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Q&A: Pressure ulcer POA code confusion resolved

CDI Strategies, November 13, 2008

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Q:What present on admission (POA) indicator should we assign when a patient presents to the hospital with a stage I pressure ulcer (code 707.21) that later develops to a stage III pressure ulcer (code 707.23) during his or her stay? Will CMS consider the stage III ulcer a hospital acquired condition (HAC)?

A: CMS does not currently consider a condition an HAC when it is POA but progresses during the hospitalization, according to Sue Bowman, RHIA, CCS, director of coding policy and compliance for the American Health Information Management Association in Chicago. CMS intends its HAC payment provision to be limited entirely to conditions that actually develop during hospitalization.

According to the ICD-9-CM Official Guidelines for Coding and Reporting, coders must assign a code only for the highest stage of an ulcer during an admission. Therefore, report code 707.23 with POA indicator of Y in the situation described in the above question. Refer to the upcoming Coding Clinic, 4th quarter, for more information.

Editor’s note: Shannon McCall, RHIA, CCS, CPC, a member of the ACDIS advisory board and director of coding and HIM at HCPro, Inc., gathered information related to this answer.

ACDIS members can access a sample form regarding pressure ulcer documentation at www.hcpro.com/acdis.com.

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