Q&A: Querying for POA pressure ulcer diagnoses
Q: Is it appropriate to query whether a pressure ulcer was present on admission (POA) if it was not documented until later in the admission?
A: First, you should review the admission documentation to verify if the patient’s skin showed signs of pressure ulcer development on admission. Looking at the initial skin assessment can be a helpful tool. Check for terminology such as “localized areas of skin redness” in areas prone to develop pressure ulcers, skin tears, open wounds, or puss-filled blisters, as these could be evidence of pressure ulcer development in the beginning stages of admission.
This is one of those times that the initial nursing documentation may be very beneficial in understanding the POA status of the ulcer, it could tell us that the ulcer really didn’t develop until after admission. This is important information to find, especially with hospital-acquired conditions (HAC), because if the ulcer really was a stage 3 or 4 ulcer on admission, or even advanced in stage, then it could qualify for a CC or MCC and impact reimbursement. If it wasn’t POA, then it could qualify as a HAC.
If you are still unsure after reviewing all possible documentation, it is recommended to query the physician.
Editor’s note: Sarah Humbert, RHIA, AHIMA-certified ICD-10-CM/PCS trainer, coding and compliance manager for KIWI-TEK, LLC, answered this questions during HCPro’s webinar Pressure Ulcer Coding: Strategies for ICD-10-CM Coding Accuracy.
This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.