen is soft, non-tender, without organomegaly. There is no CVA tenderness. No hernias noted. There is no clubbing, cyanosis, or edema in the extremities. Skin is warm and dry. The left heel is covered by a bandage and, on examination, there is a shallow, open ulcer located on the lateral aspect of the left heel, with blistering and partial thickness loss of epidermal tissue. The ulcer is approximately 6 cm in size, with a red pink wound bed without slough.
Laboratory Studies: White blood cell count was unremarkable. Hematocrit 31.9. Sedimentation rate was 57. BUN 24 and Creatinine 1.6. Cultures showed no growth thus far.
Assessment: Decubitus ulcer, left heel.
Plan: Cover with vancomycin, pending the results of the cultures. Incision and drainage will depend on possibility of infected bone.
Diagnosis: Decubitus ulcer, left heel with partial thickness epidermal skin loss.
Diagnosis code(s)
L89.622 |
Pressure ulcer of left heel, stage 2 |
Coding Note(s)
When coding pressure ulcers, documentation of the ulcer size, location, eschar and granulation tissue, exudate, odor, sinus tracts, undermining, or infection and appropriate staging (I through IV) are essential. Codes for decubitus ulcers in ICD-10-CM include site, laterality, and severity—including the four stages of pressure ulcers so only one code is necessary to describe the patient’s condition. Code L89.622 includes pressure ulcer with partial thickness skin loss involving the epidermis and/or dermis, left heel.
Non-Pressure Chronic Ulcer of Lower Limb/Other Sites/Unspecified Site
Non-pressure ulcers may also be referred to as atrophic, chronic, neurogenic, non-healing, non-infected sinus, perforating, trophic, or tropical ulcers. Non-pressure skin ulcers are typically caused by another condition which is usually vascular in nature. Common causal conditions include: atherosclerosis of the extremities, chronic venous hypertension, diabetes mellitus with circulatory complications, and postphlebitic syndrome.
In ICD-10-CM, non-pressure chronic skin ulcers of the lower extremities are classified in category L97 and non-pressure chronic skin ulcers of other sites are classified in subcategory L98.4. Codes in category L97 and subcategory L98.4 may be reported alone if the etiology is not known or they may be reported as secondary codes when the underlying condition is documented. For example, ulcers caused by circulatory system disease such as varicose veins, post-thrombotic syndrome, or chronic venous hypertension are first assigned a code from the circulatory system chapter of the Tabular List, and then a second code is assigned from category L97 or subcategory L98.4 to describe the specific anatomical location. Other causes of non-pressure chronic ulcers include diabetes mellitus and atherosclerosis. In addition to assigning the etiology as the first listed diagnosis, any gangrene is also listed before the code for the ulcer.
Non-pressure chronic ulcers are classified by anatomical location and codes further specify the severity of tissue damage, which ranges from breakdown of the skin only to necrosis of bone. Documentation of the specific anatomical site and a detailed description of the severity are necessary for optimal code assignment.
Coding and Documentation Requirements
Identify site of non-pressure chronic ulcer:
•Back
•Buttock
•Lower leg
–Ankle
–Calf
–Heel and midfoot
–Other part of foot (includes toe)
–Other part of lower leg
–Unspecified part of lower leg
•Thigh
•Other specified site / unspecified site
Identify ulcer severity as:
•Limited to breakdown of skin
•With fat layer exposed
•With necrosis of muscle
•With necrosis of bone
•With muscles involvement without evidence of necrosis
•With bone involvement without evidence of necrosis
•With other specified severity
•Unspecified severity
Identify laterality:
•Right
•Left
•Unspecified
Identify and code first any associated underlying condition:
•Atherosclerosis of the lower extremities
•Chronic venous hypertension
•Diabetic ulcers
•Gangrene
•Postphlebitic syndrome
•Post-thrombotic syndrome
•Varicose ulcer
Non-Pressure Chronic Ulcer – Calf
ICD-10-CM Code/Documentation |
Unspecified Calf |
L97.201 |
Non-pressure chronic ulcer of unspecified calf limited to breakdown of skin |
L97.202 |
Non-pressure chronic ulcer of unspecified calf with fat layer exposed |
L97.203 |
Non-pressure chronic ulcer of unspecified calf with necrosis of muscle |
L97.204 |
Non-pressure chronic ulcer of unspecified calf with necrosis of bone |
L97.205 |
Non-pressure chronic ulcer of unspecified calf with muscle involvement without evidence of necrosis |
L97.206 |
Non-pressure chronic ulcer of unspecified calf with bone involvement without evidence of necrosis |
L97.208 |
Non-pressure chronic ulcer of unspecified calf with other specified severity |
L97.209 |
Non-pressure chronic ulcer of unspecified calf with unspecified severity |
Right Calf |
L97.211 |
Non-pressure chronic ulcer of right calf limited to breakdown of skin |
L97.212 |
Non-pressure chronic ulcer of right calf with fat layer exposed |
L97.213 |
Non-pressure chronic ulcer of right calf with necrosis of muscle |
L97.214 |
Non-pressure chronic ulcer of right calf with necrosis of bone |
L97.215 |
Non-pressure chronic ulcer of right calf with muscle involvement without evidence of necrosis |
L97.216 |
Non-pressure chronic ulcer of right calf with bone involvement without evidence of necrosis |
L97.218 |
Non-pressure chronic ulcer of right calf with other specified severity |
L97.219 |
Non-pressure chronic ulcer of right calf with unspecified severity |
Left Calf |
L97.221 |
Non-pressure chronic ulcer of left calf limited to breakdown of skin |
L97.222 |
Non-pressure chronic ulcer of left calf with fat layer exposed |
L97.223 |
Non-pressure chronic ulcer of left calf with necrosis of muscle |
L97.224 |
Non-pressure chronic ulcer of left calf with necrosis of bone |
L97.225 |
Non-pressure chronic ulcer of left calf with muscle involvement without evidence of necrosis |
L97.226 |
Non-pressure chronic ulcer of left calf with bone involvement without evidence of necrosis |
L97.228 |
Non-pressure chronic ulcer of left calf with other specified severity |
L97.229 |
Non-pressure chronic ulcer of left calf with unspecified severity |
Documentation and Coding Example
Patient is a 42-year-old male with a poor healing ulceration of the right lower extremity. He states that the ulcer and surrounding redness has been present for approximately 6 months without significant improvement, but without significant worsening either. The patient denies any fevers or chills and denies any worsening redness or pain to the right lower extremity. He denies any cough or sputum. Has not had any chest pain, palpitations, or lightheadedness. He denies any orthopnea or PND. No chest pain on exertion or dyspnea on exertion. He has no trauma, headache, visual disturbances, focal weakness, numbness, or any gait disturbances. He denies any joint pain, rash, back pain, abdominal pain, vomiting, diarrhea, constipation, hematochezia, melena or any change in appetite. He has had no dysuria, hematuria, increased urinary frequency or urgency. Denies any upper respiratory infection symptoms, sore throat, or odynophagia. All other systems are reviewed and otherwise negative.
Past medical history is significant for this chronic nonhealing right lower extremity ulcer. No previous surgeries. Denies tobacco, alcohol, or illicit drug use. Family history is noncontributory. Medications: NKDA; Daily multivitamin.
Vital Signs: Blood pressure 148/90, pulse 92, respirations 21, temperature 98.5 degrees Fahrenheit oral, O2 95% on room air. This is a well-developed, well-nourished male, ambulating. Alert and oriented x3. In no acute respiratory distress. The patient is otherwise afebrile with stable vital signs and does not appear toxic otherwise. HEENT: Pupils equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes are moist. Oropharynx is clear. Neck: No JVD. Supple. Lungs: Clear to auscultation bilaterally. No wheezes or rales. Heart: Regular rate and rhythm. Normal S1, S2. Abdomen: Soft, non-tender to deep palpation in all quadrants. No rebound or guarding. Normoactive bowel sounds. Neurological: Sensation is intact to light touch. Skin: Warm and dry.
Extremities: There is a chronic shallow nonhealing ulcer on the lateral aspect of the right calf with some surrounding erythema, however, without significant warmth. The wound is shallow, limited to breakdown of skin, and does appear to have clean granulation tissue at the base. There is no fluctuance or induration. No active drainage. No proximal lymphangitic streaking. No inguinal lymphadenopathy is present. Full range of motion in all joints.
Labs were unremarkable. Lab work does not show significant leukocytosis and the patient does not appear to have significant underlying diabetes to suggest an immunocompromised state. The blood culture so far is negative.
Clinical Impression: Chronic lower extremity nonhealing ulcer which has been ongoing for 6 months. The patient was treated with one dose of IV ciprofloxacin. Wound care protocol, dressings applied. A prescription was sent to pharmacy and the patient will be provided with a 3-day supply of antibiotics. He will follow up in 2 days for repeat wound check.
Disposition: Discharged to home, stable. Follow up with primary physician in 2 days for repeat wound check. He has been given antibiotics to take as directed and will return to the emergency department for any worsening symptoms including worsening redness, fevers, chills, vomiting, or any other concerning symptoms.
Diagnosis: Chronic nonhealing ulcer, right lower leg.
Diagnosis code(s)
L97.211 |
Non-pressure chronic ulcer of right calf limited to breakdown of skin |
Coding Note(s)
ICD-10-CM codes for non-pressure ulcers specify the site as well as the severity of tissue damage from limited to breakdown of skin to necrosis of bone.
Summary
The ICD-10-CM codes include detail and specificity about various conditions of skin and subcutaneous tissue such as laterality and site designation. Provider documentation of the severity of the disease, the etiology and any secondary disease process, as well as the specific site is necessary for code assignment. Provider documentation of any cause-and-effect relationship between a medical treatment and an integumentary disorder is also required for accurate, complete code assignment.
Many combination codes exist that identify both the disorder and common manifestation. For example, decubitus ulcer codes are combination codes that include the site, laterality, and stages of pressure ulcers.
In addition to specificity, updated and standardized terminology is used in ICD-10-CM. Because the clinical information has been updated to include advances in medical diagnosis and treatment for conditions, an understanding of specific coding terms is needed along with more detailed documentation of the patient’s condition.
Resources
Documentation checklists are available in
Appendix A for the following condition(s):
•Dermatitis
•Skin ulcer, chronic, non-pressure
•Skin ulcer, pressure
Chapter 12 Quiz
1.Codes for diseases of the skin and subcutaneous tissue are classified in
Chapter 12. In ICD-10-CM these conditions are organized into:
a.Three subsections
b.Nine code blocks
c.Fourth-character subclassifications
d.Fifth-character level subclassifications
2.Where are nail disorders classified in ICD-10-CM?
a.With diseases of the connective tissue
b.With diseases of the musculoskeletal system
c.With diseases of the skin and subcutaneous tissue
d.With infectious and parasitic diseases
3.Which codes are used for pressure ulcers when the clinical documentation indicates the stage cannot be clinically determined because the ulcer is covered by eschar?
a.Assign the appropriate code for unspecified stage
b.Assign the appropriate code for unstageable pressure ulcer
c.Assign the code for the highest stage for that site
d.The provider must be queried for additional information regarding the stage of the pressure ulcer
4.The physician documents the patient’s diagnosis as boil of the neck. How is this coded?
a.Boil of neck
b.Furuncle of neck
c.Folliculitis of neck
d.All of the above
5.Which of the following statements is true regarding coding of chronic skin ulcers?
a.Requires dual coding to identify the ulcer type and the ulcer stage
b.A combination code is used to identify the ulcer type and the ulcer stage/severity.
c.Anatomic location is not part of the code description.
d.All codes require site and laterality.
6.The physician documents the patient’s diagnosis as eczema. How is this coded?
a.Acute dermatitis due to unspecified cause
b.Dermatitis, unspecified
c.Other specified dermatitis
d.Psoriasis, unspecified
7.Cellulitis may be complicated by acute lymphangitis. Which of the following is true regarding coding of cellulitis with lymphangitis?
a.There is no differentiation between cellulitis with lymphangitis and cellulitis without lymphangitis
b.There are combination codes for cellulitis and acute lymphangitis
c.There are distinct codes for cellulitis and acute lymphangitis
d.None of the above
8.Which of the following is NOT coded as a pressure ulcer?
a.Bed sore
b.Chronic ulcer of skin of lower limb
c.Decubitus ulcer
d.Plaster ulcer
9.What information is specified in both the pressure ulcer and non-pressure ulcer codes?
a.Laterality only
b.Site only
c.Site and laterality
d.Etiology
10.A patient is admitted with sacral pressure ulcers documented as healed. How is this coded?
a.Assign the appropriate code for unstageable ulcer
b.Assign the appropriate code for unspecified stage only if the patient is being treated for the pressure ulcer
c.Assign the appropriate personal history health status code (Z77-Z99)
d.No code is assigned if the documentation states that the pressure ulcer is completely healed
Chapter 12 Answers and Rationales
1.Codes for diseases of the skin and subcutaneous tissue are classified in
Chapter 12. In ICD-10-CM these conditions are organized into:
b.Nine code blocks
Rationale: The beginning of the chapter notes code blocks contained in the chapter, followed by a list of the nine code blocks included in the chapter.
2.Where are nail disorders classified in ICD-10-CM?
c.With diseases of the skin and subcutaneous tissue
Rationale: Nail disorders are classified with disorders of skin appendages in the L60-L75 code block.
3.Which codes are used for pressure ulcers when the clinical documentation indicates the stage cannot be clinically determined because the ulcer is covered by eschar?
b.Assign the appropriate code for unstageable pressure ulcer
Rationale: According to the ICD-10-CM Official Guidelines for Coding and Reporting Section I.C.12.a.2: Assignment of the code for unstageable pressure ulcer (L89.--0) should be based on the clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft).
4.The physician documents the patient’s diagnosis as boil of the neck. How is this coded?
d.All of the above
Rationale: The Index entry for Boil directs the user to see Furuncle, by site. Boil and Folliculitis of neck are listed as included conditions under code L02.12.
5.Which of the following statements is true regarding coding of chronic skin ulcers?
b.A combination code is used to identify the ulcer type and the ulcer stage/severity
Rationale: According to the ICD-10-CM Official Guidelines for Coding and Reporting Section I.C.12.a. Codes from category L89, L97 and L98.4 are combination codes that identify the type (pressure vs. non-pressure), site of the ulcer as well as the stage/severity of the ulcer and laterality, as appropriate.
6.The physician documents the patient’s diagnosis as eczema. How is this coded in ICD-10-CM?
b.Dermatitis, unspecified
Rationale: Code L30.9 Dermatitis, unspecified lists Eczema, NOS as an included condition. The Index entry for Eczema directs the coder to code L30.9 and there is a note to see also Dermatitis.
7.Cellulitis may be complicated by acute lymphangitis. Which of the following is true regarding coding of cellulitis with lymphangitis?
c.There are distinct codes for cellulitis and acute lymphangitis
Rationale: Codes in category L03, Cellulitis and acute lymphangitis, include subcategories for cellulitis by site and acute lymphangitis by site.
8.Which of the following is NOT coded as a pressure ulcer?
b.Chronic ulcer of skin of lower limb
Rationale: According to the inclusion note, codes in category L89, Pressure ulcer, include bed sore, decubitus ulcer, plaster ulcer, pressure area, and pressure sore. Category L97 Non-pressure chronic ulcer of lower limb NEC, includes chronic ulcer of skin of lower limb.
9.What information is specified in both the pressure ulcer and non-pressure ulcer codes?
c.Site and laterality
Rationale: Codes in category L89 specify the site of the ulcer including laterality, and the ulcer stage as in Pressure ulcer of left heel, stage 1 (L89.621). Non-pressure ulcer codes do not identify the stage, but site and laterality. For example, code L97.421 Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin.
10.A patient is admitted with sacral pressure ulcers documented as healed. How is this coded?
d.No code is assigned if the documentation states that the pressure ulcer is completely healed
Rationale: According to the coding guidelines, no code is assigned for patients admitted with pressure ulcers when the documentation states that the pressure ulcer is completely healed.