1. IRF-PAI Pressure Ulcer Items

2. IRF-PAI ItemsPressure Ulcers2 Presentation Overview Introduction to Pressure Ulcers covered basic concepts associated with pressure ulcers and other skin conditions. This presentation focuses on assessment guidelines and coding of Pressure Ulcer items in IRF-PAI.

3. IRF-PAI ItemsPressure Ulcers3 Objectives Identify pressure ulcer items that are documented in the IRF-PAI. Describe guidelines for assessing and coding each item. Code the IRF-PAI pressure ulcer items correctly and accurately.

4. IRF-PAI ItemsPressure Ulcers4 Overview of Pressure Ulcer Items IRF-PAI Pressure Ulcer Items: Item 48. Current Number of Unhealed Pressure Ulcers at Each Stage Item 49. Worsening in Pressure Ulcer Status Item 50. Healed Pressure Ulcers

5. IRF-PAI ItemsPressure Ulcers5 Importance of Clinical Assessment A complete and ongoing skin assessment guided by clinical standards is essential. This assessment, which identifies and evaluates all areas at risk for constant pressure and determines the etiology of all skin ulcers and skin conditions/problems, should direct the appropriate skin management interventions. Completion of Pressure Ulcer items in the IRF-PAI does not replace this assessment.

6. Item 48 Current Number of Unhealed Pressure Ulcers at Each Stage

7. IRF-PAI ItemsPressure Ulcers7 Item 48 Current Number of Unhealed Pressure Ulcers at Each Stage Documents current number of unhealed pressure ulcers at Stages 2, 3 and 4.

8. IRF-PAI ItemsPressure Ulcers8 Staging Definitions CMS has adapted the 2007 NPUAP definitions for categories of staging. Resource: www.npuap.org Free diagrams of ulcer stages can be downloaded for educational use. Reproduced with permission

9. IRF-PAI ItemsPressure Ulcers9 General Assessment and Coding Guidelines Determine current number of unhealed ulcers. Perform head-to-toe assessment of patient. Use visual inspection and palpation to identify appropriate stage. Code only wounds that are the result of pressure. Determine deepest anatomical stage of each ulcer. Do not reverse stage.

10. IRF-PAI ItemsPressure Ulcers10 General Assessment and Coding Guidelines, Cont. Determine if the pressure ulcer was present on admission and discharge. Review for location and stage at time of admission and discharge. Observation period for pressure ulcer items is 3 days. Do not report unstageable pressure ulcers on the IRF-PAI.

11. Item 48A Current Number of Stage 2 Pressure Ulcers

12. IRF-PAI ItemsPressure Ulcers12 Item 48A Number of Stage 2 Pressure Ulcers Documents number of Stage 2 pressure ulcers present at admission and discharge.

13. IRF-PAI ItemsPressure Ulcers13 Stage 2 Pressure Ulcers Partial thickness loss of dermis presenting as: Shiny or dry shallow open ulcer Red or pink wound bed Without slough or bruising

14. IRF-PAI ItemsPressure Ulcers14 Stage 2 Pressure Ulcers, Cont. May also present as an intact or open/ ruptured blister

15. IRF-PAI ItemsPressure Ulcers15 48A Coding Guidelines Differentiate Stage 2 pressure ulcer from a suspected deep tissue injury. Code only Stage 2 pressure ulcers in 48A. Do not code skin tears, tape burns, Moisture- associated Skin Damage or excoriation in 48A.

16. IRF-PAI ItemsPressure Ulcers16 48A Coding Instructions: Admission Field Enter number of Stage 2 pressure ulcers present on admission. If none, enter 0.

17. IRF-PAI ItemsPressure Ulcers17 48A Coding Instructions Discharge Field Enter number of Stage 2 pressure ulcers present at discharge. If none, enter 0.

18. Items 48B and C Number of Stage 3 and 4 Pressure Ulcers

19. IRF-PAI ItemsPressure Ulcers19 Items 48B and 48C Number of Stage 3 or 4 Pressure Ulcers Document the number of Stage 3 or 4 pressure ulcers present at admission and discharge.

20. IRF-PAI ItemsPressure Ulcers20 Stage 3 Pressure Ulcer Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Depth varies by anatomical location.

21. IRF-PAI ItemsPressure Ulcers21 Stage 4 Pressure Ulcer Full thickness tissue loss with exposed bone, tendonor muscle Slough or eschar may be present on some parts of wound bed. Often includes undermining and tunneling Depth varies by anatomical location.

22. IRF-PAI ItemsPressure Ulcers22 48B and 48C Coding Instructions Admission Field Enter number of Stage 3 and 4 pressure ulcers present on admission. If none, enter 0.

23. IRF-PAI ItemsPressure Ulcers23 48B and 48C Coding Instructions Discharge Field Enter number of Stage 3 or 4 pressure ulcers present at discharge. If none, enter 0.

24. IRF-PAI ItemsPressure Ulcers24 Item 48 Scenario #1 At admission, one pressure ulcer was noted and documented in the patient’s medical record. It was noted to be a full thickness ulcer with no exposure of bone, tendon or muscle. No other pressure ulcers were documented. How should Item 48 be coded?

25. IRF-PAI ItemsPressure Ulcers25 Scenario #1 Correct Coding In Item 48B, Stage 3, enter 1 in the Admission field. In Items 48A and C, enter 0 in the Admission field. 1 0 0

26. IRF-PAI ItemsPressure Ulcers26 Item 48 Scenario #2 At discharge, a patient has one pressure ulcer that is documented in the medical record. The pressure ulcer is covered with hard black necrotic tissue. How should Item 48 be coded?

27. IRF-PAI ItemsPressure Ulcers27 Scenario #2 Correct Coding This pressure ulcer is unstageable. It should not be included on the IRF-PAI. 00 00 00

28. Item 49 Worsening in Pressure Ulcer Status Since Admission

29. IRF-PAI ItemsPressure Ulcers29 Item 49 Worsening Pressure Ulcer Status Since Admission Documents the number of current pressure ulcers at discharge that that have worsened since admission.

30. IRF-PAI ItemsPressure Ulcers30 Item 49 Worsening Pressure Ulcer Status This includes pressure ulcers at discharge that: oWere not present at admission OR oWere at a lesser numerical stage at admission

31. IRF-PAI ItemsPressure Ulcers31 Item 49 Coding Guidelines It will be easier to assess worsening status and to code these items if a facility documents and tracks pressure ulcer status on a routine basis.

32. IRF-PAI ItemsPressure Ulcers32 Item 49 Coding Guidelines 2 Coding a pressure ulcer that was unstageable at admission: Do not consider it to be worse at discharge. If it becomes stageable, consider it as present on admission. Code at the stage when it first became stageable. If it worsens after it becomes stageable, it should be coded as worsening.

33. IRF-PAI ItemsPressure Ulcers33 Item 49 Coding Example #1 A patient is admitted with a pressure ulcer that is covered in necrotic tissue and cannot be staged. During the stay, the pressure ulcer is revealed to be a Stage 4 pressure ulcer. Should this Stage 4 pressure ulcer be coded in Item 49 as a “new or worsening” pressure ulcer?

34. IRF-PAI ItemsPressure Ulcers34 Item 49 Coding Guidelines 3 Coding a stageable pressure ulcer that becomes unstageable since admission: If it becomes Unstageable due to Slough or Eschar, do not code as worsened. If it becomes unstageable and then is debrided so it can be staged, compare its stage before and after it was unstageable. If the stage has worsened, code it as worsening.

35. IRF-PAI ItemsPressure Ulcers35 Item 49 Coding Example #2 A patient is admitted with a Stage 3 pressure ulcer. During the stay slough covers much of it. Then the ulcer is debrided and found to be a Stage 4 pressure ulcer. Should this Stage 4 pressure ulcer be coded in Item 49 as a “new or worsening” pressure ulcer?

36. IRF-PAI ItemsPressure Ulcers36 49A Stage 2 Coding Instructions Indicate the number of current Stage 2 pressure ulcers at discharge that were not present or were at a lesser stage on admission. Enter 0 if no Stage 2 ulcers are present, are new or have worsened.

37. IRF-PAI ItemsPressure Ulcers37 49B Stage 3 Coding Instructions Indicate the number of current Stage 3 pressure ulcers at discharge that were not present or were at a lesser stage on admission. Enter 0 if no Stage 3 pressure ulcers are present, are new, or have worsened.

38. IRF-PAI ItemsPressure Ulcers38 49C Stage 4 Coding Instructions Indicate the number of current Stage 4 pressure ulcers at discharge that were not present or were at a lesser stage on admission. Enter 0 if no Stage 4 pressure ulcers are present, are new, or have worsened.

39. IRF-PAI ItemsPressure Ulcers39 Item 49 Scenario A patient’s admission assessment documented a Stage 2 pressure ulcer on the right ischial tuberosity. At discharge, the pressure ulcer has deteriorated to a Stage 3 pressure ulcer. There were no other pressure ulcers at admission. How should Item 49 be coded?

40. IRF-PAI ItemsPressure Ulcers40 Scenario Correct Coding In Item 49B, Stage 3, enter 1. In Items 49A and 49C, enter 0. 1 0 0

41. Item 50 Healed Pressure Ulcers

42. IRF-PAI ItemsPressure Ulcers42 Item 50 Healed Pressure Ulcers Documents: oWhether any unhealed pressure ulcers were present on admission (Item 50A) oIf so, the number of Stage 2, 3, and 4 pressure ulcers that have completely closed since admission (Items 50B, C, and D)

43. IRF-PAI ItemsPressure Ulcers43 Item 50 Coding Guidelines A “healed pressure ulcer” is one that is: o Completely closed o Fully epithelialized o Covered completely with epithelial tissue or resurfaced with new skin, even if the area continues to have some surface discoloration Do not reverse stage.

44. IRF-PAI ItemsPressure Ulcers44 50A Coding Instructions Item 50A. Unhealed Pressure Ulcers Present on Admission? Code 0. No. Skip Items 50B-D. Code 1. Yes. Complete Items 50B-D.

45. IRF-PAI ItemsPressure Ulcers45 50B, 50C and 50D Coding Instructions Items 50B, C and D. Stage 2, 3 or 4 Pressure Ulcers on Admission That Have Healed Enter number of pressure ulcers at that stage at admission which have completely closed at discharge. If none, enter 0.

46. IRF-PAI ItemsPressure Ulcers46 Item 50 Scenario A patient is admitted with one Stage 2 pressure ulcer. By discharge, the ulcer is healed. How should Items 50B, C, and D be coded?

47. IRF-PAI ItemsPressure Ulcers47 Scenario Correct Coding Item 50B. Stage 2. Code 1 for the pressure ulcer that healed. Item 50C. Stage 3. Code 0 for none. Item 50D. Stage 4. Code 0 for none. 1 0 0