Posts tagged ‘inpatient procedure’

January 24, 2011

OASIS Q&As deal with pressure ulcers and surgical wounds

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.

M1012
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.

M1306
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.

M1342
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
  • UTIs
  • Impaired decision-making
  • M1840 and transferring … and lots more.

Looking for the Q&As?

September 9, 2010

Rehab facility status is key to answering M1010, M1012, M1016

Are rehabilitation facilities considered inpatient settings? That is the key to answering M1010, M1012 and M1016 correctly if you patient comes from such a facility.

Let’s say a patient is discharged from a hospital on Sept. 1 and goes to a rehab facility and isn’t discharged from their until Sept 24. SOC is Sept. 25.

How should M1010 (inpatient diagnosis), M1012 (inpatient procedures) and M1016 (regimen change) be answered?

The key is to remember that a rehab facility is an inpatient facility (see M1000), so the diagnoses treated there would pertain to M1010 and M1016. Procedures would not be performed at a rehab facility, so M1012 wouldn’t apply.