CCDS Pressure Ulcers and Wound Care Documentation 5 — Questions and Answers
Question 1: A pressure ulcer is documented as 'healed' at discharge. How should this be coded per ICD-10-CM guidelines?
- Code the highest stage the ulcer reached during admission
- Assign a code for healed pressure ulcer in category L89 with stage 0
- Do not assign a pressure ulcer code; there is no code for a healed pressure ulcer (Correct answer)
- Code as unstageable since it is resolved
Correct 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.
Question 2: Which body site combination requires the CDI specialist to use two separate ICD-10-CM codes for pressure ulcer documentation?
- A single sacral Stage 2 ulcer with surrounding skin breakdown
- Stage 3 ulcers on both the right and left heels (Correct answer)
- One Stage 4 ulcer with undermining and tunneling
- A unilateral trochanteric ulcer with wound infection
Correct 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.
Question 3: 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?
- Code the deep tissue injury based on the nursing note
- Ignore it since it is on the clavicle, an uncommon pressure ulcer site
- Issue a physician query asking for clinical validation and documentation of the suspected deep tissue injury (Correct answer)
- Code as unstageable since staging is uncertain
Correct 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.
Question 4: 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?
- Stage 2, the stage at admission
- Stage 3, the highest stage documented during the encounter (Correct answer)
- Both Stage 2 and Stage 3 with separate codes
- Unstageable, since the wound changed
Correct 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.
Question 5: Which of the following best supports a CDI query for 'protein-calorie malnutrition' in a patient with a non-healing pressure ulcer?
- BMI greater than 30 documented in the record
- Albumin of 2.0 g/dL, pre-albumin of 10 mg/dL, dietitian note recommending nutritional supplementation (Correct answer)
- Patient report of poor appetite for one week
- Hemoglobin of 11.5 g/dL
Correct 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.
Question 6: 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?
- L89 — Pressure ulcer
- L97 — Non-pressure chronic ulcer of lower limb (Correct answer)
- L98.4 — Non-pressure chronic ulcer of skin, not elsewhere classified
- E11.621 — Type 2 diabetes with foot ulcer
Correct 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.
Question 7: When documenting wound tunnel length in the medical record, why is this measurement clinically significant for CDI purposes?
- Tunnel length determines the ICD-10-CM stage assigned to the ulcer
- Tunneling may indicate a sinus tract or abscess formation, which could support coding of an additional complication such as abscess (Correct answer)
- Tunnel length is required for all pressure ulcer codes to be valid
- It determines the dressing reimbursement tier under Medicare Part A
Correct 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.
CCDS Pressure Ulcers and Wound Care Documentation 5
A pressure ulcer is documented as 'healed' at discharge.
How should this be coded per ICD-10-CM guidelines?