Pressure Ulcer POA Status

theonedame@hotmail.comtheonedame@hotmail.com
in Clinical & Coding

Just a quick question as I can't find any SOLID information on this.  If nursing documents in the nursing admission assessment that patient has a pressure ulcer, and the provider doesn't state it until later in the stay, can it still be POA even if provider did not specifically state POA?  My thoughts are it would be coded as not POA.


Comments

  • pollinger438@gmail.compollinger438@gmail.com
    I would query the provider for the POA status of the pressure ulcer.
  • bbogda@morrishospital.orgbbogda@morrishospital.org
    If there is documentation of the presence of the same ulcer by nursing on admission, my practice is not to query the provider for POA.  Would like to hear other opinions.
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org

    This is a 'diagnostic' question...Was the diagnosis Present on Admission"?


     A provider 'licensed to establish' the diagnosis must speak to the diagnostic issue.  So, a query is mandated.  The RN may only document stage, but may not speak to the diagnostic issues.

    REFERENCE
    ICD-10 Guidelines 2019.  Section I.B. 14


    P. Evans, RHIA, CCDS

Sign In or Register to comment.