April 24, 2012
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.
April 6, 2012
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.
July 16, 2011
Question: This gentleman has six pressure ulcers total, 2 of which are unstageable and 4 of which are a stage 4. I have coded each pressure ulcer by location and stage already and the primary diagnosis as aftercare following surgery because he had surgical debridement of these while in the hospital prior to admission onto services. I feel that is correct, but you may think differently.
He was diagnosed with severe osteo while in the hospital and also had debridement of the bone as well as the wounds. He is on po levaquin now in the home and was discharged with dx of osteo, so I am assuming that the surgical debridement and IV antibiotics while in the hospital did not rectify it all. So, I am not sure how to add the dx it into the sequence of the pressure ulcers, maybe secondary, but not quite sure on that.
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?).
Lisa says: Because you have several stage 4s code the locations and then add the 707.24 for stage 4. I would then code the paraplegia. The V code for attention to colostomy can be used as the 6th diagnosis if you feel strongly that it needs to be coded in the top six. NEVER code the status and attention to codes for the same ostomy at the same time.
Add the other codes in any order keeping in mind that the other two ulcers are coded as unstageable.
I would not code aftercare in this situation at all. You are not really providing aftercare.
Other general reminders: the same code cannot be used more than once so there is no way to code two ulcers at the same site nor is there any way to code bilateral ulcers.
Non routine supply points in this case are obtained from how M1630 (bowel ostomy), M1308 and M1324 (pressure ulcers) are answered, not on the codes. This scenario is getting a LOT of NRS points so ensure that the appropriate revenue codes and charges are added to your final bill and your HIPPS code ends in a letter (provided supplies).
February 4, 2011
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.
January 20, 2011
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:
Your patient has a pressure ulcer on coccyx that was repaired with a muscle flap. Code the aftercare of surgery first: V58.77, then 707.03, 707.25 for the unstageable pressure ulcer on the coccyx.
You have a surgical wound in M1340 and no pressure ulcers in M1306.
January 5, 2011
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.
Just because M1340 isn’t applicable doesn’t mean that you should forget your OASIS … M1350 includes any wounds or skin lesions OTHER than the pressure ulcers, stasis ulcers, surgical wounds already addressed, and bowel ostomies, which are also addressed in another item. The answer ‘yes’ on M1350 means that the skin lesion or wound requires intervention and assessment.
October 26, 2010
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.
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.
October 3, 2010
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:
- How the HHRG is obtained.
- Explain the case mix variable table.
- Identifying how to bill non-routine supplies.
- Explaining the role of diagnosis coding and OASIS answers to the financial health of a home health agency.
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:
- Define best practice.
- Discuss best practices involved in pain assessment, falls risk, depression screening and others.
- Identify the correct method for answering OASIS data items regarding best practices.
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:
- Describe how to answer OASIS and code for pressure ulcers with skin grafts.
- Describe how to answer OASIS and code for pressure ulcers with muscle flaps.
- Describe how to answer OASIS and code for pressure ulcers that “heal.”
12pm -1:45pm CST
Want more information?
September 21, 2010
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.
Let’s say this is your documentation:
M1308: a. Stage II, Number present: 2
M1320: 1- Fully Granulating
There is a note from the nurse that the ulcer is not “not healing,” so 03 on M1320 is ruled out by the agency.
Submitting this will result in a validation error on M1320. Why? Because Stage II pressure ulcers do not granulate. According to WOCN guidelines, if no granulation tissue is present, then the ulcer is not healing. If the RN is, indeed, seeing red beefy tissue (granulation) then the ulcer is likely to be at least a Stage III. OASIS does not allow any answer other than ‘not healing’ on Stage IIs.
Watch the WOCN website (linked on this blog) for definitions and pressure ulcer policy … and make sure to read your OASIS manual well for guidance!
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September 14, 2010
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.