Q: When reporting a pressure ulcer as a secondary diagnosis, is it necessary to list the site and stage, or is just the code for the stage sufficient?
A: When coding changes went into effect October 1, 2008 they required the reporting of the codes for both the site and stage of a pressure ulcer. The code for site can serve as either the principal or a pertinent diagnosis; the stage code can be only a pertinent diagnosis.
The Condition of Participation requires the plan of care to include all pertinent diagnoses. A pertinent diagnosis is “any condition actively addressed in the patient’s plan of care and also any comorbidity affecting the patient’s responsiveness to treatment and rehabilitative prognosis, even if the condition is not the focus of any home health treatment itself.” Since the diagnosis of a pressure ulcer is a relevant comorbidity, the plan of care and OASIS must report this condition. Reporting the site and the stage are necessary because they are pertinent diagnoses that help reflect the seriousness of the condition and impact the plan of care.
March 13th, 2010 at 10:38 pm
What happens if pt has multiple diagnoses and you run out of room and can only code site and not stage for one of 2 ulcers?