Q:
We have a resident with a chronic stage IV pressure ulcer who recently had flap surgery to close the wound. Do I continue to code the stage IV on the MDS?
A:
According to the RAI (pg. M-6), if a pressure ulcer is surgically closed with a flap or graft, it should be coded as a surgical wound and not as a pressure ulcer. If the flap or graft fails, continue to code it as a surgical wound until healed. Documentation elsewhere in the medical record should detail the care and services provided and support why MDS coding of skin conditions has changed from one assessment to the next.
Written by:
Yetta Christian RN, RAC-CT
MDS Consultant
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