March 20, 2012
From CMS Q&As …
Question: Our clinician reported an ostomy as a surgical wound in the OASIS M1340, Surgical Wound item. The clinician no longer works for the agency, so we cannot contact her about the error. Can this OASIS change be made by the DON without speaking to the clinician?
CMS Answer: You have described a situation where a true OASIS scoring error was discovered during the audit process. The assessment was complete. The patient had an ostomy, a clear, non-disputable fact based on the entire clinical record. The assessing clinician responsible for completing the assessment misunderstood, wasn’t aware, or made an error based on the OASIS scoring guidance, which states all ostomies are excluded as surgical wounds in M1340.
HHAs should have a policy and procedure for correcting errors that involves the assessing clinician. The policy should follow established clinical record professional practice standards and guidance found in relevant CMS regulations and guidance. Normally, if an error is identified through audit or review, the individual who made the original entry into the patient’s record would, whenever possible, make the necessary correction by following agency policy. A correction policy may allow the auditor who found the error to contact the clinician, discuss the discrepancy in the medical record and make the correction following your policy including information such as who discovered the error, and the date and time of communication with the assessing clinician who agrees that it was an error. Correction of an error will not impact the M0090, Date Assessment Completed.
In a case where, as you have described, the original documenter is not available, the clinical supervisor or quality staff may make the correction to the documentation following the correction policy. The supervisor must document why the original assessing clinician is not available to make the correction and how the error was identified and validated as a true error. When corrections are made to assessments submitted to state, you must determine the impact of the correction on the POC, HHRG, the Plan of Treatment, RAP and make corrections to those documents and billing, as applicable.
When the comprehensive assessment is corrected, the HHA must maintain the original as well as subsequent corrected assessments in the patient’s clinical record per requirements at 42 CFR 484.48.
CMS urges HHAs to make corrections and/or submit inactivations as quickly as possible after errors are identified so the state system will be as current and accurate as possible, as the data is used to generate OBQM, OBQI, PBQI, Patient-Related Characteristics Report and HHRG.
Follow the guidance found in CMS Survey & Cert Letter 01-12 New Outcome and Assessment Information Set (OASIS) Correction Policy for Home Health Agencies (HHAs)—ACTION and INFORMATION.
January 12, 2012
CMS clarified several months ago that toenail removal by a physician is an excision, not a surgical wound. Please answer M1340 accordingly.
See more CMS Q&As here.
January 24, 2011
A new set of OASIS Q&As has been posted through the OCCB website.
M1020, M1022, M1024 do not get any mention, but there are several clarifications regarding wounds, and M1012 gets a nod, as well. Below are some highlights, and the link to the full set of Q&As.
Question 3: For M1012, Inpatient Procedure, can the same relevant procedure be listed twice if the procedure was done on two different dates in the inpatient facility?
Answer 3: Currently, there would be no reason or benefit to listing a procedure more than once.
Question 8: If you have two Stage IV pressure ulcers with intact skin in-between them and a tunnel that connects them underneath the wound surface, do you have one pressure ulcer or two?
Answer 8: If a patient develops two pressure ulcers that are separated by intact skin but have a tunnel which connects the two, they remain two pressure ulcers.
Question 9: When sutures are removed from surgical wounds healing by primary intention, how does it affect the healing status of the wound?
Answer 9: For the purposes of scoring the OASIS item, M1342, Status of the Most Problematic (Observable) Surgical Wound, openings in the skin, adjacent to the incision line, caused by the removal of a staple or suture, are not to be considered part of the surgical wound when determining the status of the surgical wound. The status of these sites would be included in the comprehensive assessment clinical documentation.
When determining the healing status of the incision, follow the WOCN Guidance on OASIS-C Integumentary Items, in addition to other relevant current CMS Q&As. The status of “not healing” would only be selected if the wound, excluding the status of the staple/suture site(s), meets the WOCN descriptors.
Other topics in the Q&As:
- Influenza vaccine
- M1300, risk of pressure ulcers
- Explainer of “performing other ADLs” in M1400, dyspnea
- Impaired decision-making
- M1840 and transferring … and lots more.
Looking for the Q&As?
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.
September 28, 2010
I get many questions on venous devices and whether they are current surgical wound … Here is CMS’s official guidance.
From CMS: An implanted venous access device is considered a current surgical wound as long as it is implanted in the patient’s body. When first implanted, the incision is the surgical wound. The assessing clinician will follow the 12/09 WOCN guidance to determine the healing status of the incision. Once it is fully epithelialized, the site due to the implanted device will remain a current surgical wound with a status of “Newly epithelialized” for as long as it is present in the patient’s body, unless it later develops complications.
Looking for the official guidance? Look at CMS’s OASIS Q&A, Category 4b, Q105.3.
September 13, 2010
CMS has been answering questions regarding dialysis shunts and surgical wound rules. In short, the dialysis shunt is a surgical wound, but the 30 day rule does not apply. It is considered a surgical wound as long as it is in place. Read below for the official information:
Question: M1342 Surgical Wound –implanted venous device: I am confused by one of the CMS OASIS Q&As. The answer to Q105.3 states that an implanted venous device is considered a surgical wound until it has been epithelialized completed for 30 days at which time it becomes a scar. The next sentence of the answer says that the site is considered a surgical wound as long as the device is in place. Can you clarify this?
Answer from CMS: An implanted venous access device is considered a current surgical wound as long as it is implanted in the patient’s body.
When first implanted, the incision is the surgical wound. The assessing clinician will follow the 12/09 WOCN guidance to determine the healing status of the incision. Once it is fully epithelialized, the site due to the implanted device will remain a current surgical wound with a status of “Newly epithelialized” for as long as it is present in the patient’s body, unless it later develops complications. This guidance clarifies and supersedes CMS OASIS Q&A Category 4b, Q105.3.
Click here to do some searches on this question and others.