Pressure ulcers are one of the best-known quality-of-care conditions among medical staff, clinical documentation integrity (CDI), and coding professionals. Yet while hospitals often track any skin integrity issues, CDI professionals focus on those for which the present-on-admission status is undocumented, or those classified as a stage 3 or 4, since those stages qualify as a major complication/comorbidity (MCC), which affects Diagnosis-Related Group (DRG) assignment.
As a result, hospital leadership often finds discrepancies between the reported incidence of pressure ulcers compared to the volume that appears in claims data. That will likely change with an impending mandate that will hold hospitals publicly accountable for most pressure injuries.
It is worth noting that this measure is different from SRE 21, Patient Harm Associated with Stage 3, Stage 4, Unstageable, or Deep Tissue Pressure Injury acquired after admission. In particular, only events that are “largely preventable” are included in this measure, so documentation of proper interventions can mitigate the impact, but the same is not true for the Hospital Hare Pressure Injury eCQM measure.
Pressure ulcers have had financial consequences since Oct. 1, 2008, when the Deficit Reduction Act’s hospital-acquired condition (HAC) payment provision took effect. Stage 3 and 4 pressure ulcers were among the original conditions the Centers for Medicare & Medicaid Services (CMS) selected because they were high-volume, high-cost, and reasonably preventable through evidence-based care. When a qualifying diagnosis carries a present-on-admission indicator of “N” or “U” (not present on admission), the claim is paid as though that diagnosis was never coded, silently reverting the stay to a lower-weighted MS-DRG. In addition, pressure ulcers (PSI 03) are included within the HAC Reduction Program as part of PSI 90, which also limits tracking to those classified as stage 3, 4, or unstageable.
CMS will soon be collecting data on pressure ulcers beyond what is reported through claims data. Finalized in the Inpatient Prospective Payment System (IPPS) Final Rule for the 2024 fiscal year (FY), the new electronic clinical quality measure, CMS826, “Hospital Harm – Pressure Injury,” counts every inpatient hospitalization for patients age 18 and older in which a new stage 2, stage 3, stage 4, deep-tissue, or unstageable pressure injury develops. The National Pressure Injury Advisory Panel’s eCQM guidance should help hospitals revise documentation, coding, and reporting workflows that do not capture the majority of pressure ulcers. Reporting began with the 2025 calendar year (CY) reporting period, tied to FY 2027 payment determinations, and mandatory reporting starts in CY 2028.
Notice what changed. Stage 2 wounds, which never before triggered a payment consequence, are now counted. Deep-tissue injury, a finding that historically has been under-coded because it does not fit the intuitive image of an open wound, is also now counted. Ask a CDI director how confident they are that stage 2 pressure injuries are staged consistently and timed accurately to admission, and the answer is rarely a confident yes.
The measure’s mechanics matter here. Per the eCQI Resource Center’s specification for CMS826, eCQMs “rely on the accurate recording of codes, including POA indicators,” and both “N” and “U” indicators are accepted as evidence that a diagnosis was not present on admission. An eCQM does not read a wound care consult or a nursing skin assessment narrative. It reads the code, the stage character, and the POA flag. If a stage 2 injury was documented at the ED triage skin exam, but the POA indicator gets coded as “U” through an incomplete chart review, that hospitalization becomes a countable harm event whether or not the hospital’s own care contributed to it at all.
This is where ICD-10-CM Official Guidelines Section I.C.12.a deserves fresh attention. Category L89 codes are combination codes that identify site, laterality, and stage together, and coders must assign as many L89 codes as needed to capture every distinct pressure ulcer a patient has. Unstageable codes, the sixth character “0,” apply when slough or eschar prevents the provider from determining depth. That is a clinically different statement from unspecified stage, the sixth character “9,” which means staging was simply never documented. Accurate pressure ulcer coding is important at every stage, but the fact that unstageable pressure ulcers are now included in the measure makes staging specificity especially critical. When the documented terminology for a stage does not map to an ICD-10-CM option, or no stage is documented at all, a physician query, not a default code, is the best action.
Progression deserves the same discipline. Guidance is explicit that when a pressure injury is present on admission at one stage and advances to a higher stage during the encounter, two codes are reported: the admission stage with a POA indicator of “Y,” and the higher, hospital-acquired stage with a POA indicator of “N.” That two-code convention is exactly what CMS826 depends on to separate injuries a patient arrived with from injuries that worsened under the hospital’s own care. A CDI program that has never bothered to query for stage progression, treating “it was already there somewhere” as sufficient analysis, is quietly manufacturing its own eCQM harm events out of documentation gaps that were always fixable.
There is a second financial thread worth pulling, separate from HAC payment and eCQM scoring. Under the CMS-HCC Model V28, now fully phased in for payment year 2026, stage 2 pressure ulcers map to their own HCC category for the first time, alongside stage 3 and stage 4. Accurate staging is therefore no longer only a quality metric or a HAC-avoidance exercise. It is a risk-adjustment input for every Medicare Advantage (MA) enrollee whose care a hospital’s own coders and CDI staff document.
Hospitals do not have much time to revise current processes before mandatory CMS826 reporting begins in 2028. CDI and coding professionals should be using this time to collaborate with nursing, wound care, physical therapy, and other healthcare team members who monitor and treat pressure ulcers. Remember, the provider must make the diagnosis of a pressure ulcer and should document each location, but staging can be pulled from other documentation sources – like nursing notes. Hospitals should be building or refining their POA workflow for pressure injuries across nursing, coding, and CDI to ensure that this data is accurately documented and reported. The new pressure ulcer measure is just one of many examples of how quality-of-care performance measures require better collaboration across clinical and administrative functions.
