Pressure ulcer question.

angelisa.romanelloangelisa.romanello
edited May 2016 in CDI Talk Archive
We have a patient who was admitted with a stage 2 pressure ulcer to the sacrum. The PU has now progressed to a stage 3.

Since she was admitted with a stage 2, is the stage 3 now considered a HAC pressure ulcer?
Thank you
Lisa

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    It will be coded as a stage 3 POA (Y) ulcer. Because there was an ulcer POA it will be noted as such and only the highest stage is coded.

    So, no it will not be a HAC.

    This is a good example of why it's important to have good documentation of skin status on admission.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

  • Unknown
    edited May 2016
    No. The ulcer was POA and it should be coded at the stage 3. See below CC.





    Charlene





    Question:



    The patient was admitted with acute respiratory failure, acute kidney injury due to acute tubular necrosis and chronic kidney disease, stage 3. The patient had a prolonged hospitalization and during the hospital course, he advanced to end stage renal disease (ESRD) and was started on hemodialysis. The provider stated, "Concerning possible renal recovery, it appears unlikely he will ever be dialysis independent given his history of CKD prior to his acute on chronic kidney injury and also because he is almost three months from his initial renal insult with no signs of renal recovery." Since the chronic kidney disease, stage 3 had progressed to ESRD, requiring dialysis, what is the appropriate present on admission (POA) indicator for the ESRD?



    Answer:



    Assign POA indicator Y, for the ESRD. The patient experienced deterioration or worsening of the same condition. Even though chronic kidney disease stage 3 and ESRD are assigned different codes, only one code is reported for the highest or most severe stage. This advice is similar to that previously published in Coding Clinic, First Quarter 2009, page 19, regarding a deteriorating pressure ulcer.




  • angelisa.romanelloangelisa.romanello
    edited May 2016
    Thank you to all !

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