Guest Post: Pressure Ulcer Coding and Staging

by Lynne Spryszak, RN, CCDS, CPC

Does it sometimes seem like wound and pressure ulcer documentation is a movable feast? I’ve spent a lot of time scrutinizing wound documentation lately in anticipation of the new pressure ulcer codes being implemented October 1st and sometimes I can hardly believe what I’m seeing.

I’ve seen wound care flow sheets where vascular or diabetic ulcers are incorrectly documented with a stage (which should only be assigned to pressure ulcers) and I’ve seen pressure ulcers go from stage I to stage III or from stage III to stage I between one shift and the next.

Now I know modern medicine can sometimes work miracles, but really! Just today I was on the verge of querying a physician based on the documentation in the nursing admission assessment (a stage II coccyx decubitus) only to have the wound nurse tell me that it was probably a stage III at admission, not a stage II, but that she couldn’t change or amend that nurse’s documentation. So which stage to go with? What stage was really POA?

I’m only the CDS. What is the coder supposed to do with this kind of information? The ICD-9 Official Guidelines for Coding and Reporting, 2008 provides lots of information related to the use of these new codes and states that the coder may refer to the nurse’s or other provider’s documentation for assigning the stage of a pressure ulcer

“since this information is typically documented by other clinicians involved in the care of the patient (e.g., a dietitian often documents the BMI and nurses often documents [sic] the pressure ulcer stages).”

But if the information provided by nursing isn’t correct what are we to do? Unfortunately, most physicians don’t know how to stage pressure ulcers even if they looked for them – it’s not a priority for them.

The Official Coding Guidelines (page 50) present the following information on the “how to” of pressure code assignment:

“Two codes are needed to completely describe a pressure ulcer: A code from subcategory 707.0, Pressure ulcer, to identify the site of the pressure ulcer and a code from subcategory 707.2, Pressure ulcer stages. The codes in subcategory 707.2, Pressure ulcer stages, are to be used as an additional diagnosis with a code(s) from subcategory 707.0, Pressure Ulcer. Codes from 707.2, Pressure ulcer stages, may not be assigned as a principal or first-listed diagnosis. The pressure ulcer stage codes should only be used with pressure ulcers and not with other types of ulcers (e.g., stasis ulcer).”

One would assume that if a patient is admitted with a stage I ulcer of the sacrum that the complete code would be 707.03 (lower back) plus 707.21 (stage I), and the POA indicator for both would be “Y”, and if the wound progressed to a state III, you’d assign an additional secondary code of 707.23 (stage III) with a POA indicator of “N”.

But this is not the direction we’re given. The Coding Guidelines have this to say on page 52: “If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, assign the code for highest stage reported for that site”.

This direction says that if the wound was a stage I at admission and worsened, then the coder would have to code the highest stage as POA even if it wasn’t. I disagree with this information. If stage II, III or IV wasn’t POA, it wasn’t. It doesn’t present an accurate picture of the condition. I think it would be more accurate and compliant to code the first stage as POA and assign an additional code for the higher stage which would receive a POA indicator of “N”.

The Guidelines have a POA Example section on pages 116-119 but the only example of pressure ulcer coding (#14) relates to provider documentation that the ulcer was POA. It states that even if the initial nursing assessment documents the presence of the ulcer at admission, if the provider doesn’t document the condition until several days after admission, the provider must be queried to clarify the POA status.

Yet the very next example (#15) states that a urine C/S obtained the day of admission is enough to support a diagnosis as POA even though the condition isn’t documented until the results are available a few days later. Contradictory logic? I think so.

The CMS website offers some guidance regarding assigning the POA indicators, but not much. CMS states:

“A POA Indicator must be assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes. CMS does not require a POA Indicator for an external cause of injury code unless it is being reported as an “other diagnosis.”

You may be wondering why I have a disagreement with a guideline that will actually save a hospital’s bacon. I mean, if it’s a stage I ulcer that was POA and it progresses to a stage IV, then the stage IV would be POA according to the direction provided by the Official Coding Guidelines and CMS defers the details of the coding to them, right?

Well, my position is that right is right, for better or worse. Coders abide by a Code of Ethics that supports the accuracy and ethical practice of their profession, and I think the 2008 Coding Guidelines is asking them to code inaccurate information.

What this means to CDS is that we will have to be even more diligent about securing complete and thorough documentation of not only pressure ulcers, but every condition, so that the patient record is an accurate reflection of the patient’s diagnoses and the care provided to treat those conditions.

Editor's note: Spryszak, at the time of this article's release, was an independent HIM consultant based in Roselle, IL. Her areas of expertise include clinical documentation and coding compliance, quality improvement, physician education, leadership and program development.