AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2022 Issue 2; Ask the Editor

Deep Tissue Pressure Injury Revealed to be Stage IV Pressure Ulcer

A morbidly obese patient was admitted to the hospital with a deep tissue pressure injury (DTPI) to the bilateral gluteal region, which was revealed during the admission to be a stage IV pressure ulcer. On admission, wound care described the DTPI as bilateral inner gluteal folds with blanchable hyperpigmentation. During week one, the DTPI demonstrated areas of moist black eschar and subsequently, the two sites merged into one wound. On the discharge summary, the provider recorded, “Deep tissue pressure injury to the coccyx, present on admission, revealed to be Stage IV pressure ulcer.” What is the correct ICD-10-CM code assignment and present on admission indicator (POA) for this case? ...

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