Unstageable Pressure Ulcers not POA

christine.butka@hmhn.org

Can anybody give any guidance on how to code this scenario?
Patient admitted on 4/3, develops sacral redness 4/5.  On 4/11 nurses document a stage 2 pressure ulcer to sacrum.  On 4/12 Nurses document the sacral ulcer as being unstageable.  Wound Care Nurse (NP) is called on consult.  Documents Sacral Ulcer Unstageable. 
What gets coded?  
I've been told that if some are calling it unstageable and other nurses are giving it a stage you take the stage.  So in this case it would be coded as Stage 2 not POA.
Other thoughts are that the NP's consult and staging takes precedence  over the nursing documentation.  Thus an Unstageable Ulcer Sacrum - not POA which in this case triggers a PSI. 

katysuegood@gmail.com

sounds like this wound was progressing? To me, if nursing documents unstageable on the 12th, that negates the documentation of the stage 2 on 4/11. Then we also have the WCON documenting it as unstageable as well. I am assuming this was 4/12 or later? If some providers were not staging at all and others were, then I would take the stage. But 'unstageable' is not nonspecific, it is stating that it cannot be staged because it is covered by eschar (or graft) and if that is the scenario it is the most clinically appropriate assessment possible.  Based on what you have described, I would code it as unstageable. We are to code the highest stage.

However, if you feel there is conflicting documentation, it would be appropriate to query the attending for clarification.

Katy

christine.butka@hmhn.org

Thank you for your insight.  When you say that we code to the highest stage, does that only apply to those ulcers not POA?  Because on ulcers that are POA that advance during admission we have to code the stage on admission and the stage it evolved to.  

lostwater

When reading the 2017 guidelines (https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf), indeed the section on Pressure Ulcers (pg50) states that coding both the presenting stage and the progressed stage only applies to ulcers present on admission that are progressing to a worse stage. This appears to signify that the worsening of the ulcer is captured in codes (implying an opportunity to use data mining to discover when hospital or provider care still allows a condition to worsen).  In your particular case, you are already capturing the ulcer as occurring during the stay (POA:N), therefore what is the benefit of capturing the sequence of progression?  You will be coding the "worse" stage of the ulcer at discharge, and as far as I can see, there is no guidance or logic to say that a stage 2 is worse (more progressed) than "unstageable", meaning, unstageable would be the code I suggest given with a POA of No.

Mark

katysuegood@gmail.com

yes, the new guideline states that for POA(Y) ulcers that progress, 2 codes are applied. One for the stage on admission and one for the highest stage of progression. As far as I know, nothing has changed regarding POA(N) ulcers which we have always been directed to code the highest stage.

Katy

christine.butka@hmhn.org

Thank you both for your responses. 

jwright@chmed.org

I am copying this from a reply to a post I made in March on Unstageble PU.

"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."  Amber