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Placing priority on pressure ulcers

From the August ACP Hospitalist, copyright © 2011 by the American College of Physicians

By Richard D. Pinson, FACP

Sidebars: Pressure ulcer stages Ask Dr. Pinson

For many years, proper attention was not devoted to prevention, recognition and treatment of pressure (decubitus) ulcers, which greatly increase the risks of morbidity and mortality in hospitalized patients. However, the current emphasis on public reporting of quality scores, as well as pay-for-performance and consumer awareness, has made accurate documentation and effective management of pressure ulcers a crucial health care consideration.

Medicare now provides a substantial revenue inducement to hospitals for identifying and treating stage 3 and 4 pressure ulcers. There are also penalties for failing to do so, or allowing them to develop during hospitalization. In addition, the rate of hospital-acquired pressure ulcers is publicly reported for all hospitals as a quality indicator on the Centers for Medicare and Medicaid Services website.

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Photo by Comstock.

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Screening for and early documentation of pressure ulcers are essential. Every patient should be screened for pressure ulcers at the time of admission; when found, they must be documented, correctly staged (see sidebar) and treated. Included in the exam should be the patient's back, pre-sacral/gluteal areas and heels. If not identified upon admission, pressure ulcers are likely to be considered hospital-acquired and an indicator of inadequate care.

Pressure ulcers are classified by stage and location. They should be distinguished from other forms of cutaneous ulceration such as diabetic, ischemic, stasis (venous), varicose, malignant, traumatic, atrophic, infectious (as cause), and burns. They typically occur at pressure/contact-point locations: elbows, low back, sacrum/coccyx, buttocks, and heels.

If a patient is turned to one side for prolonged periods, decubiti may be found over the ischial tuberosities (lateral hip), ankles or even shoulders. Sheer forces and friction also contribute to decubitus formation. Risk factors include debilitation, inability to reposition oneself, malnutrition, bed or chair confinement, sensory deficits, fecal/urinary incontinence, and inability to feed oneself.

Once the protective dermal layer is lost, necrosis may easily and rapidly extend to subcutaneous tissue, muscle and bone. Ulcers beyond stage 1 almost invariably become colonized with bacteria (usually Staphylococcus, Streptococcus, and gram negatives); can easily become infected and produce cellulitis, gangrene or abscess; and often progress to systemic infection with sepsis.

In summary, check patients carefully for pressure ulcers at the first encounter and document accurately, including location and stage. Provide appropriate treatment and use preventive measures for all patients at risk.

Richard Pinson, FACP, is a certified coding specialist and co-founder of HCQ Consulting in Houston.

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Pressure ulcer stages

The stages of pressure ulcers are classified as follows:

• Stage 1: Non-blanching erythema of the skin
• Stage 2: Partial-thickness ulceration and loss of epidermis
• Stage 3: Full-thickness ulceration into subcutaneous fat but not through deep fascia
• Stage 4: Deep ulceration to muscle, tendons, joint and/or bone (often with osteomyelitis); extensive tissue necrosis/destruction

Only pressure ulcers are “staged”; other types of cutaneous ulceration are not. When covered by eschar they are considered “unstageable,” but should be debrided for proper evaluation and management.

Deep tissue necrosis (DTN) involves necrosis of subcutaneous fat and/or deep fascia and muscle while the skin remains intact—i.e., not yet “ulcerated.” With DTN the subcutaneous tissue feels “mushy” or “spongy,” and necrosis of the skin is inevitable. This condition requires extensive deep excisional debridement of all necrotic tissue.

For correct coding, a physician must identify the presence and location of pressure ulcers, and should be able to classify the correct stage. In a rare exception to Medicare rules, the coding of stage may be based on nursing documentation.

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Ask Dr. Pinson

Q: A patient is in shock and needs an arterial line. Attempt one in the right radial artery fails. Attempt two in the left radial artery fails. Attempt three in the right femoral artery is successful. Which procedures are billable in this scenario?

A: You can bill only for the right femoral artery line insertion. If extensive additional work was required related to all three attempts, you may add modifier -22, Unusual Procedural Services, but this typically does not increase reimbursement. Remember also that A-line insertion is a separately billable service during critical care, but do not count the time required for A-line insertion in the total time for critical care.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated