ICD-10 Coding: Diabetic Foot Ulcer or Pressure Ulcer?

Even a podiatrist may not know for sure.

When is a diabetic’s foot ulcer a pressure ulcer? When is a pressure ulcer a diabetic foot ulcer? These are the questions we are going to explore in this two-part series of articles elicited by my disgruntlement with the advice in the third-quarter issue of Coding Clinic.

Shear and pressure are the mechanisms that lead to what are known as “pressure injuries.” In 2016, the National Pressure Ulcer Advisory Panel (NPUAP) recommended transitioning to the terminology of “pressure injury” because although underlying tissue may be damaged, overlying skin may appear intact. Pressure injuries with skin breakdown are considered pressure ulcers. An additional L89 code specifies the stage (depth of tissue injury) and the anatomical site.

Pressure ulcers form in sites that experience shear or pressure, typically in tissue overlying bony prominences such as elbows, the sacrum, hips, or heels. After sacral, heel ulcers are the second most common type of pressure injury. The etymology of the term “decubitus ulcer” is from the Latin, decumbere, which means “to lie down,” and thus it really relates to patients who are recumbent. “Pressure ulcer” or “injury” is more accurate, because the pathology may be noted in patients in other spatial positions, such as ischial tuberosity ulceration from prolonged sitting by a paraplegic. Ambulatory patients may develop pressure injury, but reduced mobility is a significant risk factor.

The term “non-pressure ulcer” was coined to designate a primary mechanism other than shear or pressure. If there is poor circulation, such as that caused by venous or arterial insufficiency or excessive moisture or trauma, a patient may develop a non-pressure ulcer. The word “chronic” is incorporated in the coding title, although chronicity is a measure of duration of time, not specific to a mechanism of injury. The ulceration of a pressure injury is often chronic as well.

There are medical diagnoses that predispose patients to develop secondary conditions. Diabetes mellitus is a pervasive endocrinopathy whereby hyperglycemia affects every organ and system in the body, including the nerves and blood vessels. It makes a patient more prone to infection and poor healing. Diabetics are prone to foot ulcers, often with contributions from neuropathic, ischemic, and most commonly, neuro-ischemic (both) etiologies.

Neuropathy occurs due to damage to the nerves and causes impaired sensation. After 10 years, ~90 percent of Type 1 and Type 2 diabetics have some degree of neuropathy, most commonly affecting the feet and legs, and 90 percent of diabetic foot ulcers have diabetic neuropathy as a contributing factor. If the diabetic doesn’t recognize discomfort due to nerve impairment, they may not adjust their shoes and socks or seek medical attention for minor cuts or blisters.

Diabetics also often have diseases of both large and small arteries. Poorly controlled blood sugars weaken the small blood vessel walls and predispose patients to arteriosclerosis. This impairs the circulation and causes ischemia of the soft tissues, especially of the lower extremities.

Many diabetics have both diabetic peripheral neuropathy and angiopathy. This makes them that much more likely to develop foot ulcers. A “diabetic foot ulcer,” which is caused exclusively by hyperglycemia, in the absence of neuropathy or ischemia, is a rarity. That term almost always refers to an ulcer on the foot of a diabetic that derives from neuro/ischemic etiology, as opposed to being strictly and principally due to pressure injury.

Heel ulcers, however, are usually a consequence of a pressure injury, although it is also possible to have another mechanism cause a non-pressure injury involving the heel. Diabetes may accelerate or complicate the injury.

Neuropathy results in malum perforans pedis (a.k.a. bad perforating foot) ulcers. These are painless, non-necrotic, circular lesions circumscribed by hyperkeratosis. They often overlie a metatarsal head. Ischemic wounds manifest local signs of ischemia such as thin, shiny, hairless skin with pallor and coldness. These are often found at areas of friction and may be painful.

Is it a pressure ulcer, a diabetic foot ulcer, or both? Is this a difference without a distinction? Is it just semantics, or is it clinically significant?

The American Orthopaedic Foot & Ankle Society states that “ulceration is an extremely common complication in diabetic patients (up to 12 percent of the population). The plantar surface is the most common site of ulceration, especially at areas of bony prominence.” The Society also points out that “the presence of neuropathy is the key factor in development of diabetic ulceration.”

The American Podiatric Medical Association adds that “(diabetic foot) ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation (such as friction or pressure), and trauma, as well as duration of diabetes.” They go on to note that “vascular disease can complicate a foot ulcer, reducing the body’s ability to heal and increasing the risk for an infection.”

In the podiatric literature, NPUAP is often referenced as having given guidance to use “diabetic foot ulcer” for “any ulcer on the foot of a diabetic, even if arterial disease and/or pressure played a role in its development.” I think this is simplistic and derived from literature not aimed at physicians/APPs.

It is common in the literature to see the term “diabetic foot ulcer” used for all-comers. Why should we specifically carve out pressure ulcers? Pressure ulcers are deemed patient safety indicators and hospital acquired conditions because a concerted program for prevention and treatment can prevent them and protect our patients from iatrogenic harm. The diagnosis of a “pressure ulcer” may trigger prevalence and incident reporting.

Ultimately, the clinical concern is to treat the lesion appropriately, regardless of the name attached to it.

The treatment for both pressure ulcers and diabetic foot ulcers includes offloading (i.e., pressure mitigation, often by means of padding, shoe modifications, contact casts, boots, or non-weight-bearing strategies). Any non-healing wound should be assessed for neuropathy and perfusion status. Infection should be addressed, and wounds debrided as indicated. A multi-disciplinary approach, including wound care professionals, podiatry, and careful glucose management is prudent.

But you all surely want to know how to code this. You are going to have to wait for the second installment in this series for guidance on that. Until then, accept that there is sometimes clinical confusion as to whether the pathology indicates a diabetic foot ulcer or a pressure ulcer of the foot in a diabetic.


Program Note:

Listen to Dr. Remer every Tuesday on Talk Ten Tuesday, 10 a.m. ET.

Comment on this article

Facebook
Twitter
LinkedIn

Erica Remer, MD, FACEP, CCDS, ACPA-C

Erica Remer, MD, FACEP, CCDS, ACPA-C has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

The Cost of Ignoring Risk Adjustment: How HCCs Impact Revenue & Compliance

The Cost of Ignoring Risk Adjustment: How HCCs Impact Revenue & Compliance

Stop revenue leakage and boost hospital performance by mastering risk adjustment and HCCs. This essential webcast with expert Cheryl Ericson, RN, MS, CCDS, CDIP, will reveal how inaccurate patient acuity documentation leads to lost reimbursements through penalties from poor quality scores. Learn the critical differences between HCCs and traditional CCs/MCCs, adapt your CDI workflows, and ensure accurate payments in Medicare Advantage and value-based care models. Perfect for HIM leaders, coders, and CDI professionals.  Don’t miss this chance to protect your hospital’s revenue and reputation!

May 29, 2025
I050825

Mastering ICD-10-CM Coding for Diabetes and it’s Complications: Avoiding Denials & Ensuring Compliance

Struggling with ICD-10-CM coding for diabetes and complications? This expert-led webcast clarifies complex combination codes, documentation gaps, and sequencing rules to reduce denials and ensure compliance. Dr. Angela Comfort will provide actionable strategies to accurately link diabetes to complications, improve provider documentation, and optimize reimbursement—helping coders, CDI specialists, and HIM leaders minimize audit risks and strengthen revenue integrity. Don’t miss this chance to master diabetes coding with real-world case studies, key takeaways, and live Q&A!

May 8, 2025
2025 Coding Clinic Webcast Series

2025 ICD-10-CM/PCS Coding Clinic Update Webcast Series

Uncover critical guidance. HIM coding expert, Kay Piper, RHIA, CDIP, CCS, provides an interactive review on important information in each of the AHA’s 2025 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 14, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24