MDS Alert

Question: One of our residents was admitted with a cast. When the cast was removed, staff discovered a pressure ulcer beneath the dressing. No one at our facility knew about the pressure ulcer until the cast was removed. How do I code this?

Codify Subscriber

Answer: You will probably need to code as “not present on admission.” The Resident Assessment Instrument (RAI) Manual says, on page M-8: “Known pressure ulcers/injuries covered by a non-removable dressing/device (e.g., primary surgical dressing, cast) should be coded as unstageable. ‘Known’ refers to when documentation is available that says a pressure ulcer/injury exists under the non-removable dressing/device.”

“If there was no documentation seen to report that there was a known pressure ulcer under the cast, the pressure ulcer would need to be coded as ‘not present on admission’ since the first time that the pressure ulcer was seen was in the nursing facility later than admission,” says Carol Maher, RN-BC, RAC-CT, CPC, RAC-MT, director of education at Hansen Hunter & Co. P.C.  in Vancouver, Washington.

However, the Manual also says: “For each pressure ulcer/injury, determine if the pressure ulcer/injury was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement.”

If the pressure ulcer was noted in the clinical record, you may have some other options.

The RAI Manual says, on page M-8:

• “If the pressure ulcer/injury was present on admission/entry or reentry and subsequently increased in numerical stage during the resident’s stay, the pressure ulcer is coded at that higher stage, and that higher stage should not be considered as ‘present on admission.’
• “If the pressure ulcer/injury was present on admission/entry or reentry and becomes unstageable due to slough or eschar, during the resident’s stay, the pressure ulcer/injury is coded at M0300F and should not be coded as ‘present on admission.’
• “If the pressure ulcer/injury was unstageable on admission/entry or reentry, then becomes numerically stageable later, it should be considered as “present on admission” at the stage at which it first becomes numerically stageable. If it subsequently increases in numerical stage, that higher stage should not be coded as “present on admission.”

But your facility must also recognize the legal authority of any authorized executor or administrator. “A covered entity must treat a deceased individual’s legally authorized executor or administrator, or a person who is otherwise legally authorized to act on the behalf of the deceased individual or his estate, as a personal representative with respect to protected health information relevant to such representation,” the OCR says.