Reporting Pressure Ulcers

With ICD-10-CM, the code for reporting pressure ulcers now identifies the site and the stage of the ulcer.

Pressure ulcer stages are based on severity of the ulcer:

• Stages 1-4
• Deep tissue pressure injury
• Unspecified stage and
• Unstageable

If a patient has more than one pressure ulcer a code for each should be reported.

Sometimes, coders will confuse unstageable with unspecified stage of the ulcers. There is a big difference between the two meanings:

• Unstageable pressure ulcers are diagnosed when the physician or clinician is not able to stage due to the ulcer being covered by eschar or possibly even a skin graft. If a patient with an unstageable pressure ulcer has a debridement and the stage of the ulcer is then revealed and documented, only code the stage revealed and not unstageable.
• Unspecified pressure ulcers are reported when there is a lack of documentation regarding the pressure ulcer stage

There are only a few areas in coding where the coder is allowed to take documentation from anyone other than the physician. The staging of the pressure ulcer is one of those exceptions. Other clinicians (such as nurses) can document the stage of an ulcer and coders may code from this documentation. However, the diagnosis of the ulcer itself must be documented by the physician/provider.

If the stage of the pressure ulcer given is not found in the Alphabetic Index of ICD-10-CM, a physician query is needed to clarify.

Healed and Healing Pressure Ulcers

Healed and healing pressure ulcers are also seen by coders within medical record documentation. Sometimes, more information can be found regarding the pressure ulcers in the physical examination. With the copy/paste issues with medical records it is imperative that coders search the records to be sure the ulcer is either healed/history or if it is still present.

• Healed pressure ulcers are not coded
• Healing pressure ulcers are coded to the site and stage documented by the physician/clinician. If no stage is documented for the healing pressure ulcer, unspecified stage should be reported
• If a pressure ulcer is present on admission but healed at the time of discharge, only the site and stage of the pressure ulcer at the time of admission is reported

Pressure ulcer stages can change rapidly. If the patient’s pressure ulcer is one stage on admission and progresses to a higher stage during the admission, two codes are needed to report. The previous guideline stated to only assign the code for the highest stage reported for that site.

• One code for the site and stage of the pressure ulcer on admission, and
• One code for the same site of the pressure ulcer with the highest stage reported during the stay

Examples:

• Patient is admitted with stage 1 pressure ulcer to the sacrum. The ulcer is documented at the time of discharge to be completely healed. The coder would assign the code for sacral pressure ulcer stage 1.
• Patient is admitted with stage 3 pressure ulcer to the right heel.  The ulcer continues to progress and is evaluated by wound care and is now stage 4.  Patient does proceed with surgery for debridement including bone.  The coder would assign the following diagnoses: right heel pressure ulcer stage 3 (with POA indicator of Y) and right heel pressure ulcer stage 4 (with POA indicator of N).

Authored by Kim Boy, RHIT, CDIP, CCS, CCS-P

For the past 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.