Documenting skin ulcers: The pressure is on

Physicians must carefully identify patients at high risk of developing pressure ulcers and then initiate and document prevention strategies.

CMS’ Value-Based Purchasing Initiative considers pressure ulcers to be reasonably preventable and has included them on its list of so-called “no pay” conditions. In other words, hospitals won't be paid for the cost of treating pressure ulcers if they occur during a hospital stay and aren't documented as present on admission. Of the 11 hospital-acquired conditions selected for nonpayment in 2009, pressure ulcers may be the most difficult to accurately code and report. In Medicare's MS-DRG payment methodology, only stage III and IV pressure ulcers (see Table) are considered major complications or comorbidities (MCCs) resulting in a significant increase in hospital reimbursement when a physician documents them as present on admission.

For example, in a patient with a principal diagnosis of aspiration pneumonia and a secondary diagnosis of a stage I, stage II, or unstaged pressure ulcer, the MS-DRG would be 179, complex pneumonia without complications or comorbidities (CCs) or MCCs, and reimbursement would be $7,015 (all reimbursements are based on a hospital-specific rate of $5,500). In a patient with a stage III to IV pressure ulcer documented as present on admission, the MS-DRG would be 177, complex pneumonia with MCC, and reimbursement would be $10,144.


A stage III or IV pressure ulcer that develops during the hospital stay or that is not documented by the physician as present on admission will result in a payment reduction unless another MCC is documented and coded. For example, the patient above with a stage III or IV pressure ulcer not present at admission would be classified as MS-DRG 179, complex pneumonia without CC/MCC, and reimbursement would be $7,015, the same as if the pressure ulcer were less severe.

Pressure ulcers noted by wound care nurses or physical therapists and in nursing assessments are not reportable as MCCs, nor does such documentation establish that they were present on admission. Reportable diagnoses are limited to those conditions documented by the provider responsible for establishing the patient's diagnosis. However, when the physician has documented the presence of a pressure ulcer and its location, the stage of the ulcer is reportable based on nurse or physical therapist documentation (ICD-9-CM Official Guidelines for Coding and Reporting, effective Oct. 1, 2008). The ICD-9-CM code representing the stage of the ulcer determines whether the condition is an MCC.

While stage I or II pressure ulcers are not considered CCs or MCCs and don't impact MS-DRG reimbursement, they do affect the patient's risk of complication or death and should be documented by the physician and assigned ICD-9-CM codes by the hospital coder. If a patient is diagnosed with a stage I or II pressure ulcer on admission that progresses to stage III or IV during the hospital stay, the coder will report the highest stage and note that the ulcer was present on admission because the stage I, II, or unstageable ulcer was diagnosed then. Documentation should clearly indicate whether the pressure ulcer (at any stage) was present on admission or developed later.

In addition to specific documentation, hospitals and physicians must carefully identify patients at high risk of developing pressure ulcers and then initiate and document prevention strategies. The Braden Score may be used to identify risk. The IPPS FY08 rules recognized prevention guidelines for pressure ulcers as published by the National Pressure Ulcer Advisory Panel and the Agency for Health Care Policy and Research.

Document cause and related factors

Physician documentation of the specific cause of a skin ulcer is important to accurate coding. Coders may not assume cause-and-effect relationships between a disease process and a skin ulceration. When “ulcer” is documented in diabetic patients without further specification, for example, the coder will need to query the physician to clarify whether it is a diabetic ulcer or a pressure ulcer. Be sure to make the connections necessary for accurate reporting. For diabetic ulcers, for example, document any related diabetic manifestation if applicable

  • due to diabetic peripheral neuropathy;
  • due to diabetic peripheral vascular disease; or
  • due to combined diabetic peripheral vascular disease and atherosclerosis.

Also document other factors related to the skin ulcer. Is there more than one ulcer? Does the patient have cellulitis? Is the ulcer acutely infected with systemic inflammatory response syndrome (SIRS with sepsis due to infected wound)? These additional conditions will establish a higher severity of illness that will help guide treatment and will also increase the MS-DRG reimbursement.

Document associated procedures

Associated procedures such as debridement are eligible for increased reimbursement. Excisional debridement involves removal of devitalized tissue with a scalpel (as opposed to brushing or washing) and may be performed by a physician, physician's assistant, nurse or therapist in any location. The use of a sharp instrument doesn't always indicate that an excisional debridement was performed according to coding guidelines. Documentation of the depth of the debridement is necessary when it extends beyond skin or subcutaneous tissue (bone, muscle).

When multiple layers are debrided (i.e., skin and subcutaneous tissue, muscle, bone), only the deepest layer of debridement is reported. If that tissue is not specifically identified in ICD-9-CM, the procedure is reported as an excision of lesion of that site (i.e., excision of lesion of soft tissue).

The excisional procedure (although not performed in the OR) will change the MS-DRG assignment, significantly increasing reimbursement. Document the details of the procedure carefully; this procedure code is a target of Recovery Audit Contractors who recoup improper payments made for excisional debridement when the documentation does not describe the excisional nature of the procedure. “Sharp” debridement is not a substitute for excisional debridement.

Consider a patient with a principal diagnosis of aspiration pneumonia and a secondary diagnosis of a stage III to IV pressure ulcer present on admission. If excisional debridement is performed (ICD-9-CM code 86.22), the procedure is classified as MS-DRG 166, procedures for a patient admitted with a respiratory system principal diagnosis with MCC. Reimbursement would be $17,972, based on a hospital-specific rate of $5,500, compared with $10,144 if the debridement was nonexcisional (brushing, washing or snipping of devitalized tissue).