When two pressure ulcers occur in the same anatomical site and stage but have different Present on Admission (POA) indicators, coders may face a reporting challenge because ICD-10-CM guidelines allow a diagnosis code to be reported only once per encounter. This situation commonly arises when one pressure ulcer is present on admission and another develops during the hospital stay but both map to the same code. Understanding how the ICD-10-CM Present on Admission Reporting Guidelines and Coding Clinic guidance apply is essential for accurate reporting and for preserving important quality indicators such as hospital acquired conditions (HACs) and patient safety indicators (PSIs). This Coding Tip explains how to correctly assign the diagnosis code and POA indicator when multiple pressure ulcers classify to the same ICD-10-CM code.
Consider the following:
A patient arrives with a stage 2 pressure ulcer of the right ear. This condition would have a POA indicator of “Y”. During the admission, the patient develops an area documented as a deep tissue pressure injury of the cheek from pressure applied by nasal canula tubing. Documentation later in the admission reveals this injury is a stage 2 pressure ulcer. The POA indicator for the stage 2 pressure ulcer of the cheek would be “N” since it developed after admission.
This presents a dilemma. Pressure ulcers of the ear and cheek both code to the body site of head, so these conditions are both reported with the same code, L89.812 Pressure ulcer of head, stage 2. ICD-10-CM General Coding Guideline I.B.12 directs, “Each unique ICD-10-CM diagnosis code may be reported only once for an encounter. This applies…when there are.. two different conditions classified to the same ICD-10-CM diagnosis code.”
However, in this scenario the two different conditions classified to the same code have different POA indicators, so the question becomes, “ Since I can only report the code once, which POA indicator should I assign”?
It might seem plausible to report L89.812 Pressure ulcer of head, stage 2 with a POA indicator of “Y” for the stage 2 pressure ulcer of the ear, along with code L89.816 Pressure-induced deep tissue damage of head with a POA indicator of “N” for the deep tissue pressure injury of the cheek, to indicate the area of concern on the cheek was not present on admission. Yet Coding Clinic for ICD-10-CM/PCS, Second Quarter 2022, Page 8 and Coding Clinic for ICD-10-CM/PCS, First Quarter 2021: Page 24 direct that when deep tissue pressure injury is later revealed to be a stageable pressure ulcer, only the code for pressure ulcer with the appropriate 6th character indicating stage (1-4), should be assigned.
So, how do you capture a stage 2 pressure ulcer of the ear with a POA indicator of “Y” and a stage 2 pressure ulcer of the cheek with a POA indicator of “N”?
Although this may seem like a coding conundrum, the answer is clearly outlined in the guideline below from the often overlooked Appendix I Present on Admission Reporting Guidelines.
Assigning the POA Indicator - Same Diagnosis Code for Two or More Conditions
"When the same ICD-10-CM diagnosis code applies to two or more conditions during the same encounter (e.g., two separate conditions classified to the same ICD-10-CM diagnosis code): Assign “Y” if all conditions represented by the single ICD-10-CM code were present on admission (e.g., bilateral unspecified age-related cataracts). Assign “N” if any of the conditions represented by the single ICD-10-CM code was not present on admission (e.g. traumatic secondary and recurrent hemorrhage and seroma is assigned to a single code T79.2, but only one of the conditions was present on admission)."
Based on this guideline, assign only code L89.812 Pressure ulcer of head, stage 2 with POA indicator “N” for a patient with two stage 2 pressure ulcers of the head, when one was present on admission and the other was not.
Since POA indicators are key to the identification of quality considerations such as hospital acquired conditions (HACs) and patient safety indicators (PSIs), assignment of POA indicator “N” in this situation is critical to preserving the fact that one of the pressure ulcers developed during the admission.
Resources
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.