AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 1; Ask the Editor

Evolving Deep Tissue Injury

A patient presents with a sacral deep tissue injury (DTI), and undergoes surgical debridement. Following excisional debridement, the provider documents “Stage 4 pressure ulcer of the sacrum.” Should guideline I.C.12.a.7, be interpreted to mean that only one code (L89.--6) is assigned for the DTI, whether the stage is later revealed or not? What is the correct ICD-10-CM code assignment and present on admission (POA) indicator, for this case? ...

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