Since the Centers for Medicare and Medicaid Services (CMS) selected pressure ulcers as one of the present-on-admission conditions, there have been several questions and concerns about whether nurses who are not "CMS-defined" providers can stage pressure ulcers. Because pressure ulcers are now a medical diagnosis, nurses have been asking whether the usual practice of staging pressure ulcers was now beyond the scope of nursing practice. To help clarify this question, Courtney H. Lyder, ND, GNP, FAAN; Diane L. Krasner, PhD, RN, CWCN, CWS, BCLNC, MAPWCA, FAAN; andElizabeth A. Ayello, PhD, RN, ACNS-BC, ETN, CWCN, MAPWCA, FAAN, wrote the following letter to the American Nurses Association (ANA). The letter's authors are delighted to share the response received from the ANA.
Letter to the ANA
July 13, 2009
Debbie D. Hatmaker, PhD, RN, SANE-A First Vice President ANA Board of Directors
Dear Dr Hatmaker,
As thought leaders in wound care, we seek to clarify the answer to one of the most commonly asked questions by clinicians as a result of CMS selection of pressure ulcers as one of the original 8 hospital-acquired conditions for non-higher DRG payment. Thus, on October 1, 2008, in order for the hospital to qualify for payment, the pressure ulcer must be documented as present on admission (POA). CMS has stated that, for billing compliance, the "provider" (MD or any qualified healthcare practitioner legally accountable for establishing a patient's diagnosis, available at http://www.cms.hhs.gov/HospitalAcqCond/04_Reporting.asp#TopOfPage) must document pressure ulcers (location/site [codes 707.01-09] and stage [codes 707.20-25]) on admission to the hospital.
Nonprovider nurses, which depending on each US state's defined nurse practice act may include master's-prepared clinical nurse specialists, as well as staff nurses, do not have the legal authority to establish a medical diagnosis. The lack of clarity is that nurses do have the legal [authority] and ability to establish a nursing diagnosis. There is no nursing diagnosis that specifically states pressure ulcers; instead, it implies pressure ulcers when it states the following 3 NANDA-approved diagnoses:
* skin integrity, impaired
* skin integrity, risk for impaired
* tissue integrity, impaired.
As pressure ulcers are now both an ICD-9 [International Classification of Diseases, Ninth Revision] medical diagnosis as well as potentially a nursing diagnosis, we wish to ascertain clarification as to whether nonprovider nurses are practicing beyond their scope of practice when they document in the patient's medical record the existence and stage of a pressure ulcer BEFORE a CMS provider (as defined above) documents their assessment of the existence and stage of the pressure ulcer.
We appreciate your assistance in helping nurses to understand this important issue and its implications for documentation and practice. We would be happy to discuss with you further this issue and are available for a meeting (either via phone or in person) to discuss our concerns as well as to answer any questions you might have. Thank you and we look forward to your timely response.
-Courtney H. Lyder, ND, GNP, FAAN
Dean and Professor, School of Nursing,
Assistant Director of Academic Nursing,
Ronald Reagan UCLA Medical Center,
Los Angeles, California
Diane L. Krasner, PhD, RN, CWCN, CWS, BCLNC, MAPWCA, FAAN
Wound & Skin Care Consultant
York, Pennsylvania
-Elizabeth A. Ayello, PhD, RN, ACNS-BC, ETN, CWCN, MAPWCA, FAAN
Faculty, Excelsior College School of Nursing
Senior Advisor, John A. Hartford Institute of Geriatric Nursing
Clinical Associate Editor, Advances in Skin & Wound Care
Executive Editor, World Council of Enterostomal Therapists; and
Cosecretary of the World Union of Wound Healing Societies