Decubitus Ulcer now resolved

elizabeth.hyndelizabeth.hynd
in CDI Talk Archive
Good Morning and Good Monday,

I was wondering if anyone has come across this scenario and how it was final coded. This is as much a HAC/PSI Quality as a CDI question.
A patient develops a decubitus ulcer while in the hospital critically ill on the vent. The patient recovers, and by the time of discharge the ulcer has completely healed. I have one experienced coder saying not to code it and another saying it has to be coded.

Thanks in advance for your input.

Elizabeth Hynd RN, BSN, CPUR, CCDS
Clinical Documentation Specialist
863-687-1100 ext. 7313

Comments

  • lsipos@monument.healthlsipos@monument.health
    edited May 2016
    I would say of course you code it. Resources were undoubtedly used while inpt and it was a diagnosis being documented during the stay! Show the entire clinical picture of the patient. It would not matter WHAT the diagnosis was-PNA, UTI etc, code them all. We can't pick or choose. I am not a coder, but a CDI. I cannot imagine why we wouldn't code it!


    Juli Bovard RN CCDS
    Certified Clinical Documentation Specialist
    Clinical Effectiveness/Clinical Quality
    Rapid City Regional Hospital
    719-4390 (work)
    786-2677 (cell)
    "No Limit to Better......"


    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

  • elizabeth.hyndelizabeth.hynd
    edited May 2016
    Thank you for your thoughts.

    Elizabeth Hynd RN, BSN, CPUR, CCDS
    Clinical Documentation Specialist
    863-687-1100 ext. 7313

  • ddouthitddouthit
    edited May 2016
    I would code it to the deepest level documented with a N for POA. If a patient presents to facility with a Sacral Stage II decubitus ulcer and it heals during the stay a code would be assigned, therefore if a patient develops a decubitus during the stay and heals before discharge coding would assign codes also.


    Dorie Douthit RHIT,CCS

  • rmhosler1rmhosler1
    edited May 2016


    I would also say code it because a chart can be requested at any time,
    and if not coded it could look like you are trying to cover it up.
    Resources were utilized.


    Mary A. Hosler RN, MSN CDS
    Mary A Hosler, RN, MSN CDS
    Alumnus CCRN
    McLaren Bay Region
    1900 Columbus Ave.
    Bay City, Michigan 48708
    (989) 891-8072
    mary.hosler@mclaren.org

    "The difference between the right word and the almost right word is the
    difference between lightning and the lightning bug."- Samuel "Mark
    Twain" Clemens
  • jolene.filejolene.file
    edited May 2016
    I would agree with Dorie. The ulcer must be coded to the deepest level & with a POA modifier of N. I would suggest that the decubitus ulcer be documented on the discharge summary if it will influence the MS-DRG. The physician can note that the ulcer has healed. I suggest this because we have had the RAC question diagnoses which are MCC and cc's and not noted on the DS.

    Jolene File,RHIT,CCS,CPC-H,CCDS
    Documentation Improvement Specialist-Coder
    Hays Medical Center
    jolene.file@haysmed.com

    IMPORTANT: This communication contains information from Hays Medical Center which may be confidential and privileged. If it appears that the communication was addressed or sent to you in error, you may not use or copy this communication or any information contained therein, and you may not disclose this communication or the information contained therein to anyone else. In such circumstances, please notify me immediately by reply email or by telephone. Thank you.

  • annnd2009@gmail.comannnd2009@gmail.com
    edited May 2016
    I would agree with everything as well but wanted to share on thing to
    look for that I learned last week in a hcpro boot camp by Cheryl
    Richardson... To look at nursing document station for POA...the part
    that I was not familiar with was that a stage 1 that was present any
    time before actual admission to inpatient bed that changed to a
    2,3,or4 during the stay is still considered POA. So if there is a
    reddened stage 1 on admit make sure is documented. If the ulcer
    progresses it will still be considered POA because ONLY the most
    advanced stage is coded. Good educational point for nurses realizing
    that an insignificant stage 1 can matter.

    Ann Donnelly
    Annnd2009@gmail.com




  • paxnerospaxneros
    edited May 2016
    Absolutely you capture that decubitus. Yes, it happened on "our watch" but as Juli said, the facility utilized resources to treat and heal that wound and it must be captured. This can be an educational case for the facility.

    NBrunson,RHIA,CDIP,CCS,CCDS



  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    The ulcer ‘must’ be coded – what is the rationale not to code it?

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

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