Unstageable Pressure Ulcers not POA
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.
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.
Comments
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
Mark
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
"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