Pressure ulcers or bed sores occur due to increased and continuous pressure on the skin. They are a common condition affecting older hospitalized patients as they are prone to mobility problems and aging skin. These sores or “pressure injuries” as they are now called, can range from mild reddening of the skin to severe tissue damage and sometimes infection affecting muscle and bone.
Skin changes make dementia patients more vulnerable to pressure ulcers
The Jerusalem Post recently reported on a new study from Jerusalem’s Herzog Medical Center, which found significant links between two seemingly unrelated conditions — dementia and pressure ulcers. The researchers found that many patients with Alzheimer’s and other dementias – especially at an advanced stage – are more likely to develop pressure sores.
The hypothesis is that dementia causes abnormal changes in the brain, which can also affect other body systems. Dementia patients were more vulnerable to the development of pressure ulcers as they experienced changes in the skin tissue.
The findings of the study were based on a quantitative examination conducted at the Herzog geriatric-psychiatric hospital. The evaluation found that:
– 67% of geriatric patients with pressure ulcers had dementia
– Among those who did not have pressure ulcers, only 23% had dementia
The researchers concluded that conducting a skin test to diagnose and detect in the early stages could delay or halt the dementia. They said that the skin test can be a valuable tool for early detection and specific diagnosis of dementia since “not all dementia requires the same treatment and not every cognitive decline ends in dementia”. The risks of bed sores in mild dementia patients can therefore by minimized through more intensive preventive treatment protocols including frequent changes in the patient’s posture, special mattresses, and other strategies. The team says that understanding the link between dementia and skin ulcers will help in the development of appropriate treatments to slow down and stop the progression of dementia as pressure sores and cognitive impairments can be fatal.
Reporting pressure ulcers in 2017 – new documentation requirements
According to the Alzheimer’s Association, 5.5 million Americans of all ages are living with Alzheimer’s disease in 2017. An estimated 5.3 million are age 65 and older and approximately 200,000 individuals are under age 65 and have younger-onset Alzheimer’s. If the above-mentioned study is valid, most of older people with dementia face an increased risk of developing pressure ulcers. Emergency-medicine and critical-care physicians, hospitalists, geriatricians, neurologists, and general surgeons or plastic surgeons and the medical coding companies that serve these specialists need to be up-to-date on the coding requirements for pressure ulcers.
The 2017 ICD-10 Official Guidelines for Coding and Reporting brings new documentation requirements for pressure ulcer coding. Choosing the code to report pressure ulcers in ICD-10 — located in Category L89 — is based on the site of the ulcer, laterality (if applicable), and the stage of the ulcer. The concept of laterality (such as, left or right) should be included in the clinical documentation for skin ulcers.
In ICD 10 CM, pressure ulcers are categorized in stages of severity 1-4 and unstageable:
- Stage 1 pressure injury: Intact skin with a localized area of non-blanchable erythema, that is, Skin changes are limited to persistent focal edema.
- Stage 2 pressure injury: Partial-thickness skin loss with exposed dermis: The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister.
- Stage 3 pressure injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present.
- Stage 4 pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.
- Unstageable pressure injury: Obscured full-thickness skin and tissue loss, that is, the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed.
- Deep tissue pressure injury (DTPI): Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister.
Points to note:
- The new staging system identifies the stages of pressure ulcers as 1 through 4 as well as an unstageable ulcer.
- The system introduces new terms in an attempt to more accurately describe the stages and descriptions of such injuries.
- To report pressure ulcers, assign as many codes from L89.–0 as needed to identify all pressure ulcers. Assignment of the code for unstageable pressure ulcer (L89.–0) should be based on the clinical documentation. The ICD-10-CM Official Guidelines for Coding and Reporting FY 2017 specifies that if a patient presents with a pressure ulcer at one stage and during the admission it progresses to a higher stage, two separate codes have to be reported — one for the site and stage of the ulcer on admission and another for the same ulcer and the highest stage reported during the admission. The previous guideline was to only assign the code for the highest stage reported for that site.
- If a patient presents with a pressure ulcer on admission but the ulcer heals by the time of discharge, this should be reported by assigning the code for the site and stage of the pressure ulcer on admission.
- When there is no documentation regarding the stage of the pressure ulcer, the appropriate code should be assigned for unspecified stage (L89.–9).
- No code is assigned if the documentation states that the pressure ulcer is completely healed.
- The term “pressure ulcer” has been replaced with “pressure injury,” since stage 1 and deep tissue injuries describe intact skin, not open ulcers.
- An instructional note in ICD-10 instructs coding also any associated gangrene (I96).
Pressure ulcers can impact length of hospital stay, and require additional monitoring and nursing care, which impacts reimbursement for providers. As a result, auditors scrutinize the claims and documentation for these conditions. AAPC certified coders in reliable medical coding companies have a good understanding of pressure ulcers and the ICD-10-CM guidelines for coding and reporting these conditions. Physicians can overcome uncertainties related to ulcer codes by partnering with an experienced medical billing and coding company. This will allow them to focus on their patients, particularly older ambulatory patients with dementia, who are more likely to develop pressure ulcers.