Specific requirements for documenting wounds present on admission

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • 9083984500
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      Thank you for your question regarding CMS826, Hospital Harm - Pressure Injury. The measure uses codes from the following value sets to identify diagnoses or findings of stage 2, 3, 4, deep tissue, and unstageable pressure injuries:

      "Pressure Injury Deep Tissue" (2.16.840.1.113762.1.4.1147.112)
      "Pressure Injury Deep Tissue Diagnoses" (2.16.840.1.113762.1.4.1147.194)
      "Pressure Injury Stage 2, 3, 4 or Unstageable" (2.16.840.1.113762.1.4.1147.113)
      "Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses" (2.16.840.1.113762.1.4.1147.196)

      These four value sets include SNOMED CT, LOINC, and ICD-10 codes. More information on the codes contained in these value sets can be found on the Value Set Authority Center (vsac.nlm.nih.gov).

      Inpatient hospitalizations for patients are excluded from the measure's denominator if a patient has a diagnosis code in the "Pressure Injury Deep Tissue Diagnoses" or "Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses" value sets with a Present on Admission (POA) indicator code in the "Present on Admission or Clinically Undetermined" value set. Inpatient hospitalizations for patients are also excluded from the measure's denominator if the result attribute of a "Physical Exam, Performed" Quality Data Model (QDM) datatype is a code in the "Pressure Injury Deep Tissue" value set (for physical exams performed 72 hours or less after the start of the hospitalization) or "Pressure Injury Stage 2, 3, 4 or Unstageable" value set (for physical exams performed 24 hours or less after the start of the hospitalization). More information the "Physical Exam, Performed" datatype and the result attribute can be found at the eCQI Resource Center links below:

      https://ecqi.healthit.gov/mcw/2026/qdm-dataelement/physicalexamperformed.html
      https://ecqi.healthit.gov/mcw/2026/qdm-attribute/result.html
      Show
      Thank you for your question regarding CMS826, Hospital Harm - Pressure Injury. The measure uses codes from the following value sets to identify diagnoses or findings of stage 2, 3, 4, deep tissue, and unstageable pressure injuries: "Pressure Injury Deep Tissue" (2.16.840.1.113762.1.4.1147.112) "Pressure Injury Deep Tissue Diagnoses" (2.16.840.1.113762.1.4.1147.194) "Pressure Injury Stage 2, 3, 4 or Unstageable" (2.16.840.1.113762.1.4.1147.113) "Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses" (2.16.840.1.113762.1.4.1147.196) These four value sets include SNOMED CT, LOINC, and ICD-10 codes. More information on the codes contained in these value sets can be found on the Value Set Authority Center (vsac.nlm.nih.gov). Inpatient hospitalizations for patients are excluded from the measure's denominator if a patient has a diagnosis code in the "Pressure Injury Deep Tissue Diagnoses" or "Pressure Injury Stage 2, 3, 4, or Unstageable Diagnoses" value sets with a Present on Admission (POA) indicator code in the "Present on Admission or Clinically Undetermined" value set. Inpatient hospitalizations for patients are also excluded from the measure's denominator if the result attribute of a "Physical Exam, Performed" Quality Data Model (QDM) datatype is a code in the "Pressure Injury Deep Tissue" value set (for physical exams performed 72 hours or less after the start of the hospitalization) or "Pressure Injury Stage 2, 3, 4 or Unstageable" value set (for physical exams performed 24 hours or less after the start of the hospitalization). More information the "Physical Exam, Performed" datatype and the result attribute can be found at the eCQI Resource Center links below: https://ecqi.healthit.gov/mcw/2026/qdm-dataelement/physicalexamperformed.html https://ecqi.healthit.gov/mcw/2026/qdm-attribute/result.html
    • CMS0071v15
    • This would help improve and standardize present-on-admission wound documentation

      Good afternoon.
       
      I was wondering if you could help me with this question. I see that pressure injuries are not considered hospital acquired if they're documented within 24 hours of admission (for Stage 2,3,4) or 72 hours of admission (for DTPI).
       
      However, I see no specific wording that defines what "documented" means. Does it require a mere mention of the wound in the EHR (e.g. "discoloration on left foot")? Does it require specific descriptors of wound bed appearance? Measurements? Photos? General anatomical location or a specific one (e.g. "left leg" versus "left lateral malleolus")?
       
      I am a wound care nurse, and I would like to establish a better protocol for my facility to document all present on arrival wounds properly. However, I like to cite my work, and I would love to see specific wording quoted from an official authority (e.g CMS) explicitly defining what requirements must be met for wound to be considered documented on admission.

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Alexander Dragunov
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