The record documents a “decubitus ulcer” without a stage, and the c…

Question

The record documents a “decubitus ulcer” without a stage, and the coder is considering a stage 3 pressure ulcer code. What is the correct action?

Accepted Answer

Do not assign stage-specific pressure ulcer coding until the stage is documented in the health record — No stage in the chart means no stage in the code—depth guesses from measurements are not a free upgrade. Wait for documented staging before you reach for a stage 3 pressure ulcer code.

Answer

Assign stage 3 based on nursing wound measurements that imply depth

Answer

Code stage 3 because unstaged ulcers are reported as stage 3 by default

Answer

Omit any pressure ulcer coding until a photograph is attached to the chart

The record documents a “decubitus ulcer” without a stage, and the coder is considering a stage 3 pressure ulcer code. What is the correct action?

Short Explanation

Full Explanation