Presentation Overview Introduction to Pressure Ulcers covered basic concepts associated with pressure ulcers and other skin conditions. This presentation focuses on assessment guidelines and coding of Pressure Ulcer items in IRF-PAI.
Objectives Identify pressure ulcer items that are documented in the IRF-PAI. Describe guidelines for assessing and coding each item. Code the IRF-PAI pressure ulcer items correctly and accurately.
Overview of Pressure Ulcer Items IRF-PAI Pressure Ulcer Items: Item 48. Current Number of Unhealed Pressure Ulcers at Each Stage Item 49. Worsening in Pressure Ulcer Status Item 50. Healed Pressure Ulcers
Importance of Clinical Assessment A complete and ongoing skin assessment guided by clinical standards is essential. This assessment, which identifies and evaluates all areas at risk for constant pressure and determines the etiology of all skin ulcers and skin conditions/problems, should direct the appropriate skin management interventions. Completion of Pressure Ulcer items in the IRF-PAI does not replace this assessment.
Item 48 Current Number of Unhealed Pressure Ulcers at Each Stage Documents current number of unhealed pressure ulcers at Stages 2, 3 and 4.
Staging Definitions CMS has adaptedthe 2007 NPUAP definitions for categories of staging. Resource: www.npuap.org Free diagrams of ulcer stages can be downloaded for educational use. Reproduced with permission
General Assessment and Coding Guidelines Determine current number of unhealed ulcers. Perform head-to-toe assessment of patient. Use visual inspection and palpation to identify appropriate stage. Code only wounds that are the result of pressure. Determine deepest anatomical stage of each ulcer. Do not reverse stage.
General Assessment andCoding Guidelines, Cont. Determine if the pressure ulcer was present on admission and discharge. Review for location and stage at time of admission and discharge. Observation period for pressure ulcer items is 3 days. Do not report unstageable pressure ulcers on the IRF-PAI.
Item 48A Number of Stage 2 Pressure Ulcers Documents number of Stage 2 pressure ulcers present at admission and discharge.
Stage 2 Pressure Ulcers Partial thickness loss of dermis presenting as: Shiny or dry shallow open ulcer Red or pink wound bed Without slough or bruising
Stage 2 Pressure Ulcers, Cont. May also present as anintact or open/ ruptured blister
48A Coding Guidelines Differentiate Stage 2 pressure ulcer from a suspected deep tissue injury. Code only Stage 2 pressure ulcers in 48A. Do not code skin tears, tape burns, Moisture-associated Skin Damage or excoriation in 48A.
48A Coding Instructions:Admission Field Enter number of Stage 2 pressure ulcers present on admission. If none, enter 0.
48A Coding InstructionsDischarge Field Enter number of Stage 2 pressure ulcers present at discharge. If none, enter 0.
Items 48B and 48C Number of Stage 3 or 4 Pressure Ulcers Document the number of Stage 3 or 4 pressure ulcers present at admission and discharge.
Stage 3 Pressure Ulcer Full thickness tissue loss. Subcutaneous fat may bevisible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Depth varies by anatomical location.
Stage 4 Pressure Ulcer Full thickness tissue loss with exposed bone, tendonor muscle Slough or eschar may be presenton some parts of wound bed. Oftenincludes undermining and tunneling Depth varies by anatomical location.
48B and 48C Coding InstructionsAdmission Field Enter number of Stage 3 and 4 pressure ulcers present on admission. If none, enter 0.
48B and 48C Coding InstructionsDischarge Field Enter number of Stage 3 or 4 pressure ulcers present at discharge. If none, enter 0.
Item 48 Scenario #1 At admission, one pressure ulcer was noted and documented in the patient’s medical record. It was noted to be a full thickness ulcer with no exposure of bone, tendon or muscle. No other pressure ulcers were documented. How should Item 48 be coded?
Scenario #1 Correct Coding In Item 48B, Stage 3, enter 1 in the Admission field. In Items 48A and C, enter 0 in the Admission field. 0 1 0
Item 48 Scenario #2 At discharge, a patient has one pressure ulcer that is documented in the medical record. The pressure ulcer is covered with hard black necrotic tissue. How should Item 48 be coded?
Scenario #2 Correct Coding This pressure ulcer is unstageable. It should not be included on the IRF-PAI. 0 0 0 0 0 0
Item 49 Worsening Pressure Ulcer Status Since Admission Documents the number of current pressure ulcers at discharge that that have worsened since admission.
Item 49 Worsening Pressure Ulcer Status This includes pressure ulcers at discharge that: Were not present at admission OR Were at a lesser numerical stage at admission
Item 49 Coding Guidelines It will be easier to assess worsening status and to code these items if a facility documents and tracks pressure ulcer status on a routine basis.
Item 49 Coding Guidelines2 Coding a pressure ulcer that was unstageable at admission: Do not consider it to be worse at discharge. If it becomes stageable, consider it as present on admission. Code at the stage when it first became stageable. If it worsens after it becomes stageable, it should be coded as worsening.
Item 49 Coding Example #1 A patient is admitted with a pressure ulcer that is covered in necrotic tissue and cannot be staged. During the stay, the pressure ulcer is revealed to be a Stage 4 pressure ulcer. Should this Stage 4 pressure ulcer be coded in Item 49 as a “new or worsening” pressure ulcer?
Item 49 Coding Guidelines3 Coding a stageable pressure ulcer that becomes unstageable since admission: If it becomes Unstageable due to Slough or Eschar, do not code as worsened. If it becomes unstageable and then is debrided so it can be staged, compare its stage before and after it was unstageable. If the stage has worsened, code it as worsening.
Item 49 Coding Example #2 A patient is admitted with a Stage 3 pressure ulcer. During the stay slough covers much of it. Then the ulcer is debrided and found to be a Stage 4 pressure ulcer. Should this Stage 4 pressure ulcer be coded in Item 49 as a “new or worsening” pressure ulcer?
49A Stage 2 Coding Instructions Indicate the number of current Stage 2 pressure ulcers at discharge that were not present or were at a lesser stage on admission. Enter 0 if no Stage 2 ulcers are present, are new or have worsened.
49B Stage 3 Coding Instructions Indicate the number of current Stage 3 pressure ulcers at discharge that were not present or were at a lesser stage on admission. Enter 0 if no Stage 3 pressure ulcers are present, are new, or have worsened.
49C Stage 4 Coding Instructions Indicate the number of current Stage 4 pressure ulcers at discharge that were not present or were at a lesser stage on admission. Enter 0 if no Stage 4 pressure ulcers are present, are new, or have worsened.
Item 49 Scenario A patient’s admission assessment documented a Stage 2 pressure ulcer on the right ischial tuberosity. At discharge, the pressure ulcer has deteriorated to a Stage 3 pressure ulcer. There were no other pressure ulcers at admission. How should Item 49 be coded?
Scenario Correct Coding In Item 49B, Stage 3, enter 1. In Items 49A and 49C, enter 0. 0 1 0
Item 50 Healed Pressure Ulcers Documents: Whether any unhealed pressure ulcers were present on admission (Item 50A) If so, the number of Stage 2, 3, and 4 pressure ulcers that have completely closed since admission (Items 50B, C, and D)
Item 50 Coding Guidelines A “healed pressure ulcer” is one that is: Completely closed Fully epithelialized Covered completely with epithelial tissue or resurfaced with new skin, even if the area continues to have some surface discoloration Do not reverse stage.
50A Coding Instructions Item 50A. Unhealed Pressure Ulcers Present on Admission? • Code 0. No. • Skip Items 50B-D. • Code 1. Yes. • Complete Items 50B-D.
50B, 50C and 50DCoding Instructions Items 50B, C and D. Stage 2, 3 or 4 Pressure Ulcers on Admission That Have Healed Enter number of pressure ulcers at that stage at admission which have completely closed at discharge. If none, enter 0.
Item 50 Scenario A patient is admitted with one Stage 2 pressure ulcer. By discharge, the ulcer is healed. How should Items 50B, C, and D be coded?
Scenario Correct Coding Item 50B. Stage 2. Code 1 for the pressure ulcer that healed. Item 50C. Stage 3. Code 0 for none. Item 50D. Stage 4. Code 0 for none. 1 0 0