Topic: Pressure and Non-pressure Ulcers
Definition
Defined as localized damage to skin and/or underlying soft tissue due to intense or prolonged pressure often associated with immobility and/or absent sensation.
Chronic ulcers with an etiology other than pressure (aka, venous, arterial, diabetic, etc.)
Refers to skin breakdown due to various causes. Acute skin failure describes skin loss in association with hemodynamic instability and/or organ system compromised in critically ill patients.
Diagnostic Criteria — Pressure Ulcers / Injuries
(DTPI)
Coding Considerations
Instructional note to "code first" any associated underlying condition such as gangrene, atherosclerosis, chronic venous hypertension, diabetic ulcer, post thrombotic ulcer or varicose ulcer.
Excludes 2 note indicates pressure ulcers (L89), skin infections (L00-L08), and specific infections (A00-B99) can also be reported.
Unstageable vs. Unspecified
Assigned only when the documentation supports unstageable.
Used when no stage is documented.
If a DTPI or an unstageable pressure ulcer is documented by the provider with location, and after debridement or opening a stage is revealed and documented, assign only one code for the pressure ulcer with stage.
Official Guidelines for Coding and Reporting
Allows for assignment of as many codes from L89 as needed to identify all pressure ulcers that patient has during hospital admission.
Assignment of pressure ulcer stage should be guided by clinical documentation of the stage or documentation of the terms found in the alphabetic index.
States that the code assignment reflecting the depth of non-pressure ulcers and stage of pressure ulcers may be based on medical record documentation from clinicians who are not the patient's provider.
The associated diagnosis, location, and present on admission (POA) status MUST be documented by the provider.
"When laterality is not documented by the patient's provider, code assignment for the affected side may be based on medical record documentation from other clinicians."
Assignment of the code for unstageable pressure ulcer (L89. ----0) should be based on clinical documentation. These codes are used for pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated with skin or muscle graft). This code should not be confused with the codes for unspecified stage (L89. --9). When there is no documentation about the stage of the pressure ulcer, assign the appropriate code for an unspecified stage (L89. --9).
Instructs that no code is assigned if pressure ulcer is completely healed. Pressure ulcers described as healing should be assigned to the appropriate pressure ulcer stage.
CDI Practice Considerations
| ▸ | Key elements of provider documentation include presence, location, and POA status of pressure ulcer, but a corresponding stage can be taken from other clinicians as defined by the hospital policies. |
| ▸ | It is essential to document the present-on-admission status, as Stage 3 and Stage 4 pressure ulcers that are not POA are included in PSI-3. Kennedy ulcer is assigned L89 and is also included in PSI 3 if not present-on-admission and full thickness stage 3 or 4. Skin Failure is not classified as a PSI 3. |
| ▸ | Stage 3 pressure ulcers are non-CCs but assigned to HCC 382. Stage 3 and 4 pressure ulcers are MCCs and included in HCCs 379 and 381. |
| ▸ | Follow DTIs and make sure the location and POA status is noted in case they reveal to stage 3 or 4 pressure injury. |
| ▸ | For query compliance standards on a POA status of pressure injury, make sure to include unable to determine as an option. |
| ▸ | If a patient is admitted with a pressure ulcer that is POA at a specific stage and the ulcer progresses to a higher stage during the hospitalization, assign two separate codes. The first code should reflect the ulcer site and stage documented as POA, and the second code should reflect the same ulcer site at the highest stage documented during the hospital stay. |
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