Q:
The resident admitted with an unstageable pressure injury to the right heel. Now the pressure injury is stage 3. I coded stage 3 at M0300. Would the pressure injury be coded as present on admission?
A:
If a pressure ulcer or injury is documented as unstageable upon admission, entry, or reentry and later becomes numerically stageable, it should be classified as “present on admission” at the stage at which it first becomes numerically stageable. However, if the ulcer or injury progresses to a higher numerical stage after that point, the higher stage should not be coded as “present on admission.” This approach ensures accurate documentation and compliance with coding guidelines while reflecting the true progression of the condition.
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Written by:
Brandy Hayes, RN, RAC-CT, RAC-CTA
Clinical Consultant
Proactive LTC Consulting
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