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Keep Pressure Ulcers On Your Payment Radar Screen

Published on Mon Mar 21, 2005

Prevent residents with 2 decubs from slipping from a higher RUG.

What you don't code can cost you - and every dollar counts when the interdisciplinary team is trying to heal a resident's pressure ulcers.

Capturing pressure ulcers (number, location and staging) is important not only for care planning and RAI compliance, but RUGs placement, comments Leah Klusch, RN, BSN, MA, executive director of Alliance Training Center in Alliance, OH.

The bottom line: Ulcers of any stage at two or more sites (M1a,b,c,d) - or one stage 3 or 4 ulcer (M2a) - with two treatments will RUG patients into the Special Care category (given they have the requisite ADL scores). Yet some facilities miss coding that second pressure ulcer, so the resident may end up in a clinically complex RUG instead, notes Jan Zacny, RN, a consultant with BKD Southern Missouri in Springfield, MO.

"For example, the nurse doing the MDS may count two ulcers on the resident - one on the coccyx and the other on another area of the buttocks - as being in one area," Zacny says. "But the nursing documentation clearly shows the wound-care team is assessing and treating two separate areas of redness or broken skin, which would count as two ulcers of any stage."

The following MDS items count as wound treatments for purposes of qualifying for the Special Care category:

  •  M5a or b (pressure-relieving devices for chair or bed). If the facility were providing both of these, M5a and b would count as one treatment.

  •  M5c (turning/repositioning)

  •  M5d (nutrition or hydration intervention)

  •  M5e (ulcer care)

  •  M5g (application of dressings with or without topical medications other than to feet)

  •  M5h (application of ointments other than to feet)

    Capture and Track Ulcers, Rx and Healing

    To ensure accurate coding of the total number of ulcers, carefully assess, document and count all of a resident's pressure ulcers. Consider using a pressure ulcer tracking sheet - a strategy the MDS team finds successful at Green Acres Nursing & Rehabilitation Center in Gettysburg, PA. Lois Hottle, RN, wound care nurse for the facility, completes a weekly tracking sheet that lists who has pressure ulcers, their location and staging - and what the interdisciplinary team is doing to heal them. 

    "We do skin rounds every Tuesday where the interdisciplinary team discusses the wound and treatment," Hottle adds.

    Include Diagnosis Codes in  Section I3, on UB-92

    Include the specific ICD-9-CM code in Section I3 and on the UB-92 to show the location of the pressure ulcers, suggests Zacny. "That's especially important if the pressure ulcer care is the resident's primary reason for skilled care. But even if that's not the case, it's a good idea to include the codes on the MDS and claim."

    Coding tip: Code pressure ulcers using the fifth digit to specify their location (see "Coding Tips" in the next article).

    "Use more than one code if the resident has, for example, a sacral and a heel ulcer," instructs Ann Zeisset, RHIT, CCS-P, practice manager with the American Health Information Management Association. What if the resident has two ulcers on the buttocks? Code that only once in I3 or on the UB-92 - or if the resident has ulcers on each elbow, code that site only once, adds Zeisset.

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