Pressure Ulcers
Wound care nurse documents patient with stage 2 pressure ulcer sacrum POA. Three weeks later the wound care nurse determines that the same ulcer is now Unstageable. Does this mean that you code the Stage 2 pressure ulcer sacrum as POA and Unstageable Pressure Ulcer sacrum as Not POA?
Comments
The progression of a pressure ulcer during a hospital stay requires two codes 1 for the pressure ulcer that was POA and 1 for the progression of the pressure ulcer POA N. I would definitely talk to the wound care nurses and providers to determine if the POA staging was completely correct but unstageable is usually more than slough, it's thick eschar that has to be removed to reveal the stage.
ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2016 Pages: 143-144 Effective with discharges: October 1, 2016
Question:
We understand that the ICD-10-CM codes for pressure ulcers include the location of the ulcer as well as the stage. What is the correct diagnosis code and present on admission (POA) indicator for a patient admitted to the hospital with a stage 2 pressure ulcer of the left heel that worsens during the hospitalization and becomes a stage 3 ulcer?
Answer:
Assign code L89.622, Pressure ulcer of left heel, stage 2, for the site and stage of the ulcer on admission. Assign code L89.623, Pressure ulcer of left heel, stage 3, for the site and highest stage of the ulcer reported during the admission. Report a POA indicator of "Y" for code L89.622, Pressure ulcer of left heel, stage 2; and a POA indicator of "N" for code L89.623, Pressure ulcer of left heel, stage 3, to reflect that the pressure ulcer was a stage 2 on admission, but progressed to stage 3 during the hospitalization.
As of October 1, 2016, the ICD-10-CM Official Guidelines for Coding and Reporting have been revised to indicate that if a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.
Hope this Helps!
Jeff