Home Health & Hospice Week

You should be hitting the pressure ulcer items heavily in your OASIS C training, or you'll be paying the price in your reimbursement and outcomes. Don't expect to make an easy transition from OASIS B-1 to OASIS C when it comes to the integumentary items. Twelve questions address pressure ulcers in the new assessment tool taking effect Jan. 1, and only careful reading will ensure an accurate answer.

Why worry? Imagine your clinician's confusion when she gets to the integumentary items. Of the pressure ulcer questions:

• M1306 (Does this patient have at least one unhealed pressure ulcer at Stage 2 or higher or designated as "unstageable"?) applies to Stage 2, Stage 3, Stage 4, and unstageable ulcers.

• M1307 (The oldest non-epithelialized Stage 2 pressure ulcer that is present at discharge) applies to Stage 2 only.

• M1308 (Current number of unhealed [non-epithelialized] pressure ulcers at each stage) applies to Stage 2, Stage 3, Stage 4, and unstageable ulcers.

• M1310 (Length), M1312 (Width), and M1314 (Depth) apply only to Stage 3 and Stage 4 ulcers.

• M1320 (Status of most problematic [observable] pressure ulcer) applies to Stage 2, Stage 3, Stage 4, and unstageable.

• M1322 (Current number of Stage 1 pressure ulcers) applies to Stage 1 only.

• M1324 (Stage of most problematic [observable] pressure ulcer) applies to Stage 1, Stage 2, Stage 3, Stage 4, and unstageable ulcers.

Pressure ulcer item numbers are changing from the current OASIS tool to OASIS C, but so will definitions, terms used, and question topics. The Centers for Medicare & Medicaid Services updated this area "to reflect current stateof-the-art knowledge," explained CMS's Angela Richards in an OASIS C session at the National Association for Home Care & Hospice's 28th annual meeting in Los Angeles in October.

As much as possible, CMS incorporated the guidance from the Wound, Ostomy, and Continence Nurses Society and the National Pressure Ulcer Advisory Panel's work, Richards said.

Clinicians may see some inconsistency because payment items in the pressure ulcer area had to stay the same, she added.

The National Quality Forum is working on ways to measure pressure ulcer issues "across care settings," Richards explained, so its concerns also influenced the changes CMS made to these items.

Watch out: Agencies must create a way to track when a pressure ulcer developed to be able to answer M1307 and M1308 about whether a pressure ulcer was present at start of care (SOC) or resumption of care (ROC), said Elizabeth Madigan with OASIS contractor Case Western Reserve University, speaking at the NAHC conference. These items will show whether the ulcer "developed on your watch," she explained.

The pressure ulcer questions on OASIS C use the 2007 NPUAP pressure ulcer guidelines, reported OASIS expert and consultant Linda Krulish with Redmond, Wash.-based OASIS Answers, speaking at the OASIS Certificate & Competency Board's annual conference in Baltimore Nov. 10. This is a change from OASIS B-1, Krulish told attendees.

Make sure your clinicians know how to identify and stage a pressure ulcer, Krulish advised. And teach them to look carefully at each OASIS C integumentary question to be sure they are applying the right meaning. Experts point out these four tricky areas to hit in your education efforts:

• Unstageable vs. not observable. "Unstageable" in the NPUAP definitions means the same as "not observable" in the OASIS C questions about staging pressure ulcers, Krulish said. So for OASIS C staging questions, a pressure ulcer is not observable if it is covered with slough and/or eschar so the clinician can't see the wound base, or if the ulcer is covered with a non-removable dressing.

Beware: On the other hand, for questions involving the status of pressure ulcers, the only reason to mark not observable is if the ulcer is covered with a non-removable dressing, Krulish said. That is because even with a covering of slough or eschar, the status of the ulcer will either be "early/partial granulation" or "not healing," she explained.

• Disappearing pressure ulcers. Healed Stage 1 pressure ulcers are not at risk for future ulcer development, according to the NPUAP. And healed Stage 2 pressure ulcers are at minimum risk for ulcer formation, the NPUAP has concluded.

New way: Healed Stage 1 and Stage 2 pressure ulcers are no longer current pressure ulcers, CMS instructs. For example, M1308 asks for the current number of unhealed pressure ulcers at each stage.

In the past, the rule against reverse-staging pressure ulcers would have included any ulcer at Stage 2 or higher in this answer. Starting Jan. 1, you would not report any pressure ulcers if the patient only had healed ulcers that had previously been Stage 1 or Stage 2.

Caveat: Stage 3 or Stage 4 pressure ulcers that are closed once they are fully granulated and covered with epithelial tissue are never considered healed and always remain at the same stage. So even when closed, they would be counted in M1308 and other OASIS C items, Richards said.

• Measuring for M1310, M1312, and M1314. For these items, CMS directs the clinician to measure the length (M1310), width (M1312), and depth (M1314) of every existing non-epithelialized Stage 3 or Stage 4 pressure ulcer. This may confuse clinicians because by definition these ulcers can be newly epithelialized or closed -- but not epithelialized, Krulish explained.

If all Stage 3 and Stage 4 pressure ulcers for this patient are closed or are covered with a nonremovable dressing, put 00.0 in M1310, M1312, and M1314, CMS instructs.

• M1308 confusion at discharge. In the discharge assessment, M1308 contains two columns for answers. In the first column, the clinician records the current number of unhealed Stage 2, Stage 3, Stage 4, and unstageable pressure ulcers. In the second column, the clinician records the number of the ulcers in column one that were present on admission (on the most recent SOC/ROC).

Don't miss: It's easy to overlook the fact that column two doesn't mean the ulcers need to be in the same stage. So if the patient was admitted with one Stage 3 pressure ulcer and currently has one Stage 4 pressure ulcer, column one will have "1" marked next to Stage 4, but column two will have "1" marked next to Stage 3, Richards explained. "This may seem confusing at first, but it will be clear once you go through it with a few examples," she said.

Four OASIS C integumentary questions ask about the pressure ulcer assessment process. These are M1300 (Pressure ulcer assessment: Was this patient assessed for risk of developing pressure ulcers?); M1302 (Does this patient have a risk of developing pressure ulcers?); M2250 (Plan of care synopsis); and M2400 (Intervention synopsis). The process measure items are new in OASIS C and will affect outcomes, including publicly reported ones. The process measures scrutinize your agency's adherence to best practices, although CMS currently does not require agencies to do the assessments. M1300 is the one process item that doesn't require you to use a standardized tool for the assessment, Madigan said.

Caution: Even though the wording of M1300 sounds as if anyone can complete the assessment and have it qualify, that is not accurate. You can only choose a "yes" answer to this question if the clinician completing the OASIS C assessment is also the person who completed the pressure ulcer assessment, Madigan confirmed.

Note: For information on OASIS C, including the pressure ulcer process items, see Eli's OASIS Alert at www.elihealthcare.com. For reference material on pressure ulcers, go to the NPUAP Web site at www.npuap.org.