ICD 10 Codes for the WOCN

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The ICD-10 Coordination and Maintenance Committee approved the Wound, Ostomy and Continence Nurses Society’s (WOCN) application for new International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes for moisture-associated skin damage (MASD) to be added to the existing version of codes.

The ICD codes are used around the world to identify diseases and health conditions, and in the United States the codes are linked to third party payment for health care services and supplies. Due to the world’s aging population, MASD causes a significant burden on the healthcare system and can lead to irritant contact dermatitis, which causes skin inflammation and potential infection.

The previous ICD-10-CM codes did not cover the clinically relevant and prevalent forms of irritant contact dermatitis, but the new codes as initiated by WOCN specify the sources of irritant contact dermatitis and thus guide nurses and other wound care clinicians in providing optimal care to clients.

Introduction

In October 2021, the ICD-10 Coordination and Maintenance Committee approved the Wound, Ostomy and Continence Nurses Society’s (WOCN) application for new International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes for moisture-associated skin damage (MASD) to be added to the existing version of codes in an effort to improve client outcomes, clinician education, data collection, research efforts, and resource allocation (1,5,6).

The ICD codes are used around the world to identify diseases and health conditions, and in the United States the codes are linked to third party payment for health care services and supplies. These new codes as initiated by WOCN were also supported by The American Academy of Dermatology Association, American Geriatrics Society, Dermatology Nurses Association, European Association of Urology Nurses, International Continence Society, National Pressure Injury Advisory Panel, The Society for Post-Acute and Long-Term Care Medicine, and World Council of Enterostomal Therapists (6).

Due to the world’s aging population, MASD causes a significant burden on the healthcare system because it affects individuals with acute, critical, and chronic conditions in various care settings [1,11]. MASD can lead to irritant contact dermatitis, which causes inflammation and potential infection. The previous ICD-10-CM codes did not cover the clinically relevant and prevalent forms of irritant contact dermatitis that are caused by the skin’s exposure to various bodily fluids, including urine, feces, mucus, saliva, digestive secretions, perspiration, and wound drainage (1,2,3).

The past codes were both inadequate and inconsistently used, which was challenging for nurses and other clinicians because it prohibited the ability to track conditions, conduct specific research, disseminate education, and receive reimbursement (1,6,11).

The new ICD-10-CM codes require nurses to use slightly different words to document wound care, and WOCN encourages nurses to teach others and be the role models for using the new language to help improve client outcomes (11).

History of ICD Codes

The International Statistical Classification of Diseases and Related Health Problems (ICD) dates to 16th century England when the London Bills of Mortality would announce deaths from diseases, such as scurvy, leprosy, and plague (9). In the 19th century after the Crimean War, Florence Nightingale advocated for the systematic gathering of statistics on disease and death. Also in the 19th century, French physician turned statistician Jacques Bertillon published articles about comparative divorce and suicide rates among nations, and then in 1883 he succeeded his father, Louis-Adolphe Bertillon, as head of the Paris bureau of vital statistics.

During his 30-year tenure at the bureau, Jacques Bertillon expanded the types of data gathered and evolved the analysis practices of the data. He focused on causes of death and thus created the Bertillon Classification of Causes of Death in 1893. Bertillon was particularly interested in the increased rate of alcoholism and declining population growth that affected France at the time. These early efforts evolved into an internationally recognized classification system that assists clinicians, policy makers, and healthcare clients to compare healthcare systems and services today.

The United Nations, in 1946, delegated the responsibility of Bertillon’s classification system to the World Health Organization (WHO), naming it the International Statistical Classification of Diseases, Injuries and Causes of Death (8,9). In the late 1970s, the ICD-9 was introduced and was later adopted around the world in the 1980s. However, the ICD-9 did not meet the needs of the American healthcare system, so the National Center for Health Statistics (NCHS) and the Council on Clinical Classifications jointly created the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), which became the required standard for most payers, including the Centers for Medicare and Medicaid Services (CMS) in the United States (8).

Ironically, before the ICD-9 was completed, the WHO recognized that more encompassing classifications would be needed in the immediate future, so they began working on ICD-10. In

1990, ICD-10 was published and included more than 155,000 codes compared to the 17,000 codes of ICD-9 and was quickly implemented by international healthcare agencies (8). The National Center for Health Statistics (NCHS) adapted ICD-10 to American settings and the new system was tested by the American Hospital Association and the American Health Information Management Association (AHIMA) in 2003, resulting in ICD-10-CM. One of the major revisions of ICD-10-CM is that the codes are more specific and decrease the need for multiple codes to describe a certain medical condition (8). However, to accomplish this, the ICD-10 codes are longer than the previous ICD-9 codes, using three to seven digits versus the previous three to five digits.

The ICD-10 codes allow for more specific documentation of a diagnosis or procedure for billing and data tracking. The updated system accounts for new procedures and technologies, which helps providers and payors with essential information to guide disease management programs and reimbursement. In the United States, the ICD-10 codes are still in effect while the 11th edition, which is currently being used globally, is being customized for America’s payor system (2,3,5).

Moisture-Associated Skin Damage and Irritant Contact Dermatitis

Moisture-associated skin damage occurs when the skin is exposed to various sources of moisture [5]. Irritant contact dermatitis is a spectrum of injuries to the epidermis caused by exposure to sources of moisture that cause irritation to the skin (11). Wound drainage, urine and feces, perspiration, saliva, and digestive secretions (from tubes and ostomies) are sources of irritant contact dermatitis and are associated with higher incidences of pressure injury (11). These secretions were previously called “incontinence associated dermatitis” but the new term “irritant contact dermatitis” includes those body fluids that are not associated with incontinence.

Fluid from digestive stomas or fistula secretions was previously referred to as peristomal moisture associated skin damage, excoriation, or denudation, but it now falls under the “irritant contact dermatitis” umbrella (11). Digestive irritant contact dermatitis decreases ostomy pouching system wear time and diminishes client self-confidence while increasing client pain, risk for infection, and expense [11]. Irritant contact dermatitis can also occur when perspiration becomes trapped in a skin fold; it can also exacerbate friction between skin folds and is called erythema intertrigo (11).

Common signs and symptoms of irritant contact dermatitis include (1,11):

• Erythema with local inflammation that is pink or red in color, or skin color that is lighter or darker than the baseline skin tone
• Irregular borders surrounding the inflamed skin that is from contact with urine, feces, digestive secretions, mucus, saliva, perspiration, or wound drainage
• Skin that has a shiny or glistening appearance due to the erosion of the superficial layers
• Rash due to fungal or bacterial infection

Nurses should be aware that irritant contact dermatitis is not a linear, stage-based process and that the client’s health status, skin characteristics, irritant exposed to, and length of time exposed to the irritant all impact the progression of irritant contact dermatitis. In terms of skin characteristics, inflammation can appear pink or purple or even gray depending on the client’s skin tone. Even after irritant contact dermatitis is treated and cured, it can resurface if the skin comes into contact with the irritant in the future (1).

The advantages of nurses having specific knowledge of irritant contact dermatitis and thus utilizing the new ICD-10-CM codes are (11):

• The past language was limited, and thus did not accurately capture the data or diagnoses of clinically relevant conditions. The new language used to describe irritant contact dermatitis is standardized, which will not only assist clinicians, but also billing coders.
• The new standardized language encourages accurate documentation of the prevalence of irritant contact dermatitis, which leads to consistent research and improved outcome measures.
• The new standardized language and codes demonstrate the value of bedside nurses’ assessment and intervention skills by appropriately coding client conditions.
• The codes link nursing specialist interventions to client outcomes and facility billing and reimbursement. It helps enhance reimbursement of irritant contact dermatitis conditions.
• The new standardized language enhances clinician and healthcare provider education.
• The new standardized language improves client care via accurate diagnosis capture.

New ICD-10-CM Codes for Wound Specialty 

There are several new ICD-10-CM codes for irritant contact dermatitis that impact wound specialty. These codes and their indications for use are listed below in the table.  

ICD-10-CM Codes for Wound Specialty (1,2,3,5,11) 

Notes with “excludes” or “includes” are included with some of the codes. An Excludes1 note means that the excluded code should never be used at the same time as the code over the Excludes1 note. When two conditions cannot occur together, the Excludes1 note is used. An Excludes2 note means that the excluded condition is not part of the condition represented by the code and the client can have both conditions at the same time. When an Excludes2 note appears under a code, that code and the excluded code can be used together, if appropriate (1). An Includes1 note indicates the conditions for which the code is to be used. 

Nurses who do not chart ICD-10 codes are encouraged to describe irritant contact dermatitis in the client’s health record using the terminology included in the ICD-10 codes to make coding easier for the billing specialist. Wound ostomy continence specialty nurses who bill third-party payers for their services should regularly familiarize themselves with the ICD-10 codes (1). 

Nursing Assessment and Nursing Interventions

The nurse’s assessment and interventions vary depending on the type of irritant contact dermatitis and its location on the client’s body. The specific nursing assessment and interventions for each of the new ICD-10-CM codes are listed below.

ICD-10-CM Code L24A0

Irritant contact dermatitis can be caused by friction or contact with bodily fluids. When these sources of irritant contact dermatitis are unspecified, ICD-10-CM code L24A0 is used (2). The skin is exposed to an underlying moisture source (of undetermined origin) that can cause inflammation of the skin, erosion or denudation of the skin, and serous exudate. Symptoms include erythema, burning, and itching. When code L24A0 is warranted, the nurse should assess the underlying factors leading to the moisture source and irritant contact dermatitis to determine effective treatment (2).

ICD-10-CM Code L24A1

ICD-10-CM code L24A1 is used when saliva causes the irritant contact dermatitis. Excessive saliva can lead to saliva-associated irritant contact dermatitis (SAICD) causing erythema and local irritation. Saliva is produced by the salivary glands in the mouth and is composed of water (95%), mucus, digestive enzymes, and electrolytes, which help tasting, swallowing, and digesting food [2]. The pH of saliva typically ranges from 6.0 to 7.0 (2).

Cheilitis occurs when the client licks their lips and the surrounding skin excessively, especially when the client is intubated with an endotracheal tube that keeps the mouth partially open, causing oral dryness. Neurological disorders, obsessive compulsive disorder, and dementia can also lead to cheilitis [2]. Sialorrhea, excessive production of saliva, which can also cause SAICD is found in clients with head and neck cancers (2).

The signs and symptoms of SAICD are erythema, scaly skin, skin splitting at the vermillion of the lips, skin erosion, and burning and itching (2). Nursing interventions include applying topical skin protectants and corticosteroid cream if concurrent contact dermatitis exists. In clients with head and neck cancers, surgical interventions such as salivary gland excision and salivary duct ligation may be warranted. Targeted radiation, anticholinergic therapy, and botulinum toxin therapy can help reduce saliva production (2). Nurses should teach clients to gently cleanse the skin area and apply a skin protectant to reduce the skin’s exposure to saliva.

ICD-10-CM Code L24A2

Prolonged exposure to urinary, fecal, or dual incontinence is the foundation of incontinent-associated dermatitis (IAD), a type of irritant contact dermatitis that is delineated by ICD-10-CM code L24A2. Incontinence and IAD contribute to higher stage pressure ulcers, as well as frailty, increased risk of falls, depression, infections, and mortality [4]. Urine pH varies from 4.0 to 8.0 and is influenced by the client’s gender, diet, medications, and exposure to pathogens. Females have a higher absorption rate of food anions, which causes their urinary pH to be higher than that of men [2]. Soft, formed stool carries a pH of roughly 6.3, whereas semi-formed to liquid stools has a higher pH with some health conditions contributing to a pH of over 9.0 (2).

IAD can cause the skin to range in color from light pink to red to purple depending on the client’s skin tone. Associated skin erosion is shiny or glistening due to serous fluid accumulation. Edema, rash, and irregular edges are common (2). IAD can be found in the following areas: perianal, buttocks, buttocks crease, thighs, genitalia, lower abdomen, and the crease between the genitalia and thigh. The nurse should assess clients with IAD for itching, burning, and stinging in the affected areas.

Nursing interventions to manage IAD include prompt removal of urine and feces from the skin using a gentle cleanser followed by thorough, gentle drying of the area. Applying a skin barrier (cream, paste, film, spray, or wipe) followed by an emollient helps heal damaged skin (2). It is important for nurses to understand that incontinence and IAD treatment contribute to client increased length of hospital stay, increased hospital readmission, and increased cost of care (4).

ICD-10-CM Codes L24B0 and L24B1

Irritant contact dermatitis can occur when the skin surrounding a stoma or fistula experiences prolonged exposure to urine, feces, or digestive secretions. The stoma or fistula skin junction is affected first and then the irritation extends outward from there. The ICD-10-CM coding system uses L24 or L25 to delineate irritant contact dermatitis versus other types of dermatitis, such as allergic or radiation (5). Code L24B0 is assigned to unspecified irritant contact dermatitis due to stoma or fistula when the moisture source for the dermatitis is unknown. Code L24B1is used when the irritant contact dermatitis is caused by the digestive stoma or fistula.

The location of MASD occurs where the skin is exposed to the underlying moisture source and its borders follow the flow of effluent from the stoma or fistula. The borders tend to be indistinct, especially when compared to partial-thickness or full-thickness pressure ulcers that demonstrate distinct borders (5). The nurse’s assessment should include the stoma type, location of fistulous tract, effluent characteristics, surrounding skin characteristics, and the client’s symptoms of burning and itching (5). The nurse should investigate the underlying causative factors of the irritant contact dermatitis to help guide treatment. Code L24B0 is used in these situations where the causative factor of the contact dermatitis is unknown.

Code L24B1 is used when the digestive stoma or fistula is the cause of irritant contact dermatitis. The stomach and small intestines excrete digestive enzymes that break down masticated food mix that travels the digestive system after eating. These enzymes are acidic in nature and when they contact the client’s skin via effluent from a digestive stoma or fistula, the skin becomes irritated. Leaking from gastrostomy, jejunostomy, and biliary tubes can cause skin to be chronically exposed to acidic gastric contents (5). Natural tube movement can enlarge the skin opening, which can cause additional seepage of gastric contents onto the peristomal skin. Therefore, it is important for nurses to monitor the client’s tube movement and stabilize it as much as possible (5).

The clinical signs and symptoms of irritant contact dermatitis associated with abdominal stomas or fistulas are erythema, serous exudate, erosion of peristomal skin, partial-thickness skin loss with irregular borders, and client itching, burning, and pain (5).

Nurses can manage and prevent irritant contact dermatitis associated with abdominal stomas or enterocutaneous fistulas by (5):

• Properly sizing and fitting the pouching system by using belts, rings, or strips to match the client’s body contour
• Measuring the stoma and adjusting the skin barrier if client weight gain or weight loss occurs
• Securing drainage tubes with a stabilizer mechanism or external tube securement device. The nurse can gently pull up on the gastrostomy tube until the internal anchoring device (balloon or bumper) is flush with the wall of the stomach and then slide down the external stabilizer until it rests upon the skin. External stabilizing devices can also be sutured to the skin, especially in jejunostomy tubes. Replacing a leaking tube with a larger-diameter tube to obtain a better seal is not advised since this can cause the opening to enlarge and leak additional exudate. If a tube leaks consistently, it can be removed and placed in a different site, and the original opening can be left to close.
• Applying negative pressure wound therapy to manage fistula drainage, if indicated
• Teaching clients about peristomal, perifistual, and periwound care, including signs and symptoms of irritant contact dermatitis
• Teaching healthcare team members about management of leaking pouch systems and tubes
• Addressing client financial reimbursement concerns for supplies

ICD-10-CM Code L24B2

When respiratory secretions are the cause of irritant contact dermatitis ICD-10-CM code L24B2 is used. Respiratory secretions typically have a pH of 6 and are comprised of water, salts, glycoproteins, and lipids (2). Respiratory mucus acts as a protective barrier against allergens, pathogens, and other irritants.

In clients with a tracheal stoma, irritant contact dermatitis occurs in the peristomal skin and partial skin loss with irregular borders results from contact with respiratory secretions (2). Tracheostomy may be clinically necessary in cases of COVID-19, SARS CoV-2, amyotrophic lateral sclerosis (ALS), and spinal cord injury (2).

Nursing interventions for peristomal skin care include cleansing with normal saline (and avoiding hydrogen peroxide), securing the tracheostomy tube and ties, and utilizing absorbent tracheostomy dressings (and avoiding cotton gauze to prevent cotton fibers from entering the respiratory tract). A hydrocolloid dressing can reduce erosion of the peristomal skin and application of a barrier cream before absorbent dressing placement can reduce skin inflammation and erosion (2).

ICD-10-CM Code L24B3

A surgical stoma or fistula that connects the urinary system or bowel to the skin or open abdomen is at risk of irritant contact dermatitis due to urine or feces that irritate the stoma, fistula, and surrounding skin. Urinary effluent from a urostomy or vesicocutaneous fistula is rife with pathogens and both alkaline and acidic urine have also been shown to create inflammation in peristomal skin (5). The effluent from a colostomy has a higher concentration of digestive enzymes, higher water content, and lower pH than normal stool (5). ICD-10-CM code L24B3 is assigned to clients that have a surgical stoma or abnormal fistula to the intestine via the abdomen where contact dermatitis is present around the stoma or fistula and that may extend to the abdomen, flank, and back (1,5,11).

Irritant contact dermatitis in these clients develops when the pouching system leaks. Leaks can occur when the pouching system does not adequately fit the client, the system is not changed frequently enough, and the nurse uses tape to seal the leakage rather than changing the pouching system (5). The nurse should assess the client’s stoma or fistula for erythema, maceration, erosion of the surrounding skin, serous exudate, and client report of itching, burning, and pain (5). Urinary stomas can create crystals and papillomatous dermatitis (white and gray warty lesions). Nursing interventions are similar to those mentioned previously and also include teaching clients with a urostomy or ileal conduit to acidify their urine via fluids, foods, or medications to decrease irritation of the stoma and peristomal skin (5).

ICD-10-CM Code L30.4

Intertriginous erythema is an unspecified form of dermatitis that is found on skin surfaces that come into contact with each other, such as the axillae, neck creases, intergluteal fold, and between the toes; it is attributed to moisture and friction (2). ICD-10-CM code L30.4 was approved for use in the ICD-10-CM taxonomy prior to the MASD codes for irritant contact dermatitis.

The moisture source for intertriginous erythema is perspiration, which is composed of water and electrolytes and has a pH of roughly 6.3 (2). Perspiration is a result of increased core body temperature, physical exertion, and systemic infection. Inflammation and erythema occur when two folds of skin rub together. In obese individuals, skinfolds trap moisture and denuded skin can occur in the deepest portion of the skinfold where moisture and friction are greatest and where exposure to circulating air is lacking. Infection can occur in these areas. Clients at highest risk are those with increased body mass index (BMI), diabetes mellitus, and lack of mobility (2).

Nursing interventions include administering topical antiseptics, antifungal agents, antibiotics, and corticosteroids. Currently, there are no standardized evidence-based interventions or treatments for intertriginous erythema (2). Nurses should teach clients to cleanse the areas with a gentle cleanser, dry the skin with a hair dryer on a cool setting, and apply a skin protectant. Absorbent products can be placed to absorb moisture and prevent friction. Silver impregnated wicking fabrics have a similar effect while also offering infection protection (2).

Regardless of the ICD-10-CM code used, nurses must accurately document MASD characteristics, nursing interventions, and client reaction to treatment to assist other nurses and advanced practice providers in providing optimum care (2,30. Accurate documentation also permits coders to ensure that the facility and client receive appropriate reimbursement (2).

The Future of Wound Specialty

In recent news, the WOCN petitioned the National Uniform Claim Committee in July 2024 to create new taxonomy codes specifically dedicated to wound medicine professionals, including the wound medicine clinical nurse specialist, wound medicine physician assistant, and wound medicine nurse practitioner (7).

WOCN stated these reasons as justification for the new taxonomy (7):

• Wound care has evolved significantly over the past 30 years and has experienced tremendous advancements in treatments, but the lack of dedicated taxonomy codes has prevented the identification of clinicians who specialize in wound management.
• Wound care management includes several medical specialties, including plastic surgery, podiatry, emergency medicine, and infectious disease. The lack of specified taxonomy codes prevents CMS from collecting data about the specific clinicians who are practicing true wound care management. This data includes the clinicians’ geographic distribution, level of practice, client load, and proportion of wound care services in relation to other services. The lack of dedicated taxonomy codes distorts utilization data making the identification and stratification of providers delivering wound care difficult.
• Appropriate taxonomy identifies certified wound specialists and the unique resources required for wound care in the physician office setting.
• The current coding system does not highlight the nuances of wound care that can impact policy proposals, especially where product reimbursement is concerned.
• Wound care facilities create customized electronic healthcare records (EHR) to better care for clients, and these records face frequent audits that impact reimbursement. For example, the current taxonomy codes used by family practice physicians don’t align with the patterns of wound care procedures.
• The only current wound code available (163WW00000X) is specific to registered nurses and does not include other wound care specialists, including advanced practice registered nurses (APRN), clinical nurse specialists (CNS), and doctors of nursing practice (DNP).

Conclusion

The new ICD-10-CM codes for MASD allow for more specific documentation of a diagnosis or procedure for billing and data tracking. The system also guides nursing assessment and interventions that are most appropriate for the client’s condition, thus leading to improved client outcomes. Nurses have an obligation to the nursing profession, the healthcare interdisciplinary team, their employers, and their clients to adhere to accurately document MASD assessments and interventions.

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