Home Health & Hospice Week

Hint:  Be precise in medical record documentation and on the OASIS.

Wound care adds to your agency's episode costs, so to get the reimbursement you earned, answer OASIS ulcer questions accurately. Unless you can distinguish between the types of skin ulcerations your patient has, you won't be able to answer M0445 through M0476 correctly. And these questions can add from 14 to 36 points to the clinical severity portion of a patient's home health resource group score--plus $200 to $2,000 to the episode reimbursement amount.

Know Your Ulcer Types

Use these pointers to identify wound types so you correctly answer the related M0 questions:

1. Pressure ulcer. OASIS item M0445 defines a pressure ulcer as any lesion caused by unrelieved pressure resulting in tissue hypoxia and damage of the underlying tissue. Look for skin breakdown over bony prominences, says Donna Collins, the director of nursing for Little Flower Manor in Wilkes-Barre, PA.

Watch for: "Patients may also have skin breakdown on the back of their heads--especially if they lay too long on an operating room or procedure table in the hospital," adds Clare Hendrick, a geriatric nurse practitioner and consultant in San Clemente, CA. "You might also find ulcers on earlobes."

Reminder: A debrided ulcer is still a pressure ulcer, but if the ulcer is repaired with a skin flap, it becomes a surgical wound, says Collins.

Experts warn: Don't overlook skin breakdown caused by friction and shear, which can cause pressure ulcers. For example, an abrasion that the clinician knows was caused by a shearing force or friction--such as when a patient transfers or slides down in the chair--should be coded as a pressure ulcer, says Rena Shephard, president of RRS Healthcare Consulting in San Diego.

2. Stasis ulcer. M0468 defines a stasis ulcer as one caused by inadequate venous circulation in the area affected (usually lower legs). This lesion is often associated with stasis dermatitis.

To help identify a venous stasis ulcer, "look for a brownish deposit around the wound," suggests Laura Bolton, a wound-care expert and researcher in Metuchen, NJ. "Or if the patient has highly pigmented skin, look for a darker area around the wound," she says.

What it looks like: The ulcer may have a moist, granulating wound bed, be superficial   and have minimal to copious serous drainage unless infected. If the physician diagnoses the ulcer as a "diabetic ulcer," it would be considered a wound in M0440 but would not be counted as a pressure ulcer or stasis ulcer, the Centers for Medicare & Medicaid Services says in its OASIS questions and answers.

Rule Out Other Types Of Ulcers

Although only pressure and stasis ulcers have proven useful for outcome measures and risk factor adjustments, it's "extremely important" to document other types of wounds in the clinical record, CMS says in its OASIS Q&As. You also need to recognize these types to distinguish them from the pressure and stasis ulcers, experts say.

3. Arterial ulcer. An arterial ulcer or arterial wound is an ulceration that results from arterial occlusive disease. The area of tissue necrosis results from "non-pressure related disruption" of the arterial blood flow to an area.

How to identify it: The arterial ulcer occurs in the distal portion of the lower extremity. It may be over the ankle or bony areas of the foot (e.g., top of the foot or toe, or outside edge of the foot). Look for a dry, pale wound bed with minimal or no exudate, Bolton says.

Suspect an arterial ulcer if the patient has poor pedal pulses and the skin looks white and pale--"almost translucent, shiny and lacks hair," advises Peggy Dotson, principal of Healthcare Reimbursement & Strategy in Yardley, PA. "Arterial ulcers are also painful," she says.

4. Malignant and autoimmune lesions. Lesions or ulcers can be secondary to a disease process such as cancer. Even experienced clinicians can mistake a malignant wound for a pressure ulcer or other chronic wound. In one case, a patient who fell down the steps had a "mushy wound on his sacral area for eight months, reports Michael Miller, medical director of the Wound Healing Center in Terra Haute, IN. Everyone assumed the wound was due to the accident. But when a surgeon excised the wound, the pathology report showed it was a basosquamous cell carcinoma."

Don't ignore non-healing wounds: If a wound doesn't show progress after four to six weeks of adequate therapy, biopsy it, advises Miller. And biopsy earlier than that if a wound worsens despite adequate treatment, he says.

"You want to make sure the wound isn't malignant--or that it isn't the result of an autoimmune condition, such as vasculitis that will preclude healing. You also want a tissue culture to look for bioburden and infection," he adds.

News Flash: Effective July 27, HHAs must code surgical wounds following the recently revised guidance of the Wound Ostomy Continence Nurses Society, the Centers for Medicare & Medicaid Services announces.

The WOCN guidance "OASIS Skin and Wound Status M0 Items" was revised in July and includes changes to the definition of wounds healing by primary intention (approximated incisions). The new definitions no longer include the presence of a healing ridge as evidence of whether a wound is fully granulating, partially granulating or non-healing.

The definition change is crucial in accurately answering M0488 (Status of most problematic [observable] surgical wound).  This OASIS item can add from seven to 15 points--and hundreds of dollars to a patient's episode payment.

Note: For the revised WOCN OASIS guidance, go to www.wocn.org/education/pdf/WOCNOASISguidanceRev072406.pdf.