Coding Tip: Reporting Pressure Ulcers

by | Dec 2, 2016 | Coding Tips, Education, ICD-10 | 0 comments

Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

A change has been made in how coders will report pressure ulcers when the stage of the ulcer changes during the admission.

Per the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 Page 51, if a patient presents with a pressure ulcer at one stage and during the admission it progresses to a higher stage, two separate codes would be reported.  One for the site and stage of the ulcer on admission and another for the same ulcer and the highest stage reported during the admission.

The previous guideline stated to only assign the code for the highest stage reported for that site.

If the patient presents with a pressure ulcer on admission but the ulcer heals by the time of discharge, the coder would assign the code for the site and stage of the pressure ulcer on admission.

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).

References:

ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 Page: 51
AHA Coding Clinic Fourth Quarter 2016 Page: 124 and 143-144

Happy Coding!

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.

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