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Pressure ulcer of contiguous site of back, buttock and hip, stage 4
ICD10CM code
Name of the Condition
- Pressure Ulcer of Contiguous Site of Back, Buttock, and Hip, Stage 4
- Also known as advanced bedsore or decubitus ulcer.
Summary
- This condition is a severe form of skin breakdown where extended pressure on the skin and underlying tissues leads to significant damage, often exposing muscle and bone.
Causes
- The primary cause is prolonged pressure on the skin, often due to immobility. It compromises blood flow and leads to tissue necrosis.
- Friction, shear, and moisture may exacerbate the situation.
Risk Factors
- Physical immobility, such as being bedridden or wheelchair-bound.
- Advanced age, poor nutrition, and dehydration.
- Medical conditions affecting blood flow, like diabetes and vascular disease.
- Incontinence leading to prolonged skin moisture.
Symptoms
- Deep open wound with exposed tissue or bone.
- Infection signs like odor, pus, and redness or warmth around the ulcer.
- Pain or tenderness in the affected area.
Diagnosis
- Primarily through a comprehensive physical examination.
- Assessment of the wound's location, size, depth, and any signs of infection.
Treatment Options
- Debridement: Removal of dead tissue to promote healing.
- Wound Care: Use of dressings and pressure-relieving devices.
- Antibiotics: To treat or prevent infection.
- Surgery: Skin grafts or flap surgery for significant tissue damage.
- Nutritional support to enhance recovery.
Prognosis and Follow-Up
- Varies based on overall health, timely treatment, and adherence to care plan.
- Regular follow-ups are crucial to monitor healing, manage infection, and adjust treatment.
Complications
- Increased risk of infection like cellulitis or sepsis.
- Prolonged healing time or permanent tissue damage if untreated.
- Negative impact on quality of life and increased hospitalizations.
Lifestyle & Prevention
- Frequent repositioning to alleviate pressure.
- Use of support surfaces like specialized mattresses and cushions.
- Maintain optimal nutrition and hydration.
When to Seek Professional Help
- Immediate attention if new ulcers develop or current ulcers worsen.
- Signs of infection in the ulcer such as increased redness, warmth, swelling, pain, or discharge.
Additional Resources
Tips for Medical Coders
- Ensure accurate documentation of the ulcer's location and stage for precise coding.
- Avoid misclassifying the pressure ulcer stage by confirming with clinical notes.
- Double-check for any related conditions or complications that may also require coding.