Q&A: Querying for pressure injuries with proper documentation

February 7, 2020
Medicare Web

Q: What is your recommendation for pressure-injury querying using the nursing staff’s documentation?

Should we query for pressure injuries when they’re only documented by nursing? Our wound care nurses determined that staff nurses identify pressure injuries correctly only 60% of the time. If we’re querying based on nursing documentation, our administration is concerned that we’re running the risk of getting pressure injuries coded that are not truly pressure injuries. The physicians generally state they are not experts in staging and agree with the nursing wound care assessment.

A: Identification of a pressure ulcer is a medical diagnosis, so before it can be staged and identified as a deep-tissue pressure injury the provider must diagnose it as a pressure ulcer. Then we can obtain staging from nursing staff (stage 1, 2, 3, 4, unstageable, or deep tissue). The provider must identify the etiology and the location of the wound.

All that said, I would query for the etiology from the provider—based on the patient’s history, location, and appearance of the wound, the provider can determine if it is a traumatic, non-healing surgical, non-pressure, chronic, or pressure ulcer. Once this determination is made, the nursing documentation can clarify the stage or the depth for the chronic ulcers.

I would also suggest that nurses receive education on identifying/staging wounds and the importance of reporting to the provider so an accurate diagnosis can be made. I would add that you may want to also offer education to providers about the importance of correct capture of the etiology and clinical criteria to use that diagnosis.

Some organizations require wound care referrals to assess and plan/monitor treatment for all wounds.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, CDI education director at HCPro in Middleton, Massachusetts, answered this question in the CDI Journal.

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.

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