NPUAP updates pressure ulcer terminology and stages
Sepsis isn’t the only clinical condition with an updated definition that could impact coding and documentation. A task force of the National Pressure Ulcer Advisory Panel (NPUAP) recently changed terminology related to pressure ulcers that includes new terms that are not yet part of ICD-10-CM.
While coding for pressure ulcers already changed for ICD-10-CM, the new terms are an attempt to more accurately describe the stages and descriptions of such injuries. The NPUAP no longer uses the term “pressure ulcer,” replacing it with “pressure injury,” since stage 1 and deep tissue injuries describe intact skin, not open ulcers.
The NPUAP has defined a pressure injury as:
… localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.
The definitions for each type of pressure injury are now:
- Stage 1 pressure injury: Non-blanchable erythema of intact skin
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. - Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds (e.g., skin tears, burns, abrasions). - Stage 3 pressure injury: Full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. - Stage 4 pressure Injury: Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury. - Unstageable pressure injury: Obscured full-thickness skin and tissue loss
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema, or fluctuance) on an ischemic limb or the heel(s) should not be removed. - Deep tissue pressure injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (i.e., unstageable, stage 3, or stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.
With the new ICD-10-CM codes for 2017 already decided, codes will not be updated to incorporate these terminology changes until at least October 1, 2018.
“This is much like how we struggled with the professional descriptions related to systolic and diastolic heart failure versus the more recent terminology of reduced or preserved ejection fraction,” says Sharme Brodie, RN, CCDS, a clinical documentation improvement specialist with HCPro, a division of BLR, in Danvers Massachusetts. “When providers use terms that were not evident within the code set, we have to query for the needed specification.”