CCDS Pressure Ulcers and Wound Care Documentation 5

Question 1

A pressure ulcer is documented as 'healed' at discharge. How should this be coded per ICD-10-CM guidelines?

Accepted Answer

Do not assign a pressure ulcer code; there is no code for a healed pressure ulcer

Answer

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?

Accepted Answer

Stage 3 ulcers on both the right and left heels

Answer

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?

Accepted Answer

Issue a physician query asking for clinical validation and documentation of the suspected deep tissue injury

Answer

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?

Accepted Answer

Stage 3, the highest stage documented during the encounter

Answer

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?

Accepted Answer

Albumin of 2.0 g/dL, pre-albumin of 10 mg/dL, dietitian note recommending nutritional supplementation

Answer

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.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Pressure Ulcers and Wound Care Documentation 5