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Help in answering our queries on pressure ulcers
Identify ulcers by type, and whether POA
By Catherine Trevis, RN, clinical documentation specialist
When coding a pressure/decubitus ulcer, physicians must document two pieces of information. First, identify the ulcer by type, either as a pressure/decubitus ulcer or other type of ulcer (such as a diabetic ulcer or a venous stasis ulcer). Second, document if the ulcer was present on admission. The stage of the ulcer can be taken from nursing documentation; the physician needs to document the stage if not done by the bedside nurse or CWON.
The Centers for Medicare & Medicaid Services will not pay for certain hospital-acquired conditions. Since pressure ulcers are considered preventable, the hospital will not be reimbursed for its treatment if the condition was not POA.
When you get a query about a skin ulcer, remember that two questions are always included. Make sure you document the type of the ulcer AND if it was POA.
Questions? Please email me.