CCDS Pressure Ulcers and Wound Care Documentation

Question 1

Which staging system provides the basis for ICD-10-CM pressure injury code assignment?

Accepted Answer

National Pressure Injury Advisory Panel (NPIAP) staging

Answer

Wagner Grading System

Answer

Braden Scale score

Answer

PUSH Tool measurement

Question 2

What condition must be documented for a pressure ulcer to be coded as 'unstageable' in ICD-10-CM?

Accepted Answer

The physician documents the ulcer cannot be visually assessed due to eschar, slough, or necrotic tissue

Answer

Any wound that is clinically difficult to treat

Answer

A wound exhibiting undermining or tunneling beyond its edges

Answer

Any pressure wound that was present on admission

Question 3

Why is a CDI query regarding present-on-admission (POA) status especially critical for pressure injuries?

Accepted Answer

Ambiguous POA status for pressure injuries can result in HAC designation, affecting reimbursement and quality scores

Answer

POA status affects only the length of stay calculation

Answer

POA queries are routine for all diagnoses and carry no special significance for pressure injuries

Answer

POA status for pressure injuries is automatically determined by admission nursing notes

Question 4

Which statement best describes ICD-10-CM anatomic site options for pressure ulcer coding?

Accepted Answer

Multiple specific sites are provided including sacrum, coccyx, hip, buttock, heel, ankle, and others

Answer

Only three anatomic sites are recognized: sacrum, heel, and hip

Answer

Only six sites are available, limiting specificity

Answer

Only two sites (sacrum and heel) are clinically significant for coding

Question 5

A patient is admitted with a Stage 2 pressure ulcer that progresses to Stage 3 during the hospital stay. What stage should be coded?

Accepted Answer

Stage 3, the highest stage documented during the admission

Answer

Stage 2, the stage present on admission

Answer

Stage 3 only if it developed after 48 hours

Answer

Both Stage 2 and Stage 3 are coded separately

Question 6

A patient with diabetes has a foot ulcer. What documentation elements must the CDI specialist verify for accurate code assignment?

Accepted Answer

Type of diabetes and the depth/severity of the ulcer

Answer

Type of diabetes only, since all foot ulcers are coded the same

Answer

Only wound measurements and wound care orders

Answer

Only the treatment plan and specialist consulted