General Guidance on PU/PI Staging

• The NPUAP classification is intended for documentation of ulcers resulting from pressure and/or shear, and not ulcers with other etiologies. [2][4]
• Verify that there is clinical agreement in PU/PI classification amongst health professionals responsible for classifying PU/PI.[4] 
• Differentiate between blanchable (normal reactive hyperemia) and non-blanchable (Stage 1 PU/PI). Blanchable erythema is seen when a skin area that is reddened turns pale as a result of applying pressure with a finger or plastic disc and preventing blood flow to the region. As the pressure is released, skin turns red again.[4]( Figure 1). It is important to note that blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes and represent an opportunity to implement offloading and pressure redistribution strategies before further skin damage occurs.

• To stage each PU/PI, consider the deepest anatomical point that is visible or palpable when staging. [3] If a PU/PI's tissues are obscured such that the depth of soft tissue damage cannot be observed, it is considered to be unstageable [3] Stage of a PU/PI can only be determined when enough slough and/or eschar is removed to expose the anatomic depth of soft tissue damage involved. [5] (Figures 2 and 3)

• Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heels serves as “the body’s natural (biological) cover” and should only be removed after careful clinical consideration, including ruling out ischemia.[5]  (Figure 4)

• Do not reverse or back stage, that is, change a PU/PI stage as it heals.[3][6] Clinical standards do not support reverse staging or backstaging as a way to document healing, as it does not accurately characterize what is occurring physiologically as the ulcer heals. PUs/PIs do not heal in a reverse sequence, that is, the body does not replace the types and layers of tissue (e.g., muscle, fat, and dermis) that were lost during PU/PI development before they re-epithelialize. Stage 3 and 4 PUs/PIs fill with granulation tissue. This replacement tissue is never as strong as the tissue that was lost and hence is more prone to future breakdown. A Stage 4 ulcer will always be a Stage 4, even after it heals (i.e, healed/closed Stage 4 PU/PI).[3][6]
• To document signs of improvement, clinicians can describe characteristics of the wound (i.e., depth, width, presence or absence of granulation  tissue, etc.) or use a validated pressure ulcer healing tool, such as the PUSH tool. [3][6]
• When examining PU/PI in individuals with darkly pigmented skin, rely on assessment of skin temperature, change in tissue consistency and pain rather than identification of non-blanchable erythema in Stage 1, inflammatory redness from cellulitis or discoloration from deep tissue injury. [4] 
• Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage.[3]
• It is suggested that medical device-related PU/PI due to pressure of nasogastric/nasoenteric tubes on the skin of the nasal vestibule and exterior nose be  staged as a PU/PI (stage 1-4, unstageable or deep tissue injury) and not as mucosal membrane pressure injuries. The nasal vestibule is lined by skin with hair follicles, sebaceous glands and sweat glands, and terminates at the limen nasi posteriorly. [7]  
  

Coding Guidance for "Present on Admission" PU/PI in Acute Care Setting

According to Coding Clinic and Medicare report on coding for hospital acquired conditions [8][9], if a lower stage PU/PI was recognized on admission and progressed to a higher stage ulcer during the hospital stay, the ulcer would be coded at the higher stage and would be confirmed as "present on admission". That is, if for instance a Stage 1 PU/PI is diagnosed and documented upon admission but progresses to PU/PI Stage 3 during hospital stay, this PU/PI would be coded as a Stage 3 that was "present on admission" [NOTE: a lower stage PU/PI such a Stage 1 PU/PI needs to be recognized and documented as such at the time of admission].

• It may appear inconsistent to report a Stage 3 PU/PI as "present on admission" (POA) since the PU/PI gradually deteriorated during the hospital stay. However, because the lower stage ulcer was recognized and documented upon admission, the indicator "present on admission" (POA) should be used by coders. In terms of coding and POA reporting, a pressure ulcer is only coded and reported once, at its highest stage.[9]
• In 2008, CMS introduced a claim-level payment penalty that denied increased reimbursement for discharge records that contained a documented hospital-acquired condition (HAC). [10][11] PU/PIs Stages 3 and 4 are one of the 14 HACs subject to payment penalty. However, this list of reportable events excludes a PU/PI of lower stage that progressed to Stage 3 or 4, if the lower stage was recognized upon admission.[9]
• Under the 2008 CMS HAC payment provision, hospitals are required to report a corresponding POA indicator for each PU/PI diagnosis. Possible values for the POA indicator include among others [10][12]:
• "Y", indicating that the diagnosis was present at the time of admission
• "N", indicating that the diagnosis was not POA (i.e., and thus considered a HAC).
• Current coding guidelines for the POA indicator allow HACs to be coded as POA for conditions diagnosed during the admission that were clearly present but not diagnosed until after admission occurred.[12] See other POA Criteria in Appendix I of the CDC ICD-10-CM Official Guidelines for Coding and Reporting FY 2019.[12]
• Despite these coding guidelines issued by CMS, CDC, Coding Clinic, reports [8][9][12] show that there are variances in interpretation among acute care facilities, so clinicians might want to confirm local practice with their specific coding/billing department. 

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