The CMS HAC Reduction Program compares and financially penalizes hospitals based on performance in multiple categories, one of which is hospital-acquired pressure injury rates, included as patient safety indicator 3 (PSI-3).  Stage 3, 4 or unstageable pressure injuries that are not present on admission or progress during the stay may impact a hospital’s quality ratings and are considered avoidable.

From a reimbursement standpoint, a stage 3 or 4 pressure injury is classified as an MCC for MS-DRGs, which can lead to a significant increase in DRG reimbursement.

The term “skin failure” has been proposed as an alternative term for skin injuries that are not pressure related and would not be classified as PSI-3. Skin failure, in general, describes skin breakdown due to many different causes. It can be either systemic, such as due to multi-organ failure, and/or localized, such as due to pressure or moisture-associated skin damage (MASD).  Skin failure is not a specific diagnosis but rather a manifestation of an underlying disease.

Pressure injuries are the most commonly diagnosed skin failure in hospitals and are often avoidable. However, when pressure is not the primary factor in skin failure, these causes can be unavoidable, such as with Kennedy (terminal) ulcers.

Clinically differentiating between pressure injury and skin failure not due to pressure can also be important for proper patient management. For example, current protocols to reduce skin breakdown, such as turning patient every two hours, may fail in patients with multiple risk factors and associated conditions.

Therefore, differentiating between pressure injury and acute skin failure (not due to pressure) is not only important for accurate coding, DRG reimbursement, and quality ratings, but a more accurate diagnosis may lead to more appropriate treatment strategies, less wasted resources, and improved quality of care for affected patients.

Let’s review these different skin injuries:

Pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure in combination with shear and often associated with immobility and/or absent sensation; moisture and nutritional deficiency (or obesity) also contribute. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, perfusion, comorbidities, and condition of the soft tissue.  Pressure ulcers commonly occur over bony prominences like sacrum/coccyx, heel, buttocks (gluteal), low back, elbow.

Acute skin failure has been used to describe skin loss in association with hemodynamic instability (hypoperfusion) and/or organ system compromise in critically ill patients, especially in the context of a multi-organ dysfunction syndrome (MODS), or as part of the dying process at the end of life. As with pressure ulcers, pressure points like boney prominences are most vulnerable to acute skin failure. Although pressure plays a role, acute skin failure is not responsive to typical pressure ulcer management and is therefore considered unavoidable.

Kennedy (terminal) ulcers typically occur between 1 day and 6 weeks before end of life. These terminal ulcerations have been characterized as skin failure as a result of ischemia. It has been suggested that the Kennedy ulcer is a type of acute skin failure occurring at the end of life.  As such, Kennedy ulcers may be considered unavoidable.

Coding Implications: Pressure Injuries vs. Skin Failure

Pressure injuries by site and stage are assigned to ICD-10 category L89. Kennedy ulcers are also assigned to category L89. There is no specific code assignment for acute skin failure.

Kennedy ulcers are also classified as pressure ulcers and because they are usually not POA, these could potentially be classified as PSI 03 (Pressure Ulcer Rate) just like any stage 3, 4, unstageable pressure ulcer that is not POA.

Acute skin failure is a non-indexed term for which codes L98.8 or L98.9, Other or unspecified disorders of the skin and subcutaneous tissue, have been suggested. Because these codes are not included in PSI 03, overuse of them may artificially inflate quality performance. Use of these codes when a pressure injury is clinically valid could also reduce DRG reimbursement. These L98 codes should not be substituted for coding of the underlying cause and, in fact, as a manifestation, should probably not be coded at all.

When a stage 3, 4, or unstageable pressure ulcer or Kennedy ulcer is documented, should the provider be queried regarding the cause?  It depends.  To be compliant, a query should not be submitted to a provider as an attempt to remove a diagnosis from being classified as a HAC. In many circumstances, a pressure ulcer may be due to both pressure and non-pressure causes. Proper provider education of the different terms and definitions may be more effective.

Get our CDI Pocket Guide® for more information regarding pressure and skin ulcers.

References: Pressure Ulcer and Acute Skin Failure

National Pressure Ulcer Advisory Panel (NPUAP) announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury.

Skin failure: A two-faced concept. Dermatol Reports. 2022; 1: 9406.

The Pathophysiology of Skin Failure vs. Pressure Injury: Conditions That Cause Integument Destruction and Their Associated Implications. Wounds 2020; 32:319–327.

A case of acute skin failure misdiagnosed as a pressure ulcer, leading to a legal dispute. Arch Plast Surg. 2019 Jan; 46: 75–78.