Q: Does the physician have to document the stage of a decubitus ulcer or can it be a wound care nurse? Does that person have to document stage 1 or can he or she describe the wound?
A: A wound care nurse can document the stage of the ulcer and the physician has to document the site and the type.
If the wound care nurse does not document the stage, but rather describes the stage, and that description is similar to the inclusion term in the tabular part of the ICD-9-CM Manual, then you can report that stage without the wound care nurse actually saying the stage.
Also, this is a present-on-admission (POA) issue. If the ulcer is not POA, then it does not act as an MCC. Remember that you would assign Y as the POA indicator and would code to the highest level of evolution of a decubitus ulcer if it’s POA. So if the patient comes in with a stage I and he or she evolves to a stage III, you’d code stage III and you’d code it with a Y indicator for the POA.
Editor’s note: William E. Haik, MD, FCCP, CDIP, director of DRG Review, Inc., in Fort Walton Beach, Fla., answered this question.
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.
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