Home Health & Hospice Week

If you don't keep up with new "clarifications," you'll be answering M0488 wrong, and collecting money you'll have to send back.

In the latest quarterly set of OASIS questions and answers posted in July on the OASIS Certificate & Competency Board's Web site, the Centers for Medicare & Medicaid Services re-tracted its previous guidance about what a scab means when answering OASIS item M0488 (Status of most problematic [observable] surgical wound).

Old way: CMS responded to previous M0488 questions about scabs by reminding clinicians to rely on the Wound, Ostomy and Conti-nence Nurses Society document WOCN Guidance on OASIS Skin and Wound.

Using this document's Glossary clarifies that a scab equates to avascular tissue, which equates to necrotic tissue, CMS said. And in a wound healing by primary intention (the typical surgical wound), any amount of "incisional necrosis" is considered "not healing," CMS reasoned. Therefore, the surgical incision with a scab would be defined as "3 - Not Healing" for M0488, CMS said.

New way: In its July 15 Q&As, in question 12, CMS says its answer "represents a retraction of previous guidance that indicated a scab was considered avascular or necrotic tissue, and therefore an indicator of a non-healing surgical wound."

Now CMS concludes: "A scab is a crust of dried blood and serum and should not be equated to either avascular or necrotic tissue when applying the WOCN guidelines. Therefore while the presence of a scab does indicate that full epithelialization has not occurred in the scabbed area, the presence of a scab does not meet the WOCN criteria for reporting the wound status as 'not healing.'"

This new CMS guidance will supersede prior guidance found in CMS OASIS Q&As Category 4, Questions 112.1, 112.2, and 112.3, CMS notes.

What this means for you: This change will affect both reimbursement and outcomes, says consultant Judy Adams with Charlotte, NC-based Lar-sonAllen.

Good news: This new way of classifying a surgical wound with a scab will decrease adverse events and improve outcomes, Adams expects. "Under the old guidance, many agencies were ending up with 'non-healing' wounds at discharge, when in fact the wound was healing," she says. This made it look like the wound had deteriorated under the agency's care.

And when the agency admitted the patient with a early/partially granulating wound after surgery, but discharged the patient with a non-healing wound because of a small scab, this triggered an adverse event, even though the wound actually was improving, she says.

Bad news: The presence of a scab used to result in the wound being classified as not healing, which garners more case mix points for the home health resource group and the nonroutine supplies reimbursement, Adams says. Now that the same wound will be classified as early/partial granulation.

A non-healing wound has 4 points in all four PPS equations, while an early/partial granulation surgical wound only receives 2 points in equation 2 and 3 points in equation 3 with 0 points in equations 1 and 4. The effect of the new definition on reimbursement depends on what other points the patient has and which equation the episode belongs in (based on early/later and number of therapy visits), Adams explains.

One example: Based on the old CMS guidance, in Equation 1 (early episode, low therapy), the 4 points for non-healing surgical wound status you would have received is the top of the scale for the C1 category. So any other clinical items worth even 1 point -- such as diag-noses, vision, pain, dyspnea, etc. -- would have caused the case mix score to move to a C2 and nearly half-way to a C3 (9 points or more). On the other hand, under the new CMS guidance the early/partial granulation characterization of the same surgical wound receives no points in Equation 1.

Heads up: The new guidance was effective as soon as it was released through the OCCB web site in the official CMS OCCB Q&As, Adams instructs. Agencies need to be aware of this change in interpretation and alter the way they are answering M0488 (surgical wound healing status) beginning immediately with new OASIS assessments. There is no requirement to go back and retroactively change previous assessments, she says.