CCDS Pressure Ulcers and Wound Care Documentation 4

Question 1

A patient with a Stage 3 pressure ulcer on admission has the wound worsen to Stage 4 during hospitalization. How should the CDI specialist query this scenario?

Accepted Answer

Query to clarify whether the Stage 4 ulcer was present on admission or developed/worsened during the stay

Answer

The CDI specialist must clarify POA status because worsening from Stage 3 to Stage 4 may indicate a hospital-acquired condition, which has significant quality and reimbursement implications.

Question 2

Which ICD-10-CM code category is used to identify a pressure ulcer that cannot be clinically staged because the wound base is covered by eschar?

Accepted Answer

L89 with a 9 suffix indicating unstageable

Answer

Unstageable pressure ulcers, obscured by slough or eschar, are coded with the 9 suffix under the L89 category in ICD-10-CM.

Question 3

A CDI specialist reviews documentation showing a sacral wound with 'full-thickness skin loss involving subcutaneous tissue but not bone or muscle.' Which pressure ulcer stage does this describe?

Accepted Answer

Stage 3

Answer

Stage 3 pressure ulcers involve full-thickness skin loss with visible subcutaneous fat, but bone, tendon, and muscle are not exposed.

Question 4

When a wound care note describes 'serosanguineous drainage, moderate amount, periwound erythema' for a pressure ulcer, which documentation element is most important for the CDI specialist to verify is also captured by the physician?

Accepted Answer

Clinical diagnosis of wound infection or cellulitis if clinically present

Answer

Periwound erythema and drainage may indicate infection or cellulitis; the physician must document a clinical diagnosis to support coding of a complication.

Question 5

For DRG reimbursement purposes, which comorbid condition most significantly increases the complexity of a pressure ulcer admission?

Accepted Answer

Osteomyelitis underlying the pressure ulcer

Answer

Osteomyelitis underlying a pressure ulcer is a major complication/comorbidity (MCC) that can shift the DRG to a significantly higher-paying tier.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Pressure Ulcers and Wound Care Documentation 4