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Monthly CDI Scenario Discussion – June 2020

Topic: Deep Tissue Injury and Pressure Ulcers

Scenario: 88-year-old female patient with wound to buttock


HPI: 88-year-old female brought in from nursing home facility with concern of an open wound to left buttock. Patient has contractures due to previous CVA with left-sided hemiparesis. Patient is limited in mobility due to obesity.

  • PMH: CVA left-sided hemiparesis with contractures; HTN, Hyperlipidemia; DM2; CKD 3; Dementia; CHF; CAD
  • Home Medications: Lisinopril 5mg PO; Humalog; Lipitor 20mg PO; Lasix 20mg PO
  • PE: Obese female with residual left hemiparesis due to past CVA; pleasant yet unaware of day or time; possible Alzheimer’s with a history of dementia per family; skin warm to touch; wound to left buttocks, most likely pressure ulcer and redness to the left heel; left limb contracted up and inward. Edema to BLE
  • Labs: UA: WBCs: 12; RBCs: present; Cloudy; positive for Leukocyte esterase; UC: resulted E. coli; WBCs 10.3; RBCs: 4.0; H&H: 12 & 36; Glucose: 207; 233
  • Radiology Studies: Chest X-ray: Enlarged Heart; mild pulmonary edema
  • Consult: Deep tissue injury to left heel
  • Wound Care Nurse: Pressure Ulcer noted at the left buttock stage 3
  • Cardiology: CHF; echo 2 weeks ago stated an EF of 24%
  • Vitals: BP: 188/86; P: 76; RR: 18; Temp: 98.7; BMI 41.2
  • Discharge Summary: Wound to left buttocks and heel;CHF; CKD 3; HTN; Hyperlipidemia; DM2; Dementia; CAD
  • Discharge Medication: Lisinopril 5mg PO; Humalog; Lipitor 20mg PO; Lasix 20mg PO; Bactrim PO BID

Question: Are there query opportunities based on the scenario stated above?


According to the Wound Care nurse, the patient has a stage 3 pressure ulcer to left buttock with deep tissue injury to the left heel. Note that the physical exam mentions, “wound to left buttocks, most likely pressure ulcer and redness to the left heel” with the discharge summary indicating, “Wound to left buttocks and heel”. The provider did not carry the diagnosis of likely pressure ulcer of the left buttock to the discharge summary or indicate any other specific diagnosis of the left heel.

According to the ICD-10-CM Official Guidelines for Coding and Reporting, Section III. C. Uncertain Diagnosis: If the diagnosis documented at the time of discharge is qualified as “probable”, “suspected”, “likely”, “questionable”, “possible”, “still to be ruled out”, “compatible with” “consistent with” or other similar terms indicating uncertainty, code the condition as if it existed or was established.

The cardiology consult states patient has Heart Failure with EF of 24%. Pt noted with BLE edema and mild pulmonary edema, however continued with the home med dose of PO Lasix during stay and to discharge. UC noted E. coli with Bactrim ordered and given through discharge.

UASI Recommends:

  • Possible Query opportunities:
    • Query for Documentation Clarification: Left Buttock Wound Type; Left Heel Wound Type
    • Query for HF Type
    • Query for Documentation Clarification: Alzheimer’s Dementia
    • Query for DM with Hyperglycemia
    • Query for Obesity specificity
    • Query for UTI due to E.coli

(Be alert that prioritization of query submission may be needed)

Documentation without clarification:

Working Principal Dx: Unspecified Open Wound of Unspecified Buttock, Initial Encounter (S31.809A)

Working Secondary Dx:   Hemiplegia/Hemiparesis following Cerebral infarction affecting Left Dominant Side (I69.352); HTN Hrt & Chr Kidney Dis w Hrt Failure (I13.0); Heart Failure, Unspecified (I50.9); CAD (I25.10); Hyperkalemia (E78.5); CKD 3 (N18.3); DM2 w Diabetic CKD; (E11.22); Unspecified Dementia without Behavioral Disturbance (F03.90); Obesity (E66.9); BMI 40-44.9 (Z68.41)

Working DRG: DRG 605: Trauma to the skin, subcutaneous tissue & breast w/o MCC

RW 0.8757        GMLOS: 2.6     SOI/ROM: 2/2

Documentation with clarification:

Working Principal Dx:  Pressure Ulcer Left Buttock, Stage 3 (L89.323)

Working Secondary Dx: UTI (N390); Chronic Systolic Heart Failure (I50.22); Hemiplegia/Hemiparesis following Cerebral Infarction  affecting Left Dominant Side (I69.352); HTN Hrt & Chr Kidney Dis w Hrt failure (I13.0); Morbid Obesity (E66.01); BMI 40-44.9 (Z68.41); CAD (I25.10); Hyperkalemia (E78.5); CKD 3 (N18.3); DM2 with Hyperglycemia (E11.65); DM2 w Diabetic CKD(E11.22); Alzheimer’s Disease, Unspecified (G30.9); Dementia in Other Diseases Classified Elsewhere without Behavioral Disturbance (F02.80); Pressure-Induced Deep Tissue Damage of Left Heel (L89.626); Unspecified E. Coli as Cause of Diseases Classified Elsewhere (B96.20)

Working DRG: DRG:593 Skin Ulcers w CC

RW: 1.1478    GMLOS: 5.3     SOI/ROM: 2/2

CDI Educational Tips:

  • Code assignment for the stage of the pressure ulcer can be assigned from nursing documentation, however the associated diagnosis of pressure ulcer must be documented by the patient’s provider per OCG 1.B.14 ‘Documentation by Clinicians Other than the Patient’s Provider’
  • Monitor wound care notes from nursing and provider notation closely for both conflicting and continuance of documentation through discharge
  • Monitor for POA for pressure ulcers or injuries
  • Monitor chronic illnesses with acute treatment while admitted
  • Confirm any labs for possible sepsis
  • Monitor cultures for linking results and treatments to a diagnosis
  • Be alert for functional quadriplegia when contractures are noted; review carefully provider documentation and ancillary notes for support of nonfunctional status

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.