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Ulcer documentation tips

15 Mar 2020

You’ll get a query if documentation lacking

By: Toni Salchenberg, clinical documentation specialist

Coders and CDI are not allowed to code ulcers from wound care nurses (CWON) or nursing assessments (Flowsheet), the diagnosis must be made by a physician. The physician must document the type or cause, location and presence on admission (POA or Not POA), of an ulcer. The stage of the ulcer can be coded based on CWON nurse or nursing Flowsheet documentation (ICD-9-CM Official Guidelines for Coding and Reporting, effective Oct. 1, 2008).

When an ulcer is not documented by the physician, a query must be sent. Often there are TWO questions in the query, and both need to be addressed in a query response.

  1. To clarify the presence type and location of the ulcer.
  2. Status on Admission

Did you know?

  • In 2008, The Centers for Medicare & Medicaid Services stopped reimbursement for hospital acquired pressure ulcers.
  • In 2016, the National Pressure Ulcer Advisory Panel changed the term “pressure ulcer” to “pressure injury”.
  • Effect: 2.5 million patients are affected per year.
  • Cost: Pressure ulcers cost $9.1 to $11.6 billion per year in the US. Cost of individual patient care ranges from $20,900 to $151,700 per pressure ulcer. Medicare estimated in 2007 that each pressure ulcer added $43,180 in costs to a hospital stay.
  • Lawsuits: More than 17,000 lawsuits are related to pressure ulcers annually. It is the second most common claim after wrongful death and greater than falls or emotional distress.
  • Pain: Pressure ulcers may be associated with severe pain.
  • Death: About 60,000 patients die as a direct result of a pressure ulcer each year.