Hospitals Responsible For Post-Admit Pressure Sores (Bed Sores, Decubitus Ulcers, Pressure Ulcers)

Under new guidelines, hospitals won’t be paid for the cost of treating pressure ulcers (pressure sores, decubitus ulcers, bed sores) if they occur during a hospital stay and aren’t documented as present on admission. Of the 11 hospital-acquired conditions selected for nonpayment in 2009, pressure ulcers may be the most difficult to accurately code and report. In Medicare’s payment methodology, only stage III and IV pressure ulcers are considered major complications or comorbidities (MCCs) resulting in a significant increase in hospital reimbursement when a physician documents them as present on admission.

For example, in a patient with a principal diagnosis of aspiration pneumonia and a secondary diagnosis of a stage I, stage II, or unstaged pressure ulcer, the MS-DRG would be 179, complex pneumonia without complications or comorbidities (CCs) or MCCs, and reimbursement would be $7,015 (all reimbursements are based on a hospital-specific rate of $5,500). In a patient with a stage III to IV pressure ulcer documented as present on admission, the MS-DRG would be 177, complex pneumonia with MCC, and reimbursement would be $10,144.

A stage III or IV pressure ulcer that develops during the hospital stay or that is not documented by the physician as present on admission will result in a payment reduction unless another MCC is documented and coded. For example, the patient above with a stage III or IV pressure ulcer not present at admission would be classified as MS-DRG 179, complex pneumonia without CC/MCC, and reimbursement would be $7,015, the same as if the pressure ulcer were less severe.

In addition to specific documentation, hospitals and physicians must carefully identify patients at high risk of developing pressure ulcers and then initiate and document prevention strategies. For more, read the story.


Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia. 


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