Unstageable Pressure Ulcer POA then debrided

cmorell

I was hoping the ACDIS advisory board could address this and/or send to coding clinic to provide clarification under these circumstances. Based on the new coding clinic guidance, the scenario of when a patient is admitted with an unstageable pressure ulcer and then has a debridement performed and subsequently the pressure ulcer can be staged (e.g. stage 4) is confusing unless the physician documents stage 4 POA.  Thoughts? It seems that of course it should be POA, but the physicians also state they have no way of knowing what the stage was before it was debrided. How are others handling this?

lprescott1

This is an interesting question and one that there is little direction out there presently to conclude an answer. Obviously we cannot stage an unstageable pressure ulcer because we cannot see the wound bed. My thought is that we can code the stage 4 pressure as being present on admission if the provider clarifies it as such. For example the statement, "admitted with unstageable pressure ulcer, which was debrided on day 2 demonstrating an ulcer and necrosis seen to the bone. after debridement, it was evident that the Stage four pressure was present on admission." 

Again this is only my thoughts, you may wish to submit this question to coding clinic for further clarification.

jwright@chmed.org

I consulted with our Wound Care nurses on the issue of "unstageable PU". They told me that unstageable ulcer are ALWAYS "at least a stage 3". They changed their documentation to reflect this. Now when staging a "Unstageable" they document "Unstageable but at least a stage 3". We capture the highest stage which in this case would be a 3. Some may feel this is wrong but we feel the purpose of a stage 3 or 4 being a MCC is because of the extra resources and LOS that most of this type of patients needs. So far we have not had to defend this in a appeal.

lprescott1

agreer@chmed.org said:

I consulted with our Wound Care nurses on the issue of "unstageable PU". They told me that unstageable ulcer are ALWAYS "at least a stage 3". They changed their documentation to reflect this. Now when staging a "Unstageable" they document "Unstageable but at least a stage 3". We capture the highest stage which in this case would be a 3. Some may feel this is wrong but we feel the purpose of a stage 3 or 4 being a MCC is because of the extra resources and LOS that most of this type of patients needs. So far we have not had to defend this in a appeal.

That is an interesting approach and it makes complete sense. Thank you for sharing. 

cseluke

The wound care nurse at my hospital told me that any unstageable pressure ulcer is at least a stage 3. When I looked at the code book it seems that the ulcer would have to be documented as "at least a stage 3" in order to code it as such, though.

afloyd24

I have asked this question to coding clinic already (a couple of months ago) and asked that the response be published!  Inquiry #50018494

We have been sending a query to ask if the post debridement stage ____  pressure ulcer was the same unstageable pressure ulcer documented on admission so we can code it as POA.  Not sure that is the best answer but it's what we have been doing and have not had a denial as of yet.   

annnd2009@gmail.com

I have heard the approach of getting a unstageable ulcer to be stated at least a stage 3, and it being coded, but I feel it pushes a little ethically as per the National Pressure Ulcer Association - a unstageable by definition is at least a stage 3 or 4, so getting the term stage 3 documented and coded seems like 'unbundling" or coding a condition" integral "to another, which seems disallowed by coding guidelines.
2017 coding guidelines:
" b. general coding guidelines-

1. Conditions that are an integral part of a disease process

   Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. 

The solution seems like the code should be an MCC and possibly increased SOI/ROM that would at least mirror a stage 3 ulcer( not sure what the soi/rom is on unstageable). 

Another consideration in avoiding a HAC in the messy way the new POA ruling on pressure ulcers are coded -- if you query your provider and they are willing to say that the unroofed/debrided stage 4 was likely POA , you are all set. it won't be a HAC and it should be an MCC.

I think that if you query and they say NO- you don't have an MCC and you have a HAC,

BUT- if you ask and they say "unable to determine" you have a "w" ( not a Y and not an N) for POA. W response, which should be coded, and CMS will pay for the MCC. BUT IT MUST BE QUERIED- insufficient documentation is different than the provider actually saying he/she is unable to determine.

2017 coding guidelines

" Documentation does not indicate whether condition was present on admission
Assign “U” when the medical record documentation is unclear as to whether the condition was present on admission. “U” should not be routinely assigned and used only in very limited circumstances. Coders are encouraged to query the providers when the documentation is unclear.

Documentation states that it cannot be determined whether the condition was or was not present on admission

Assign “W” when the medical record documentation indicates that it cannot be clinically determined whether or not the condition was present on admission. "

https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitalacqcond/coding.html

Even if it is a W, I think it might still count as a HAC but not sure on this part- anyone know? Coders?

afloyd24

I have received the long awaited response to my above coding clinic request....seems like I asked a difficult question.  The response I got was as follows:

Response to request for coding advice ref. #50018494

Dear Ms. Floyd,

This letter is in response to your request for assistance of the correct POA status and coding of an unstageable pressure ulcer that becomes stageable after debridement.

This issue requires referral to the Editorial Advisory Board (EAB) of Coding Clinic. Following resolution by the EAB, you will receive a definitive answer.

I trust this information will be of assistance to you.

MichelePasch

Hi there.  I know this is from a while ago but we just hat this question come up.  Did you hear back about the answer to this question?

Michele