IRF-PAI
Pressure Ulcer Items
Presentation Overview
• Introduction to Pressure Ulcers covered
basic concepts associated with pressure
ulcers and other skin conditions.
• This presentation focuses on assessment
guidelines and coding of Pressure Ulcer
items in IRF-PAI.
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Pressure Ulcers
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Objectives
• Identify pressure ulcer items that are
documented in the IRF-PAI.
• Describe guidelines for assessing and
coding each item.
• Code the IRF-PAI pressure ulcer items
correctly and accurately.
IRF-PAI Items
Pressure Ulcers
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Overview of Pressure Ulcer Items
IRF-PAI Pressure Ulcer Items:
• Item 48. Current Number of Unhealed
Pressure Ulcers at Each Stage
• Item 49. Worsening in Pressure Ulcer
Status
• Item 50. Healed Pressure Ulcers
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Pressure Ulcers
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Importance of Clinical
Assessment
• A complete and ongoing skin assessment
guided by clinical standards is essential.
• This assessment, which identifies and evaluates
all areas at risk for constant pressure and
determines the etiology of all skin ulcers and skin
conditions/problems, should direct the appropriate
skin management interventions.
• Completion of Pressure Ulcer items in the IRF-PAI
does not replace this assessment.
IRF-PAI Items
Pressure Ulcers
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Item 48
Current Number of
Unhealed Pressure Ulcers
at Each Stage
Item 48 Current Number of Unhealed
Pressure Ulcers at Each Stage
• Documents current number of unhealed
pressure ulcers at Stages 2, 3 and 4.
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Staging Definitions
• CMS has adapted the 2007 NPUAP definitions
for categories of staging.
• Resource: www.npuap.org
• Free diagrams of ulcer
stages can be downloaded
for educational use.
Reproduced with permission
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General Assessment and
Coding Guidelines
• Determine current number of unhealed
ulcers.
• Perform head-to-toe assessment of patient.
• Use visual inspection and palpation to identify
appropriate stage.
• Code only wounds that are the result of pressure.
• Determine deepest anatomical stage of each ulcer.
• Do not reverse stage.
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General Assessment and
Coding Guidelines, Cont.
• Determine if the pressure ulcer was
present on admission and discharge.
• Review for location and stage at time of
admission and discharge.
• Observation period for pressure ulcer items
is 3 days.
• Do not report unstageable pressure ulcers
on the IRF-PAI.
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Item 48A
Current Number of
Stage 2 Pressure Ulcers
Item 48A Number of Stage 2
Pressure Ulcers
• Documents number of Stage 2 pressure
ulcers present at admission and discharge.
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Stage 2 Pressure Ulcers
Partial thickness loss of dermis
presenting as:
• Shiny or dry shallow
open ulcer
• Red or pink
wound bed
• Without
slough or
bruising
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Stage 2 Pressure Ulcers, Cont.
• May also present as an
intact or open/ ruptured blister
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48A Coding Guidelines
• Differentiate Stage 2
pressure ulcer from a
suspected deep tissue
injury.
• Code only Stage 2
pressure ulcers in 48A.
• Do not code skin tears,
tape burns, Moistureassociated Skin Damage
or excoriation in 48A.
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48A Coding Instructions:
Admission Field
• Enter number of Stage 2 pressure
ulcers present on admission.
• If none, enter 0.
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48A Coding Instructions
Discharge Field
• Enter number of Stage 2 pressure
ulcers present at discharge.
• If none, enter 0.
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Items 48B and C
Number of Stage 3 and 4
Pressure Ulcers
Items 48B and 48C Number of
Stage 3 or 4 Pressure Ulcers
• Document the number of Stage 3 or 4
pressure ulcers present at admission
and discharge.
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Stage 3 Pressure Ulcer
• Full thickness tissue loss.
• Subcutaneous fat may be
visible but bone, tendon,
or muscle is not exposed.
• Slough may be present
but does not obscure the
depth of tissue loss.
• May include undermining and tunneling.
• Depth varies by anatomical location.
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Stage 4 Pressure Ulcer
• Full thickness tissue
loss with exposed bone,
tendonor muscle
• Slough or eschar may
be present on some parts
of wound bed.
• Often includes
undermining and tunneling
• Depth varies by anatomical location.
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48B and 48C Coding Instructions
Admission Field
• Enter number of Stage 3 and 4
pressure ulcers present on admission.
• If none, enter 0.
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48B and 48C Coding Instructions
Discharge Field
• Enter number of Stage 3 or 4 pressure
ulcers present at discharge.
• If none, enter 0.
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Item 48 Scenario #1
• At admission, one pressure ulcer was
noted and documented in the patient’s
medical record.
• It was noted to be a full thickness ulcer with
no exposure of bone, tendon or muscle.
• No other pressure ulcers were documented.
• How should Item 48 be coded?
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Scenario #1 Correct Coding
• In Item 48B, Stage 3, enter 1 in the Admission
field.
• In Items 48A and C, enter 0 in the Admission field.
0
1
0
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Item 48 Scenario #2
• At discharge, a patient has one pressure
ulcer that is documented in the medical
record.
• The pressure ulcer is covered with hard
black necrotic tissue.
• How should Item 48 be coded?
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Scenario #2 Correct Coding
• This pressure ulcer is unstageable.
• It should not be included on the IRF-PAI.
IRF-PAI Items
0
0
0
0
0
0
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Item 49
Worsening in Pressure Ulcer
Status Since Admission
Item 49 Worsening Pressure
Ulcer Status Since Admission
• Documents the number of current pressure
ulcers at discharge that that have worsened
since admission.
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Item 49 Worsening
Pressure Ulcer Status
• This includes pressure ulcers at
discharge that:
o Were not present
at admission
OR
o Were at a lesser
numerical stage
at admission
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Item 49 Coding Guidelines
It will be easier to assess worsening status
and to code these items if a facility documents
and tracks pressure ulcer status on a routine
basis.
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Item 49 Coding Guidelines2
Coding a pressure ulcer that was
unstageable at admission:
• Do not consider it to be worse at discharge. If it
becomes stageable, consider it as present on
admission. Code at the stage when it first
became stageable.
• If it worsens after it becomes stageable, it should
be coded as worsening.
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Item 49 Coding Example #1
• A patient is admitted with a pressure
ulcer that is covered in necrotic tissue
and cannot be staged.
• During the stay, the pressure ulcer is
revealed to be a Stage 4 pressure ulcer.
• Should this Stage 4 pressure ulcer be
coded in Item 49 as a “new or worsening”
pressure ulcer?
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Item 49 Coding Guidelines3
Coding a stageable pressure ulcer that
becomes unstageable since admission:
• If it becomes Unstageable due to Slough or
Eschar, do not code as worsened.
• If it becomes unstageable and then is debrided
so it can be staged, compare its stage before
and after it was unstageable. If the stage has
worsened, code it as worsening.
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Item 49 Coding Example #2
• A patient is admitted with a Stage 3
pressure ulcer.
• During the stay slough covers much of it.
• Then the ulcer is debrided and found to
be a Stage 4 pressure ulcer.
• Should this Stage 4 pressure ulcer be
coded in Item 49 as a “new or worsening”
pressure ulcer?
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49A Stage 2 Coding Instructions
• Indicate the number of current Stage 2
pressure ulcers at discharge that were
not present or were at a lesser stage on
admission.
• Enter 0 if no Stage 2 ulcers are present,
are new or have worsened.
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49B Stage 3 Coding Instructions
• Indicate the number of current Stage 3
pressure ulcers at discharge that were not
present or were at a lesser stage on
admission.
• Enter 0 if no Stage 3 pressure ulcers are
present, are new, or have worsened.
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49C Stage 4 Coding Instructions
• Indicate the number of current Stage 4
pressure ulcers at discharge that were not
present or were at a lesser stage on
admission.
• Enter 0 if no Stage 4 pressure ulcers are
present, are new, or have worsened.
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Item 49 Scenario
• A patient’s admission assessment
documented a Stage 2 pressure ulcer
on the right ischial tuberosity.
• At discharge, the pressure ulcer has
deteriorated to a Stage 3 pressure ulcer.
• There were no other pressure ulcers at
admission.
• How should Item 49 be coded?
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Scenario Correct Coding
• In Item 49B, Stage 3, enter 1.
• In Items 49A and 49C, enter 0.
0
1
0
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Item 50
Healed Pressure Ulcers
Item 50 Healed Pressure Ulcers
• Documents:
o Whether any unhealed pressure ulcers
were present on admission (Item 50A)
o If so, the number of Stage 2, 3, and 4
pressure ulcers that have completely
closed since admission (Items 50B, C,
and D)
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Item 50 Coding Guidelines
• A “healed pressure ulcer” is one that is:
o Completely closed
o Fully epithelialized
o Covered completely with epithelial tissue or
resurfaced with new skin, even if the area
continues to have some surface discoloration
• Do not reverse stage.
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50A Coding Instructions
Item 50A. Unhealed Pressure
Ulcers Present on Admission?
• Code 0. No.
• Code 1. Yes.
Skip Items 50B-D.
IRF-PAI Items
Complete Items 50B-D.
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50B, 50C and 50D
Coding Instructions
Items 50B, C and D. Stage 2, 3 or 4
Pressure Ulcers on Admission That Have
Healed
• Enter number of pressure ulcers at that stage
at admission which have completely closed at
discharge.
• If none,
enter 0.
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Item 50 Scenario
• A patient is admitted with one Stage 2
pressure ulcer.
• By discharge, the ulcer is healed.
• How should Items 50B, C, and D be
coded?
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Scenario Correct Coding
• Item 50B. Stage 2. Code 1 for the pressure
ulcer that healed.
• Item 50C. Stage 3. Code 0 for none.
• Item 50D. Stage 4. Code 0 for none.
1
0
0
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