Posts tagged ‘stage 4 pressure ulcers’

November 23, 2011

M1308, the question that keeps on giving …

Several questions in CMS’s 3rd quarter Q&As deal with pressure ulcers and M1308.

The highlights (in my words, not CMS’s!):

  • Should a muscle flap be reported in M1308 as a current pressure ulcer? No. It is a surgical wound (as are skin advancement flap, or rotational flap)
  • If the pressure ulcer has a skin graft, how is it treated? Not as a surgical wound but as unstageable until it heals, then Stage III or IV.
  • How do you report a Stage III that is closing to the point of a pinpoint? As a Stage III …

Find CMS’s full answers here.

July 16, 2011

Read on … this patient has something for everyone

Question:  This gentleman has six pressure ulcers total, 2 of which are unstageable and 4 of which are a stage 4.  I have coded each pressure ulcer by location and stage already and the primary diagnosis as aftercare following surgery because he had surgical debridement of these while in the hospital prior to admission onto services. I feel that is correct, but you may think differently.
He was diagnosed with severe osteo while in the hospital and also had debridement of the bone as well as the wounds. He is on po levaquin now in the home and was discharged with dx of osteo, so I am assuming that the surgical debridement and IV antibiotics while in the hospital did not rectify it all.  So, I am not sure how to add the dx it into the sequence of the pressure ulcers, maybe secondary, but not quite sure on that.

educating and providing care to this as well.  So, I know that I need to add “colostomy status (v44.3)” and “attn to colostomy, (v55.3)” in the sequence. Our primary focus in the home of course is the wounds, but the colostomy is very important as well, so do I sequence it under the wounds? The wounds just take up so much in the coding scenario that I do not want the colostomy to get missed or I put it too far down in the “line up”.

I am still unclear how to code for supplies on this and we will be providing to him his colostomy supplies.

He is a paraplegic (344.1), so of course I will code that and he also was diagnosed sarcodosis (136.5?) leukocytosis (288.60) and malnutrition (236.9?).

Lisa says: Because you have several stage 4s code the locations and then add the 707.24 for stage 4. I would then code the paraplegia. The V code for attention to colostomy can be used as the 6th diagnosis if you feel strongly that it needs to be coded in the top six. NEVER code the status and attention to codes for the same ostomy at the same time. 
Add the other codes in any order keeping in mind that the other two ulcers are coded as unstageable. 
I would not code aftercare in this situation at all. You are not really providing aftercare. 
Other general reminders: the same code cannot be used more than once so there is no way to code two ulcers at the same site nor is there any way to code bilateral ulcers. 
Non routine supply points in this case are obtained from how M1630 (bowel ostomy), M1308 and M1324 (pressure ulcers) are answered, not on the codes. This scenario is getting a LOT of NRS points so ensure that the appropriate revenue codes and charges are added to your final bill and your HIPPS code ends in a letter (provided supplies). 
February 4, 2011

3 reasons why your patient’s pressure ulcer is unstageable

Question: I have a patient with an old Stage 4 pressure ulcer on the buttock. The patient is coming from a nursing home, and the ulcer is “pretty much healed” down to a pin point. Now the patient is in home health. The nurse wants to call it an unstageable ulcer on the OASIS, and I said “once a stage 4 always a stage 4” – at least for coding purposes?

Lisa says: There are three situations that make a pressure ulcer unstageable–1) eschar and slough, 2) dressing or device that cannot be removed, 3) deep tissue injury. A closing Stage 4 pressure ulcer should be marked as a fully granulating Stage 4. Once it is closed, it is marked as a newly epithelialized Stage 4 and will continue to be marked that way unless the pressure ulcer breaks down again. The pressure ulcer is coded as a Stage 4.

September 14, 2010

Always code Stage 3 and 4 pressure ulcers

Here is subject I field many, many questions on: the coding of stage 3 and 4 pressure ulcers.

Question: I recently read that closed pressure ulcers, regardless of stage, should not be coded. Is this true? I thought all Stage 3 & 4 closed pressure ulcers should still be coded.

Lisa says: Stage 3 and 4 pressure ulcers are never considered healed, but they can close. Because there is a strong risk that they will open again, they should be coded in a patient’s episode. If they are open ulcers, they would require much care, so they probably would be listed higher in your coding sequence, but the sequence will always depend on the seriousness of conditions, not just that these are difficult pressure ulcers. If they are closed pressure ulcers, you would probably code them lower, based on the time of care expended vs. the patient’s other needs.

Remember (and never forget) that closed stage 3s and 4s always require active intervention, including assessment and pressure ulcer risk interventions. The tissues lost are replaced by granulation tissue and they are always at risk. Because they should be addressed in the POC, they should be coded.


As for Stage 1 and 2 pressure ulcers: Code them when they are open. When they are closed and evidence of them is gone, they are considered healed, and they should not be coded.

In any case, watch the OASIS: There are nine items that deal with pressure ulcer assessment; be sure to watch all of them.

Looking for references on pressure ulcers? This is the WOCN’s position statement, which is considered official guidance.

July 26, 2010

Pressure ulcer answers!

I always get questions during and after education seminars. Here are a few dealing with one of our favorite home health questions: pressure ulcers

Is a reddened coccyx with a few scabbed areas considered a Stage 2 because of the scabs?

Lisa says:  A Stage 1 has intact skin. The presence of scabs would be considered more than Stage 1; however, it cannot be staged if the wound bed is not visible.

If we have a Stage 3 that is closed and would be a Stage 3 on admit and discharge, do we put zeros for MO1310 1312 and 1314 to reflect that it is closed.

Lisa says: A closed Stage 3 is never fully healed, so will continue to be called a Stage 3 at each time point unless it breaks down and becomes a Stage 4. The correct response to M1310,1312 and 1314 is 000.

If a patient went in hospital for shoulder surgery and was kept in observation and left just shy of 24 hours, would the admission MO1000 be NA ?

Lisa says: This patient would still be marked ‘Hospital’ as M1000 is not related to the criteria for a transfer assessment. The item simply asks from which facility was the patient discharged. (A transfer assessment  is not required.) Note: Before you mark ‘Hospital,’ make sure this patient was not considered outpatient, e.g., had outpatient surgery.