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April 2018

A Tricky Trio
By Selena Chavis
For The Record
Vol. 30 No. 4 P. 12

The coding of pressure ulcers, including whether present on admission, BMI, and obesity has far-reaching effects.

Pressure ulcers are both a high-cost and high-volume adverse event that have notable bottom-line consequences when coded inaccurately. In tandem, body mass index (BMI) and obesity have become important clinical documentation pieces as they pertain to meeting severity of illness criteria and advancing chronic disease processes.

Hospitals and health systems rely on clinical documentation improvement (CDI) programs to accurately capture and code these conditions. Yet, the nuances of aligning documentation with coding guidelines can be tricky in all three areas. In addition, the ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 introduced changes to how coders report pressure ulcers, adding complexities to the mix.

In light of these hurdles, how can health care organizations have confidence in their data?

According to Patty Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI CCS, director of HIM practice excellence for AHIMA, it all comes down to the quality of the documentation and the coding professional's aptitude. "Documentation is the foundation for everything," she says, pointing out that data quality across the industry will vary because not all CDI programs have reached a level of maturity to support high reliability. "You need your documentation to be accurate and specific for your foundation, but then you need to use your specificity to help ensure the documentation captures the complete picture. And your coding professionals need to fully understand the nuances of the coding guidelines each year when the changes are made."

Donna Rugg, RHIT, CDIP, CCS, director of HIM practice excellence for terminology mapping, coding, and data standards with AHIMA, notes that the guidelines for reporting pressure ulcers were expanded October 1, 2017, to be more specific. Speaking to one change, she explains that "if a pressure ulcer is present on admission (POA), but is healed at the time of discharge, then the site and stage of the ulcer at admission is what is coded."

Pointing to an additional change, she adds that "if a patient comes in with a pressure ulcer at one stage and the ulcer progresses to a higher stage during the admission, then two separate codes are assigned." As such, the POA indicator would be different for each of the codes assigned.

There is a lot riding on the accurate coding of pressure ulcers, obesity, and BMI. With that in mind, industry professionals underscore the importance of coder knowledge and interpretation.

Katie Robin, RHIA, CCS, CIC, senior manager of facility coding and compliance with Aviacode, recommends coders use the American Hospital Association's Coding Clinic Advisor in conjunction with the guidelines for further clarity. "The guidelines and Coding Clinic Advisor, while ever changing and evolving, are designed to guide coders," she says, adding that recent changes to the guidelines may improve accuracy. "Speaking to the pressure ulcer coding guidelines, while there have been changes in the recent past, these changes have made it easier for coders to determine correct coding and reporting of those diagnoses."

Impact on Quality and Reporting: A Deeper Look
With it being a critical identifier of patient risk, it's imperative to capture obesity, says Mark Dominesey, RN, BSN, MBA, CCDS, CDIP, CHTS-CP, manager of excellence in clinical documentation for Children's National Medical Center in Washington, D.C. "It's important for CDI professionals to really tease that out of the record. Morbid obesity is a huge contributor to severity of illness or risk of mortality," he says, pointing out that the Centers for Medicare & Medicaid Services (CMS) deemed that it's always appropriate to include a diagnosis of obesity or morbid obesity and to use BMI data to support those diagnoses. "In many cases, morbid obesity will move a patient 25% up through the 1 to 4 scale of severity of illness. It will move them from one to two almost every time."

It's important to note that while BMI data can be documented by nonphysician clinicians, the diagnosis for obesity must come from a physician.

Obesity is often associated with pressure ulcers—a condition that comes with its own significant quality concerns, according to Mazette Edwards, MA, CDIP, CCS, COC, director of clinical coding practice at New York's Montefiore Medical Center. "If a pressure ulcer is not accurately coded as POA, there can be a reimbursement impact. Those scores suggest that the facility does not provide accurate care," she says. "It's up to the facility to make sure your POA are on point or at least 95% accurate. We try to reach 100%."

Specifically, Robin points out that stage III and IV pressure ulcers that are not flagged as POA represent a hospital-acquired condition, for which CMS no longer provides reimbursement. In addition, Buttner notes that hospitals can face other reputational and financial consequences associated with the incidence of pressure ulcers through such quality initiatives as Hospital Compare, value-based purchasing, and the Medicare Access and CHIP Reauthorization Act of 2015.

"CDI professionals and coders have to be careful as we are reviewing information. Physicians and nurses can be sloppy in the way they document," Dominesey emphasizes. "We have to get physicians to characterize the type of ulcer so we can properly code it. And to code that ulcer, we have to know if it's POA or not."

Identifying Pressure Ulcers POA
In terms of POA reporting, coders must use the following reporting designations:

Edwards says that, similar to BMI data, nonphysician clinicians can document the depth and stages of pressure ulcers, but ultimately the diagnosis must come from a physician. Emphasizing the importance of physician follow-through with the diagnosis, Edwards says that hospitals must understand the prevalence of pressure ulcers entering their facilities. For instance, "If a patient is coming from a nursing home, 95% of the time there is pressure ulcer" that needs a POA designation, she says.

Edwards adds that pressure ulcers with a POA designation that heal before discharge from an inpatient stay are assigned the code related to the stage of the ulcer upon admission. Additionally, patients admitted with pressure ulcers that evolve into another stage during an inpatient stay receive two separate code assignments.

As of October 1, 2016, the ICD-10-CM Official Guidelines for Coding and Reporting have been revised to indicate that if a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.

Robin suggests adhering to the following physician documentation guidance from the ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2016, pages 143-144:

"Effective with discharges October 1, 2016. Assign code L89.622, Pressure ulcer of left heel, stage 2, for the site and stage of the ulcer on admission. Assign code L89.623, Pressure ulcer of left heel, stage 3, for the site and highest stage of the ulcer reported during the admission. Report a POA indicator of 'Y' for code L89.622, Pressure ulcer of left heel, stage 2, and a POA indicator of 'N' for code L89.623, Pressure ulcer of left heel, stage 3, to reflect that the pressure ulcer was a stage 2 on admission, but progressed to stage 3 during the hospitalization."

ICD-10 guidelines do not specify a timeframe for provider documentation of POA, Robin says. Specifically, they indicate that "it may not be possible for a provider to make a definitive diagnosis (or a condition may not be recognized or reported by the patient) for a period of time after admission. In some cases, it may be several days before the provider arrives at a definitive diagnosis. This does not mean that the condition was not present on admission. Determination of whether the condition was present on admission or not will be based on the applicable POA guideline as identified in this document, or on the provider's best clinical judgment."

Accurately Identifying Pressure Ulcer Stages
Dominesey notes that the Wound, Ostomy and Continence Nurses Society offers standard criteria for staging pressure ulcers through the National Pressure Ulcer Advisory Panel Staging System. "It's by depth of tissue affected and how that tissue appears," he says. "It's pretty standard, universal criteria. That part of it is not controversial."

In a presentation at the 2017 AHIMA Convention and Exhibit, Edwards provided the following definitions:

Stage I: Pressure ulcers manifest as nonblanchable erythema, usually over a bony prominence. This stage is a misnomer in the sense that an actual ulcer (a defect of skin into the dermis) is not yet present.

Stage II: Pressure ulcers manifest as a loss of epidermis (erosion) with or without true ulceration (defect beyond the level of the epidermis); subcutaneous tissue is not exposed. The ulcer is shallow with a pink to red base. Stage II also includes intact or partially ruptured blisters secondary to pressure.

Stage III: Pressure ulcers manifest as full-thickness loss without underlying muscle or bone exposure.

Stage IV: Pressure ulcers manifest as full-thickness loss with exposure of underlying bone, tendon, or muscle.

Unstageable: Pressure ulcers are those covered with debris or eschar, which does not allow assessment of depth. Stable, nonfluctuant heel lesions with dry eschar should never be debrided for the sake of staging.

Deep Tissue Injury: A newer category of findings that suggest damage to underlying tissue. Findings include purple to maroon areas of intact skin, and blood-filled vesicles or bullae. The area may feel firmer, boggier, warmer, or cooler compared with surrounding tissue. Pressure ulcers do not always present as stage 1 and then progress to higher stages. Sometimes the first sign of a pressure ulcer is a deep, necrotic stage III or IV ulcer. In a rapidly developing pressure ulcer, subcutaneous tissue can become necrotic before the epidermis erodes. Thus, a small ulcer may in fact represent extensive subcutaneous necrosis and damage.

Rugg reemphasizes that providers or another clinician—such as a wound care nurse—can document the stages.

Setting the Stage for Greater Accuracy
ICD-10 guidelines for POA are clear, according to Robin. The physician provider is responsible for documenting the diagnosis of a pressure ulcer. Therefore, if the POA stage is unknown at the time of admission but later clarified, best practices dictate that the patient's attending physician be queried for clarification. "It's important to remember that there are times we must query the provider to determine correct POA or diagnosis code reporting," Robin says. "When in doubt, and you've done your research, query the provider."

Marisa MacClary, CEO of Artifact Health, points out that the only way to exclude a hospital-acquired condition is through a query if documentation does not support POA. "The query is instrumental in this," she emphasizes. "If the physician didn't document everything accurately, coders can't code accurately. Hospitals are losing millions of dollars a year to this issue."

Another issue, according to Dominesey, rests with physician response to queries, which has been historically low at Children's National Medical Center. "We can't track it because we are using e-mail," he explains.

To improve the outlook, the organization is deploying technology from Artifact Health that will enable real-time delivery of queries to a physician's mobile device. Once delivered, the device prompts the physician for response at various intervals and tracks data related to response rates.

According to MacClary, the device-based query application has moved response rates up to nearly 100% at some hospitals. "CDI specialists are the first line of defense against inaccurate information," she says. "That's exactly what they are trying to correct in the chart. Their mission is to make that chart as accurate as possible before the patient is discharged."

Buttner says that the coding of pressure ulcers, BMI, and obesity is only as good as the documentation. "If the provider is not documenting specificity of findings, it's difficult for anyone working in coding to assign the most appropriate code. It all drills down to documentation by the provider," she says.

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications, covering everything from corporate and managerial topics to health care and travel.