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Reader Questions:

A Physician Doesn’t Have to Diagnose a Pressure Injury in This Situation

Published on Mon Aug 08, 2022 Print Friendly and PDF PDF

Question: So much of what I’ve read about ICD-10 coding suggests that everything is dependent on a physician’s diagnosis. But I thought that the presence of pressure injuries was determined by nurses?

Michigan Subscriber

Answer: Choosing a correct ICD-10 diagnosis code is dependent upon a physician’s diagnosis. But for assessments, like in planning care or recording a resident’s condition for the MDS, direct care staff and nurses should be consulted, according to guidance in the RAI Manual. The RAI Manual provides instructions for assessing pressure injuries for MDS item M0210 (Unhealed Pressure Ulcers/Injuries).

On page M-5, the RAI Manual instructions for assessment say the assessor should:

  1. Review the medical record (including skin care flow sheets or skin tracking forms).
  2. Speak with direct care staff and the treatment nurse.
  3. Examine the resident via a full body skin assessment in a well-lit room.
  4. Identify (and record) any known or likely unstageable pressure injuries.

Note the absence of any instruction requiring a diagnosis from a physician.

However, make sure you note this caveat, when assessing and coding pressure injuries for the MDS: “For MDS assessment, initial numerical staging of pressure ulcers and the initial numerical staging of ulcers after debridement, or [deep tissue injury] DTI that declares itself, should be coded in terms of what is assessed (seen or palpated, i.e., visible tissue, palpable bone) during the look-back period. Nursing homes may adopt the [National Pressure Ulcer Advisory Panel] NPUAP guidelines in their clinical practice and nursing documentation. However, since CMS has adapted the NPUAP guidelines for MDS purposes, the definitions do not perfectly correlate with each stage as described by NPUAP. Therefore, you must code the MDS according to the instructions in this manual.”

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