A Stage 3 Sacral Pressure Injury and the Present-on-Admission Flag
An 82-year-old woman is admitted at 22:40 after a fall at home with a right femoral neck fracture. The admission nursing skin assessment documents 'sacral area: 2 cm area of non-blanchable erythema, skin intact.' She undergoes hemiarthroplasty on day 2 and is ambulating with physical therapy by day 3. On day 4 the wound care nurse documents 'stage 3 pressure injury, sacrum, 2.5 cm, subcutaneous tissue visible, no bone or tendon exposed.' The coder assigns L89.152 with a present-on-admission flag of Y. Quality review flags the case because a stage 3 pressure injury is a hospital-acquired condition, and the day-4 physician note says 'pressure ulcer, likely from immobility, now stage 3.'
1. Is the POA flag of Y correct? What documentation governs?
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Y is well supported.
- POA is determined from documentation of the patient's condition at the time of admission. The 22:40 admission skin assessment describes non-blanchable erythema at the sacrum with intact skin - that is a stage 1 pressure injury, present before any hospital care.
- Clinically, a stage 3 injury does not form in roughly 60 hours from previously intact skin. Deep tissue injury evolves over days, and pressure injuries do not 'progress' from stage 1 to stage 3 on that timeline. The day-4 staging is a refinement of a lesion that was already there.
- The physician's phrase 'likely from immobility' is speculation about mechanism, not a statement that it developed in-house. It does not override the admission assessment.
- The flag would be wrong if the admission assessment had described blanchable erythema or intact normal skin at that site. Before finalizing, read the ED note, the admission nursing assessment, and the day-1 through day-3 skin checks as a set; query if they conflict.
2. Is the stage 3 designation itself supportable, and what would change if the wound nurse had documented 'unstageable'?
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Stage 3 fits the description; staging is the clinician's call, not the coder's.
- Stage 3 = full-thickness loss with subcutaneous fat visible and no exposed bone, tendon, or muscle. The note describes exactly that: subcutaneous tissue visible, no bone or tendon exposed. L89.152 (pressure ulcer of sacral region, stage 3) matches.
- Stage 4 requires exposed bone, tendon, muscle, or fascia (or a directly palpable deep structure). It is not present here.
- If the wound had been covered with slough or eschar so the depth could not be assessed, the correct assignment would be the unstageable code in the same L89.15- family, and the coder would need a query only if the clinician later debrided and re-staged.
- Coders do not stage pressure injuries and do not upgrade or downgrade a documented stage. If two clinicians document different stages on the same day, query rather than picking one.
- Note that pressure injuries never reverse-stage; a documented improvement means healing, not a lower stage.
3. If the POA flag had to be N, what are the payment and quality consequences, and what would you verify first?
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Real consequences - which is why the flag must be evidence-based, not defensive.
- Payment: the diagnosis is still coded (L89.152) and reported with POA = N, but under the IPPS HAC policy a hospital-acquired condition that would otherwise function as a CC/MCC is not recognized as a CC/MCC for payment purposes. The case would group as though the pressure injury were absent.
- Quality: CMS treats stage 3, stage 4, and unstageable pressure ulcers acquired after admission as HACs, and the case feeds PSI 03 and the HAC Reduction Program, which can reduce all of the hospital's Medicare payments. POA indicators also flow into public reporting and risk-adjusted outcome models.
- Verify first: the admission nursing assessment and ED record (already favorable here), the OR and PACU records, day-1 through day-3 turning and skin documentation, and whether any staging was done by a wound nurse who never saw the admission assessment. Then query with the specific documents cited, asking the provider to clarify whether the lesion was present on admission - neutrally, with options.
- Do not flip the flag to N to 'be safe' with quality, and do not leave it Y to protect revenue. Both are documentation integrity failures, and either is discoverable in an audit.