November 23, 2011
Several questions in CMS’s 3rd quarter Q&As deal with pressure ulcers and M1308.
The highlights (in my words, not CMS’s!):
- Should a muscle flap be reported in M1308 as a current pressure ulcer? No. It is a surgical wound (as are skin advancement flap, or rotational flap)
- If the pressure ulcer has a skin graft, how is it treated? Not as a surgical wound but as unstageable until it heals, then Stage III or IV.
- How do you report a Stage III that is closing to the point of a pinpoint? As a Stage III …
Find CMS’s full answers here.
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.
July 26, 2010
I always get questions during and after education seminars. Here are a few dealing with one of our favorite home health questions: pressure ulcers
Is a reddened coccyx with a few scabbed areas considered a Stage 2 because of the scabs?
Lisa says: A Stage 1 has intact skin. The presence of scabs would be considered more than Stage 1; however, it cannot be staged if the wound bed is not visible.
If we have a Stage 3 that is closed and would be a Stage 3 on admit and discharge, do we put zeros for MO1310 1312 and 1314 to reflect that it is closed.
Lisa says: A closed Stage 3 is never fully healed, so will continue to be called a Stage 3 at each time point unless it breaks down and becomes a Stage 4. The correct response to M1310,1312 and 1314 is 000.
If a patient went in hospital for shoulder surgery and was kept in observation and left just shy of 24 hours, would the admission MO1000 be NA ?
Lisa says: This patient would still be marked ‘Hospital’ as M1000 is not related to the criteria for a transfer assessment. The item simply asks from which facility was the patient discharged. (A transfer assessment is not required.) Note: Before you mark ‘Hospital,’ make sure this patient was not considered outpatient, e.g., had outpatient surgery.