Health Information Management

Q&A: Pressure sores present on admission

CDI Strategies, March 10, 2016

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Q: We are having trouble determining how to assign a code for a pressure ulcer that begins as a Stage I concern that is present on admission (POA) but advances during the patient’s stay to a Stage II or a Stage III. Coding Clinic, Fourth Quarter 2008, p. 194, tells us that even if the ulcer advances it would still be coded as POA, but would even an advanced stage still be considered POA?

A: In terms of coding and POA reporting, a pressure ulcer is only coded and reported once at the highest stage. 

The information published in Coding Clinic, Fourth Quarter 2008, p. 194, instructs coders to report a Stage II pressure ulcer that progresses to a Stage III as a POA condition.

The pressure ulcer was present on admission; therefore, the POA should be “yes.” This advice is consistent with the National Quality Forum (NQF) endorsed measures. The NQF established a standardized set of serious reportable events also called never events. The list of serious reportable events excludes the progression of a pressure ulcer from Stage II to Stage III, if Stage II was recognized upon admission.

Editor’s Note: Sharme Brodie R.N, CCDS, AHIMA Approved ICD-10 CM/PCS Trainer, CDI Educational Instructor at HCPro in Danvers Massachusetts, answered this question. Contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.



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