Health Information Management

Q&A: Coding for a stasis ulcer

JustCoding News: Inpatient, May 26, 2010

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QUESTION: I am new to home care coding and was wondering what codes I should report for a stasis ulcer when there is no documentation of venous insufficiency?

ANSWER: Depending on the documentation, you can report ICD-9-CM code 454.0 (varicose veins of lower extremities with ulcer) for the stasis ulcer with varicose veins or code 454.2 (varicose veins of lower extremities with ulcer and inflammation) for a stasis ulcer that is inflamed or infected.

For a stasis ulcer without varicose veins, you may report code 459.81 (venous [peripheral] insufficiency, unspecified). Coders may also use this code to report stasis dermatitis without varicose veins or a personal history of deep venous thrombosis.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at

This answer was provided based on limited information submitted to Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

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