Q&A: Querying for pressure ulcer stages

Q: If the provider documents: “Pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue, right elbow,” does the CDI specialist need to query for the stage? Or, will it be coded as a stage 3 automatically?

A: Section I.A.11 of the Official Guidelines for Coding and Reporting tells us that “inclusion” terms are a list of terms included under some codes. These terms are the conditions for which the code is to be used. The terms may be synonyms of the code title, or in the case of “other specified” codes, the terms are a list of the various conditions assigned to the code. The inclusion terms are not necessarily an exhaustive list. Additional terms found only in the Alphabetic Index may also be assigned to a code.

So, with that in mind, the answer to this question is no, you don’t have to send a query. When you look up a code, in this case code L89.013, Pressure ulcer of right elbow stage 3, under the main bolded term you will find the inclusion terms. In this particular case you will find listed “healing pressure ulcer of right elbow stage 3” and “pressure ulcer with full thickness skin loss involving damage or necrosis of subcutaneous tissue, right elbow.”

Also, as a reminder, the Official Guidelines for Coding and Reporting Section I.B.14, stated that documentation for a patient’s body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and National Institutes for Health Stroke Scale (NIHSS) codes, may be assigned based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis), since this information is typically documented by other clinicians involved in the care of the patient.

However, the associated diagnosis, such as overweight, obesity, acute stroke, or pressure ulcer, must be documented by the patient’s provider. If there is conflicting documentation in the medical record, either from the same or different clinicians, the patient’s attending provider should be queried for clarification. Additionally, the BMI, coma scale, and NIHSS codes should only be reported as secondary diagnoses.

Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.