Awareness : OBC Tips

How To Properly Document and Code Pressure Ulcers

Patients admitted with pressure ulcers documented as healing Pressure ulcers described as healing should be assigned the appropriate pressure ulcer stage code based on the documentation in the medical record.

If the documentation does not provide information about the stage of the healing pressure ulcer, assign the appropriate code for unspecified stage. If the documentation is unclear as to whether the patient has a current (new) pressure ulcer or if the patient is being treated for a healing pressure ulcer, query the provider. For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.