Pressure ulcers
So I just completed an audit of coded pressure ulcers that was recently requested. It was a mess and brought up lots of questions. Basically, documentation is inconsistent between WCON's, bedside nurses, and physicians. Staging often does not match. Physicians tend to say a stage once and then C&P this through the record, not updating as the ulcer evolves. MD's seem to call everything a 'pressure ulcer' whereas WCON's are clarifying between true decubiti, skin tears, or incontinence associated dermatitis (IAD). But these are being coded as pressure ulcers because of MD documentation.
Clearly I think this is something CDI can help with. However I have a few questions that have come out of this.
1. How would you code out Incontinence associated dermatitis?
2. Do you code skin tears? If so, How?
3. What about 'shearing' injuries?
4. What do you recommend in instances where we had a wound that was staged at some point in the admission but is later 'unstageable'?. For ex: Patient admitted with a stage II pressure ulcer. During a prolonged admission it progresses to a stage IV. Then later, eschar develops and it is stated to be 'unstageable'. Do you code a stage IV pressure ulcer (MCC, SOI/ROM 3/2) or an unstageable pressure ulcer (NCC, SOI/ROM 1/1)?
5. Whose documentation do you accept for staging? I realize we can take documentation from physicians, WCON's, Physical Therapy, etc. But do you also accept staging from bedside nurses?
Thanks!!
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
Clearly I think this is something CDI can help with. However I have a few questions that have come out of this.
1. How would you code out Incontinence associated dermatitis?
2. Do you code skin tears? If so, How?
3. What about 'shearing' injuries?
4. What do you recommend in instances where we had a wound that was staged at some point in the admission but is later 'unstageable'?. For ex: Patient admitted with a stage II pressure ulcer. During a prolonged admission it progresses to a stage IV. Then later, eschar develops and it is stated to be 'unstageable'. Do you code a stage IV pressure ulcer (MCC, SOI/ROM 3/2) or an unstageable pressure ulcer (NCC, SOI/ROM 1/1)?
5. Whose documentation do you accept for staging? I realize we can take documentation from physicians, WCON's, Physical Therapy, etc. But do you also accept staging from bedside nurses?
Thanks!!
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