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Updates on the Skin Failure ICD-10-CM Code Proposal with Dr. Diane Krasner

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During WoundCon Spring 2025, Diane L. Krasner, PhD, RN, FAAN, FAAWC, MAPWCA, WOCNF, and Thomas P. Stewart, PhD, presented a session covering a proposal to update ICD-10-CM codes for skin failure. Dr. Krasner recently joined us to answer a few questions about this session, providing additional details about the progress on this proposal and how it may impact both practitioners and patients.

What are the AADA and PAWSIC, and why have these groups come together to propose new ICD-10-CM codes relating to skin failure?

Dr. Krasner explained that on October 1, 2023, the Centers for Medicare & Medicaid Services (CMS) issued new guidance for Section M of the Minimum Data Set (MDS), which affects long-term care wound assessment. As a part of that guidance, they made the determination that skin changes at the end of life (SCALE), also referred to as Kennedy Terminal Ulcers, as well as skin failure, should no longer be coded as pressure injuries, which she noted was a good recognition. 

“We've been waiting for that for years,” said Dr. Krasner, “but the problem is, it left no place for people to code those conditions. And if you can't code them, you have this coding gap, and you can't get reimbursement for the treatment you do for them. So, it created a huge problem immediately for long-term care and will have ramifications across the continuum of care.” 

In early November 2023, one of the board members of the Post-Acute Wound and Skin Integrity Council (PAWSIC) brought this problem to the very first PAWSIC board meeting at the Symposium on Advanced Wound Care (SAWC) Fall. The PAWSIC board decided to take this issue on, because it was a significant problem for its constituents in long-term care. PAWSIC submitted an ICD-10-CM code proposal for “end-of-life skin and wound changes” in late November 2023. After a call with ICD-10-CM staffers in February 2024, PAWSIC was advised to alter the wording to “skin failure” to be more in line with standard ICD-10-CM nomenclature.

The ICD-10-CM staffers also suggested that PAWSIC start working with the American Academy of Dermatology Association’s (AADA) manager of coding, Faith McNicholas, as they felt that she would be a helpful guide in this proposal process. Thus, PAWSIC joined forces with the AADA, and resubmitted a proposal for skin failure codes in September 2024. Dr. Krasner gave a clinical presentation to the ICD-10-CM Committee and Faith McNicholas answered questions posed by meeting attendees on coding.

What are some of the main codes being proposed, and what current gaps would these fill for clinicians? 

Dr. Krasner noted that the September code proposal included 12 codes, which she calls “symmetrical.” There are three new sub-subcategories: acute skin changes due to skin failure, chronic skin changes due to skin failure, and end-stage skin failure. Within each of these sub-subcategories is a code for skin intact, partial thickness, full thickness, plus the instruction to “code also underlying condition.” 

“We tried to make the skin failure code structure simpler to use than the structure that, for example, is used for pressure injury, where all the different body parts are listed and there are dozens of codes,” said Dr. Krasner. 

After September, there was a public comment period, and several organizations suggested that additional codes be added for “skin failure, unspecified.” These unspecified codes are what coders use when there's not enough information to pick one of the other 12 codes. As such, 4 more unspecified codes have been added to the 12 already in the proposal.

What has the process of submitting these proposals looked like? What are the current challenges?

 “First of all, we've learned that this is a marathon, not a sprint,” Dr. Krasner expressed. “It's not unusual to have this process take 2 or even 3 years. And it seems that skin-related and wound-related things are very complicated. And those code proposals traditionally take longer than some of the other simpler diseases that can sort of speed through the process faster.”

One challenge, she noted, has been developing coding language that is consistent with both ICD-10-CM and CMS nomenclature. “We've tried to be simple and clinically practical, knowing that this has global ramifications because these codes will be used worldwide. Most important, we've tried to be inclusive of all the publications and research in this area over the past 35 years.”

The newest challenge facing this proposal is the government’s freezing of communications with the ICD-10-CM committee and layoffs from Department of Health and Human Services, including the Centers for Disease Control and Prevention (CDC), which is home to the ICD-10-CM Committee. The March 2025 ICD-10-CM meeting where the tweaks of the unspecified codes were meant to be presented for approval was canceled. According to Dr. Krasner, there might be a meeting in the fall, but even that's not certain at this point. 

Have there been any updates since the WoundCon presentation?

“We are in this limbo, and we don't know what the future holds,” Dr. Krasner said, “so we've decided that rather than sit around twiddling our thumbs, we are going to pivot and start a couple of the activities that we were waiting to start after the codes were accepted. We're going to start them now before the codes are accepted. That includes launching the Skin Failure Shared Interest Group (SF SIG) of PAWSIC, which will be a SIG that all PAWSIC members can join. We have approval from the PAWSIC Board of Directors, and we have designated 3 co-chairs: Heidi Cross, Pamela Scarborough, and Cindy Sylvia. In addition, we are starting work on an International Position Paper on Skin Failure (IPPSF). We have 35+ international experts who have agreed to help with that endeavor. And we are currently in the process of designing our study protocol. We plan to use an e-Delphi approach to develop consensus statements on skin failure that will be released and then published in 2026.”

Can you briefly outline the Langemo-Brown definitions for skin failure and why this terminology is important to the proposed skin failure codes? 

Dr. Krasner explained, “When the ICD-10-CM committee came back to us and suggested that we use the term ‘skin failure,’ we reviewed the literature specifically looking for a conceptual framework amongst all those articles that have been published on skin failure that would be clinically useful and easy for clinicians to interpret and implement in clinical practice. And we felt then, and we continue to believe, that while there are many theories out there, the Langemo-Brown has many, many advantages.” 

One of these advantages, she noted, is that it is clinically relevant, so clinicians can distinguish between skin failure due to hypoperfusion that has its primary concurrent illness as an acute condition, a chronic condition, or an end-stage condition. 
The codes will ask clinicians to identify that number one condition that is causing the hypoperfusion that results in skin failure, which is to be distinguished from the primary etiology of pressure that causes a pressure injury. 

“The framework allows us also to incorporate all those terms that are currently in use in clinical practice,” said Dr. Krasner. “Kennedy lesion, Kennedy terminal ulcer Trombley-Brennan terminal tissue injury, SCALE—they all fall under end-stage skin failure. So it's not taking away any terminology that is currently used in clinical practice. And we felt that that was important, and it was important to honor the research and publications that are already out there.” 

Assuming this code proposal is accepted, how quickly would these changes be expected to go into effect, and what guidance or resources will be available? 

If the additional codes are presented in the fall and accepted, then they could go into effect as early as either April of 2026 or October of 2026, Dr. Krasner predicted. “In the interim, we're going to be busy developing various guidelines and tools that can be disseminated through AADA, PAWSIC, and our endorsing organizations,” she added. 

Dr. Krasner also noted that the American Hospital Association and the American Health Care Association are typically very involved in disseminating new code information, as are the coders’ associations. Thus, all the tools that get developed will then be pushed out by a variety of stakeholders in this area. Among these tools already in progress is a clinical assessment guide that helps clinicians distinguish between skin failure, pressure injury, and other kinds of wounds, as well as a similar tool for providers that have the actual codes that they will need to use on them. 

“And finally, and probably most importantly, with the help of Faith McNicholas and AADA, we'll develop these guidelines for coders to help them go from what's written in the record to correctly coding the wound or wounds they see. And in some cases, patients will have multiple codes, because they could have acute skin failure next to a chronic skin failure, or they could have an acute skin failure wound right next to a pressure injury. So it is complicated,” Dr. Krasner explained.

What do you ultimately hope the implication of these changes will be for both patients and practitioners?

“The codes will enable practitioners worldwide to improve their assessment, diagnosis, and coding of these skin failure wounds. And that will, for clinicians, enable better data collection globally and will also support much-needed research in this area,” said Dr. Krasner. She noted that it's always been difficult to find that group of patients that have skin failure, because they're often mixed in with patients who have pressure injuries. Doing so will help to clean up the database, getting skin failure patients out of the pressure injury database where they do not belong. 

“For me, the benefit for patients, families, and caregivers is potentially enormous, because when we confuse skin failure and pressure injuries, and skin failure patients get treated as if those were pressure injuries, they get put down the wrong care pathway, and they may get very aggressive care that isn't appropriate for them as skin failure patients, where maybe maintenance or palliative care would be more appropriate,” Dr. Krasner explained. “So, it will also help patients, families, and caregivers understand that skin failure is unavoidable. And it's not just about turning and repositioning a patient. This is much more than that. This is organ failure, just like the heart fails and the kidneys fail. The skin is the largest organ of the body and it can fail, too. That understanding will help patients who may be dealing with feelings of guilt or anger to understand that this is just part of, in many cases, the dying process with end-stage skin failure, and it's nobody's fault, and help them make care decisions that will be more appropriate and help relieve pain and suffering as opposed to trying to heal wounds that aren't healable. So I think that that is going to be the biggest impact of these codes and disseminating this information of this thing called skin failure.”

The views and opinions expressed in this content are solely those of the contributor, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.