The FY 2026 ICD-10-CM Official Guidelines specifically address a pressure ulcer that progresses to a higher stage during an inpatient admission. Two codes are assigned: one representing the site and stage present on admission and another representing the same ulcer site at the highest stage documented during the hospitalization.
Therefore, this patient's stage 2 sacral pressure ulcer on admission and subsequent progression to stage 3 must both be represented according to the applicable coding instructions.
The distinction is important for both clinical and quality purposes because the record must accurately show what condition existed when the patient entered the hospital and how the wound subsequently evolved. Coding only the stage 3 ulcer would lose information about its status at admission. Coding only stage 2 would fail to represent the deterioration that occurred during the stay.
Pressure-ulcer staging is also one of the circumstances in which qualified non-provider clinician documentation, such as wound-care nursing documentation, may be used to establish stage when the diagnosis itself is appropriately documented.
For CDI, accurate wound location, stage, progression, and POA documentation are essential because advanced pressure injuries may influence MS-DRG severity and hospital quality reporting.
CCDS Reference Topics: Pressure ulcers; staging; POA; wound-care documentation; Official Guidelines.
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