Definition

Pressure ulcers are localized damage to the skin and/or soft tissue caused by prolonged pressure, often associated with immobility and/or lack of sensation. Contributing factors can include moisture and nutritional deficiencies.

Diagnostics

Stages and Definitions (NPIAP; www.npiap.com):

• Stage 2: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may present as an intact or ruptured serum-filled blister.
• Stage 3: Full-thickness skin loss. Adipose tissue is visible in the ulcer, with granulation tissue and epibole (rolled wound edges) often present. Slough and/or eschar may be visible.
• Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. Slough and/or eschar may be present.
• Unstageable: Obscured full-thickness skin and tissue loss where the extent of tissue damage cannot be confirmed due to slough or eschar. Removal may reveal a Stage 3 or Stage 4 injury.

Treatment

• Wound care/dressings, debridement, wound care referral, hyperbaric oxygen therapy
• Pain management, antibiotics, topical treatments
• Advanced stage treatment may include necrotic tissue excision, wet-to-dry saline or hypochlorite solution dressings, topical antibiotics, or specialized gels

Background

The term "pressure ulcer" is outdated. The National Pressure Ulcer Advisory Panel (NPIAP), founded in 1987, changed its terminology to "pressure injury" in 2016 and updated its name in 2019. A pressure injury is now defined as localized skin and soft tissue damage typically found over a bony prominence or caused by medical devices.

Statistics on pressure injuries are limited. The 1999 Fifth National Pressure Prevalence Survey reported a 14.8% prevalence in acute care hospitals, with 7.1% occurring during hospital stays.

Increased Risk Factors: Neurologic disease, cardiovascular disease, prolonged anesthesia, dehydration, malnutrition, hypotension, and surgery.

ICD-10 Codes and HCC Mapping:

• HCC 379: Community, Non-Dual, Aged - 1.965
• HCC 381: Community, Non-Dual, Aged - 1.075
• HCC 382: Community, Non-Dual, Aged - 0.838

Coding and CDI Tips

• Document the pressure ulcer's location and its stage
• Note treatment and any complications related to the ulcer
• Indicate if there was a referral to wound care
• Clarify that pressure injuries are coded as pressure ulcers
• Differentiate pressure ulcers from moisture-associated skin damage (MASD)
• Specify ulcer stage, including unstageable ulcers, to ensure accurate HCC assignment
• For ulcers described as "healing," assign the code for the current stage. If "healed," no code is necessary
• Distinguish between pressure and chronic non-pressure ulcers, which map to different HCCs (380, 383)

Query Example

Visit note from [date] indicates the presence of a pressure ulcer on the right heel. The stage is not documented. Exam on [date] describes full-thickness ulceration into subcutaneous soft tissue.

Please specify the stage of the pressure ulcer:

• Stage 2
• Other stage (please specify)

References

• Centers for Medicare and Medicaid. (2023). Announcement of Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. CMS
• Edsberg, L. E., et al. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System. J Wound Ostomy Continence Nurs, 43(6), 585-597. doi:10.1097/won.0000000000000281
• Tang, C., Pinson, R. (2024). CDI Pocket Guide by Pinson and Tang. CDI Plus
• Zaidi SRH, Sharma S. (2024). Pressure Ulcer. In StatPearls [Internet]. NCBI