A Lisa Selman-Holman blog
CMS recently stated that only wounds and lesions of the integumentary system are recorded in OASIS, not wound or lesions in mucosal membranes.
Those pressure ulcers are reported in the comprehensive assessment and documentation.
Want to see the clarification? Go to the April 2012 link.
CMS has posted its first OASIS C training module, which addresses medication items.
The agency says more sessions should come online soon, including: care planning and interventions; neuro/emotional/behavioral status items; and integumentary/pressure ulcer items.
educating and providing care to this as well. So, I know that I need to add “colostomy status (v44.3)” and “attn to colostomy, (v55.3)” in the sequence. Our primary focus in the home of course is the wounds, but the colostomy is very important as well, so do I sequence it under the wounds? The wounds just take up so much in the coding scenario that I do not want the colostomy to get missed or I put it too far down in the “line up”.
I am still unclear how to code for supplies on this and we will be providing to him his colostomy supplies.
He is a paraplegic (344.1), so of course I will code that and he also was diagnosed sarcodosis (136.5?) leukocytosis (288.60) and malnutrition (236.9?).
Question: I have a patient with an old Stage 4 pressure ulcer on the buttock. The patient is coming from a nursing home, and the ulcer is “pretty much healed” down to a pin point. Now the patient is in home health. The nurse wants to call it an unstageable ulcer on the OASIS, and I said “once a stage 4 always a stage 4″ – at least for coding purposes?
Lisa says: There are three situations that make a pressure ulcer unstageable–1) eschar and slough, 2) dressing or device that cannot be removed, 3) deep tissue injury. A closing Stage 4 pressure ulcer should be marked as a fully granulating Stage 4. Once it is closed, it is marked as a newly epithelialized Stage 4 and will continue to be marked that way unless the pressure ulcer breaks down again. The pressure ulcer is coded as a Stage 4.
I often get questions about how to code a pressure ulcer that now has a muscle flap. Luckily, the coding guidelines are clear on this point (and many others regarding pressure ulcers) in its Chapter 12 guidelines:
2) Unstageable pressure ulcers
Assignment of code 707.25, Pressure ulcer, unstageable, should be based on the clinical documentation. Code 707.25 is used for pressure ulcers whose stage cannot be clinically determined (e.g., the ulcer is covered by eschar or has been treated with a skin or muscle graft) and pressure ulcers that are documented as deep tissue injury but not documented as due to trauma. This code should not be confused with code 707.20, Pressure ulcer, stage unspecified. Code 707.20 should be assigned when there is no documentation regarding the stage of the pressure ulcer.
As a quick aside: don’t routinely use 707.20. I would only consider using it when there is a pressure ulcer under a cast or other device where the stage cannot be determined and it doesn’t meet the definition of unstageable in the guideline.
You can code aftercare after a flap or skin graft. Remember on OASIS that the pressure ulcer covered with a muscle flap can be classified as a surgical wound in M1340 only. This is where the coding guidelines and the OASIS guidance take a whole different path. After the now-flapped pressure ulcer has been declared a surgical wound, the coding guidelines still consider the muscle flapped pressure ulcer an unstageable pressure ulcer. (Pressure ulcers with skin grafts are still pressure ulcers!)
Consider this scenario:
Question: If my patient had a debridement, can I mark 1 (Yes, patient has at least one (observable) surgical wound) in M1340?
Lisa says: No, debridement is not a surgical treatment, and CMS clearly states this in its M1340 specific instructions: Debridement or the placement of a skin graft does not create a surgical wound, as these are treatments performed to an existing wound. The wound would continue to be defined as the type of wound previously identified.
However, debridement is a place where OASIS and coding may not always match up. For example, you can code V58.77, Aftercare of surgery of the skin and subcutaneous tissue, NEC, in some cases. For example, for a patient with a debrided diabetic ulcer of the elbow, you can code V58.77 in M1020, and then code 250.80, 707.1x in M1024. The V58.77 code as primary indicates that the focus of care is a wound that is resolving without complications and considering the complexity and chronicity of diabetic ulcers, the V58.77 code is likely not the best choice.
IF V58.77 is used, remember that as a Diabetes case-mix diagnosis, 250.80 and 707.1x can go in both M1024 and M1022, if active. This is still active, of course, so code in M1022.
I’m thinking of creating a pressure ulcer page on the blog … I get so many questions on these wounds! At the end of this post, you’ll see some key words in green … if you want to find all posts that deal with stage II pressure ulcers, click on that link and you will have the archive!
Question: We have a patient being recertified. She has a stage II pressure ulcer and has been coded as such up to now. There is a discussion as to how to appropriately code with the placement of a wound VAC. Some are saying to code 891.1, complicated open wound, to account for the VAC. I’m thinking that I will continue to code the pressure ulcer to the ankle with a code for the stage. There is no documentation of the wound being infected, it’s just slow to heal and is now being treated with the VAC. I didn’t think there was a code we could use to capture the VAC.
Any advice?
Lisa says: You are correct! The wound is still a pressure ulcer, and there is no code for wound VAC. Coding the wound with an 800 code is incorrect and is considered upcoding. The nature of a pressure ulcer is chronic. The 800 codes are used for trauma wounds.
As we start our new code year, we’re always scrambling for education on codes, but what about other subjects, like PPS fundamentals or OASIS best practices or coding and filling out OASIS information on those pressure ulcers?
It’s time for new education in the new year, and I’m offering these in the month of October, in addition to my live education around the country.
PPS Fundamentals, Monday, October 11
Understand the fundamentals of PPS that are essential to agency operations for administrators, quality personnel and coders. This includes information on:
12pm -1:45pm CST
OASIS C Best Practices, Monday, October 18
What is a “best practice”? And what does it mean to your agency? The first quality reports have been released from OASIS C. How did CMS derive the information and how can your agency do better next time? In this education, we will:
12pm -1:45pm CST
Pressure ulcers, coding and OASIS-C, Monday, October 25
Coding pressure ulcers and responding to OASIS data items regarding pressure ulcers are some of the most difficult areas of home health practice. Lisa will lead your staff through the latest guidance on answering OASIS-C regarding pressure ulcers and contrast that with coding guidance. Lisa will:
12pm -1:45pm CST
Correct documentation, and wording in that documentation, are crucial to correct OASIS and coding. Pressure ulcers have very specific wordings, and using the incorrect phrase with a certain stage ulcer can result in rejection or validation errors as you electronically submit your records.
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Here is subject I field many, many questions on: the coding of stage 3 and 4 pressure ulcers.
Question: I recently read that closed pressure ulcers, regardless of stage, should not be coded. Is this true? I thought all Stage 3 & 4 closed pressure ulcers should still be coded.
Lisa says: Stage 3 and 4 pressure ulcers are never considered healed, but they can close. Because there is a strong risk that they will open again, they should be coded in a patient’s episode. If they are open ulcers, they would require much care, so they probably would be listed higher in your coding sequence, but the sequence will always depend on the seriousness of conditions, not just that these are difficult pressure ulcers. If they are closed pressure ulcers, you would probably code them lower, based on the time of care expended vs. the patient’s other needs.
Remember (and never forget) that closed stage 3s and 4s always require active intervention, including assessment and pressure ulcer risk interventions. The tissues lost are replaced by granulation tissue and they are always at risk. Because they should be addressed in the POC, they should be coded.
As for Stage 1 and 2 pressure ulcers: Code them when they are open. When they are closed and evidence of them is gone, they are considered healed, and they should not be coded.
In any case, watch the OASIS: There are nine items that deal with pressure ulcer assessment; be sure to watch all of them.
Looking for references on pressure ulcers? This is the WOCN’s position statement, which is considered official guidance.
