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Relieving the Pressure of Coding Reopened Pressure Ulcers

In the updated Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, v1.18.11, the Centers for Medicare & Medicaid Services (CMS) added several clarifications to help ease the pressure that nurse assessment coordinators (NACs) experience attempting to code section M accurately. Although strong clinical documentation of these wounds is still required for accurate coding, CMS has answered common challenging questions about particularly complex situations regarding how to code reopened pressure ulcers.

  1. How do I code a pressure ulcer that was healed and then reopens in the same location?

The RAI User’s Manual clarifies that the terms “healed” versus “unhealed” pressure ulcers refer to whether the ulcer is “closed” or “open.”

Healed = Closed
Unhealed = Open  

RAI Definition of Healed Pressure Ulcer:
Completely closed, fully epithelialized, covered completely with epithelial tissue, or resurfaced with new skin, even if the area continues to have some surface discoloration (p. M-2).  

However, CMS further specifies that some pressure ulcers, such as a deep tissue injury, an intact Stage 2 blister, or an unstageable ulcer completely covered with slough or eschar, may be “closed” but would not be considered healed. These types of pressure ulcers/injuries have intact skin and therefore are considered closed, but they do not meet the full definition of healed, which means “fully epithelialized.”

But we must remember that once a pressure ulcer has healed, the area is at a much higher risk of reopening due to damage to the tissue and the loss of tensile strength of the overlying tissue. CMS notes that the “tensile strength of the skin overlying a closed pressure ulcer is 80% of normal skin tensile strength” (p. M-2).

CMS does not specify the amount of time between closing and reopening but offers this clarification to the steps for determining the deepest anatomical stage: “A previously closed pressure ulcer that opens again should be reported at its worst stage, unless currently presenting at a higher stage or unstageable” (p. M-8). Thus, facility staff may need to improve pressure ulcer documentation and monitoring to ensure it clearly and accurately supports the anatomical location and prior highest stage. If a nurse is not familiar with the resident’s skin history, the result could be an inaccurate staging of a pressure ulcer and a correspondingly erroneous Minimum Data Set (MDS) assessment. Consider the following scenarios.

Mrs. Bruno had a Stage 4 pressure ulcer to her left trochanter that healed six months ago. A nurse new to the facility completed a weekly skin assessment on Mrs. Bruno and identified a shallow open ulcer to the left trochanter.  

Inaccurate documentation and MDS coding:
In a facility with poor wound documentation and monitoring, the nurse would be unaware of Mrs. Bruno’s skin history. The pressure ulcer would be assessed and documented as Stage 2. But based on the medical record documentation, Mrs. Bruno was coded on the MDS with a Stage 2 pressure ulcer, not present on admission.  

Accurate documentation and MDS coding:
In a facility with effective monitoring and communication about previous pressure ulcer sites and stages, the nurse would be aware of the high risk of pressure ulcer development to the left trochanter and the history of a Stage 4 pressure ulcer at the location. The nurse would stage the reopened pressure ulcer to the left trochanter as a Stage 4, based on current and historical levels of tissue involvement. The MDS would reflect this stage.
  • If a pressure ulcer reopens, how do I determine if it was present on admission?

To evaluate whether a reopened pressure ulcer was present on admission or not remains a complex decision. However, CMS adds this clarification: “If a resident has a pressure ulcer/injury that was documented on admission then closed that reopens at the same stage (i.e., not a higher stage), the ulcer/injury is coded as “present on admission” (p. M-9).

Note that this coding tip specifically addresses a pressure ulcer originally “present on admission” and then healed in the facility. If this area reopens, that pressure ulcer can only be considered as “present on admission” if it is not at a higher anatomical stage. Consider these two scenarios:

Mr. Andrews admitted with a Stage 3 pressure ulcer to his coccyx. The facility healed the wound five months later. After another eight months, Mr. Andrews condition declined, and the facility noted a Stage 3 pressure ulcer to the coccyx.  

Because this pressure ulcer was originally “present on admission” and reopened to the same stage (not a higher stage), this wound is still considered to be present on admission.
Mr. Andrews admitted with a Stage 3 pressure ulcer to his coccyx. The facility healed the wound five months later. After another eight months, Mr. Andrews condition declined, and the facility noted a Stage 4 pressure ulcer to the coccyx.  

This pressure ulcer was originally “present on admission” as a Stage 3 and reopened to a higher stage, a Stage 4; therefore, this wound cannot be considered present on admission.

These tips may help NACs make key coding decisions regarding reopened pressure ulcers, but the most critical part of coding pressure ulcers accurately is precise clinical documentation. NACs may need to work with clinical leaders to establish a process for wound documentation that supports MDS coding more accurately and tracks the history of skin problems for a resident. These clinical processes will lead to improved accuracy of assessments and quality reporting.

For more helpful tips on how to determine the conclusion “present on admission” for pressure ulcers, see AAPACN’s Pressure Ulcer Coding Algorithm.

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