CDI and Ethics
Good morning. I am posing a scenario for the sake of discussion regarding ethics in our work as CDI.
In this scenario, a patient is admitted as an inpatient 1/3/15-1/12/15, discharge time 1735. During this first encounter, the patient develops a stage II pressure ulcer. The following morning, 1/13/15, 850, less than 24 hours later, the patient is readmitted and stays an inpatient until 1/26/15. During this encounter the patient's pressure ulcer worsens to a stage III later during the stay.
Knowing that your patient developed a pressure ulcer while hospitalized and the fact that the patient was home less than 24 hours in a 23 day period, how would you code the pressure ulcer POA?
In this scenario, a patient is admitted as an inpatient 1/3/15-1/12/15, discharge time 1735. During this first encounter, the patient develops a stage II pressure ulcer. The following morning, 1/13/15, 850, less than 24 hours later, the patient is readmitted and stays an inpatient until 1/26/15. During this encounter the patient's pressure ulcer worsens to a stage III later during the stay.
Knowing that your patient developed a pressure ulcer while hospitalized and the fact that the patient was home less than 24 hours in a 23 day period, how would you code the pressure ulcer POA?
Comments
Tracy M Peyton RN, CCDS
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
But again, my first question would have to be looking to see if the charts should be combined.
Juli
I don’t think this really is an ethical issue but rather a coding guideline issue. The guidelines define POA assignment and coders must follow those guidelines (as should CDI).
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
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.
Coding Clinic, First Quarter 2009 Page: 19 Effective with discharges: March 27, 2009 Frequently Asked POA Questions Clarification
Stage II Pressure Progressing to Stage III
Question:
Coding Clinic Fourth Quarter 2008, page 194 stated that a stage II pressure ulcer, which was present on admission, and progresses to become a stage III pressure ulcer during the stay is reported as “Yes” for the present on admission (POA) indicator. However, the POA indicator is reported for conditions present at the time of inpatient admission. It appears inconsistent to report a Stage III pressure ulcer as present on admission since the pressure ulcer gradually deteriorated during the hospital stay. Could Coding Clinic please clarify this issue for coders and clinical teams that rely on this guidance?
Answer:
In terms of coding and POA reporting, a pressure ulcer is only coded and reported once at the highest stage. The information published in Coding Clinic Fourth Quarter 2008, page 194, instructing to report a Stage II pressure ulcer that progresses to a Stage III as present on admission is correct. The pressure ulcer was present on admission; therefore, the POA should be yes. This advice is consistent with the National Quality Forum (NQF) endorsed measures. The NQF established a standardized set of serious reportable events also called never events. The list of serious reportable events excludes the progression of a pressure ulcer from