Pressure Ulcers and Wound Care Documentation Flashcards
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Read the first 7 Pressure Ulcers and Wound Care Documentation flashcards as text
A pressure ulcer is documented as 'healed' at discharge. How should this be coded per ICD-10-CM guidelines?
Answer: Do not assign a pressure ulcer code; there is no code for a healed pressure ulcer
Per ICD-10-CM official guidelines, no code is assigned for a pressure ulcer documented as healed at the time of discharge.
Which body site combination requires the CDI specialist to use two separate ICD-10-CM codes for pressure ulcer documentation?
Answer: Stage 3 ulcers on both the right and left heels
Bilateral pressure ulcers must be coded individually with separate codes for each site, as ICD-10-CM laterality codes do not combine bilateral wounds.
A CDI specialist notices the wound care nurse documents 'suspected deep tissue injury' on the clavicle area, but the physician does not address this in any note. What is the appropriate CDI action?
Answer: Issue a physician query asking for clinical validation and documentation of the suspected deep tissue injury
Diagnoses documented only in nursing notes cannot be coded; the CDI specialist must query the treating physician to clinically validate and document the condition.
Under ICD-10-CM coding guidelines, if a patient has a pressure ulcer that is documented at Stage 2 on admission but progresses to Stage 3 during the stay, which stage is coded?
Answer: Stage 3, the highest stage documented during the encounter
Per ICD-10-CM guidelines, when a pressure ulcer progresses during an encounter, the code for the highest stage documented is assigned.
Which of the following best supports a CDI query for 'protein-calorie malnutrition' in a patient with a non-healing pressure ulcer?
Answer: Albumin of 2.0 g/dL, pre-albumin of 10 mg/dL, dietitian note recommending nutritional supplementation
Low albumin and pre-albumin combined with dietitian documentation of nutritional deficiency provides strong clinical indicators supporting a query for protein-calorie malnutrition as a contributing comorbidity.
A wound is documented as a 'venous stasis ulcer of the right lower leg with surrounding hyperpigmentation.' Which ICD-10-CM code category should the CDI specialist verify is used?
Answer: L97 — Non-pressure chronic ulcer of lower limb
Venous stasis ulcers of the lower limb are coded under L97, not L89 (pressure ulcers), since etiology is venous insufficiency rather than sustained pressure.
When documenting wound tunnel length in the medical record, why is this measurement clinically significant for CDI purposes?
Answer: Tunneling may indicate a sinus tract or abscess formation, which could support coding of an additional complication such as abscess
Documented tunneling may indicate an underlying sinus tract or abscess, which the CDI specialist should query the physician to confirm and potentially code as an additional complication.