ICD-10 Guide

Stage 4 Sacral Ulcer

ICD-10 Coding for Stage 4 Sacral Ulcer(L89.154)

PRIMARY SPECIALTYWound Care

COMPLEXITYHigh

LAST UPDATED09/15/2025

Sam Tuffun, PT, DPT

Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Stage 4 Sacral Ulcer?

Essential facts and insights about Stage 4 Sacral Ulcer

Key Clinical Considerations:

Presence of full-thickness skin loss with exposed bone, tendon, or muscle
Infection or necrosis may be present
Pain and discomfort in the affected area

Clinical Information

Clinical Criteria & Documentation Requirements

Detailed description of ulcer size, depth, and stage
Assessment of surrounding skin condition and any signs of infection
Photographic evidence of the ulcer may be required

Coding Guidelines

Usage Guidelines & Examples

Follow guidelines for staging pressure ulcers to avoid misclassification
Common errors include using lower stage codes for stage 4 ulcers

Code Exclusions

Important Exclusions

Other types of ulcers such as venous or arterial ulcers
Alternative codes for non-pressure related skin injuries

Specialty Focus

Primary Specialty

Wound Care

Specialty Applications

Elderly patients, patients with limited mobility, and those with chronic illnesses
Long-term care facilities, hospitals, and outpatient wound care clinics

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

Comprehensive clinical documentation
Accurate code selection based on clinical criteria
Proper exclusion considerations
Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

Ensure proper documentation for billing
Verify code specificity requirements
Check for any additional codes needed
Review payer-specific guidelines

Common Issues

Insufficient clinical documentation
Incorrect code selection
Missing supporting diagnoses
Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Document the stage, size, location, and any complications.

Billing considerations?

Ensure accurate coding to reflect the severity and treatment provided.

Stage 4 Sacral Ulcer

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?

Stage 4 Sacral Ulcer

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?