Q&A: Should documentation specify pressure injuries or pressure ulcers?

Why This Topic Matters

Clear documentation language affects accurate code assignment, clinical communication, and CDI review for pressure-related skin conditions. The article helps readers understand the broader terminology shift and the documentation elements that support compliant coding workflows.

Article Sections

1. Q&A: Documentation terminology for pressure injuries and pressure ulcers

   Introduces the documentation question and frames the topic for providers and coding staff.

2. Terminology and ICD-10-CM coding context

   Explains the relationship between pressure-related terminology and ICD-10-CM category guidance, including how related wording is discussed in the Tabular List.

3. 2016 NPUAP terminology update and staging context

   Summarizes the terminology change announced by the National Pressure Ulcer Advisory Panel and the general staging context discussed in the article.

4. Stage 1 example codes in category L89.-

   Presents a set of representative ICD-10-CM examples referenced in the discussion of stage 1 pressure ulcers.

5. Coding Clinic, Third Quarter 2016 guidance

   Reviews the Coding Clinic discussion of how the terminology change was addressed and how related documentation concepts were described.

6. Deep tissue injury index guidance

   Notes the index-related discussion for deep tissue injury and its relationship to pressure ulcer terminology in ICD-10-CM.

7. Editor’s note and submission disclaimer

   Includes the article’s editorial attribution and reminder that final code assignment depends on the full documentation in each case.