Home Health & Hospice Week

Don't let these common mistakes cost you $1,500 per patient.

The message is clear: OASIS coding of wound care is in the spotlight.

Intermediaries' medical reviewers are combing through home health agencies' OASIS items on wound care and downcoding claims when they don't find correct documentation. And surveyors are clued into correct OASIS coding procedures after being required to watch the Centers for Medicare & Medicaid Services' two-and-a-half hour training session April 23.

It won't be long until the HHS Office of Inspector General and other fraud and abuse hounds are on the trail of the OASIS items that can make a $1,500 difference in per-episode payments, experts predict.

At the session, CMS and its OASIS contractor, the Center for Health Services and Policy Research at the University of Colorado Health Sciences Center, offered these tips for accurately filling out the OASIS items on wound care:

Pressure Ulcers

M0440 (Does this patient have a Skin Lesion or an Open Wound? This excludes "OSTOMIES.") Adds 21 to clinical severity domain if the patient has a burn or trauma diagnosis.

Experts have advised that almost every patient has some sort of skin lesion, which is defined as "all alterations in skin integrity" in the OASIS Manual Chapter 8. But HHAs have been reluctant to mark lesions if they are not addressed in the care plan.

Not to worry, said CHSPR's Kathy Crisler. Agencies can mark lesions, such as old scars, that aren't receiving current interventions or treatments.

Bottom line: Agencies also shouldn't hesitate to mark "yes" to M0440 if they don't later mark any pressure ulcers, stasis ulcers or surgical wounds. Other wounds, such as diabetic and arterial ulcers, aren't specifically captured in the OASIS tool, Crisler noted.

M0445 (Does this patient have a Pressure Ulcer?). No points.

The OASIS items on pressure ulcers have long bewildered HHA clinicians, because you must mark a pressure ulcer even when it is fully healed. "This is the only lesion that continues to be marked as present once it heals," Crisler confirmed.

M0450 (Current Number of Pressure Ulcers at Each Stage). Adds 17 to clinical severity score if two or more ulcers are stage 3 or 4.

Even more confusing for clinicians is that reverse staging is prohibited for pressure ulcers. That means you must score the ulcer at its worst condition, even once it is completely healed.

That approach reflects the fact that the skin where the ulcer was is never as strong as it was before the ulcer, wound care expert Dorothy Doughty from Emory University in Atlanta said in the session.

If your patient comes on service with a healed pressure ulcer, you must consult the patient's physician or referral source to determine the worst stage the ulcer has been, Crisler said.

Don't be fooled: To muddy the waters even more, agencies earn no points toward reimbursement for the wounds if they are non-observable. But you don't count them as non-observable if they are fully healed, Crisler emphasized. They are non-observable only if there is a non-removable dressing or cast over them, or if there is eschar or necrotic tissue covering them.

Strategy: HHAs often have complained of losing reimbursement on wound care patients due to eschar. Doughty recommended making every attempt to have the wound debrided before the home care admission, to make it visible for staging.

If the patient's wound is debrided during the episode, agencies can claim a significant change in condition (SCIC) as long as it is allowed in their own SCIC policies, Crisler answered one caller.

M0460 (Stage of Most Problematic [Observable] Pressure Ulcer). Adds 15 points to score for stage 1 or 2 ulcer; adds 36 points to score for stage 3 or 4.

Answering this item is easy if there is only one pressure ulcer, or if ulcers are non-observable (mark NA).

But how do you decide which is most problematic if there is more than one ulcer? Use your assessment findings and clinical judgment, Crisler advised. You may want to choose the ulcer that is the largest, the most difficult to access for treatment or from which it is the most difficult to relieve pressure, for example.

M0464 (Status of Most Problematic [Observable] Pressure Ulcer). No points.

Use the guidance issued by the Wound, Ostomy and Continence Nurses Society and adopted by CMS to assess the degree of healing for the ulcer you chose in M0460, Crisler instructed. The WOCN guidance is at www.cms.hhs.gov/medicaid/survey-cert/080601.pdf.

Stasis Ulcers

M0468 (Does this patient have a Stasis Ulcer?). No points.

Once you get into the M0 items on stasis ulcers and surgical wounds, remember NOT to count them once they are healed, Weakland reminded viewers.

Hint: A good time to look for stasis ulcers, which generally occur on the lower leg and ankle, is when you are assessing patients' activities of daily living for the lower body (M0660), Weakland suggested. When you ask them to demonstrate that they can remove and put back on their socks and shoes, be on the look-out for stasis ulcers.

M0470 (Current Number of Observable Stasis Ulcers). No points.

The OASIS experts didn't have much to say about this straightforward item. HHAs should remember "'non-observable stasis ulcers' include only those that are covered by a nonremovable dressing," the OASIS manual emphasizes.

M0474 (Does this patient have at least one Stasis Ulcer that Cannot be Observed due to the presence of a non-removable dressing?). No points.

If a non-removable dressing like a unna boot is being used, plan a visit on the day it is being removed for treatment to identify and assess possible stasis ulcers, counseled CMS' Mary Weakland.

M0476 (Status of Most Problematic [Observable] Stasis Ulcer). Adds 14 points for early/partial granulation (box 2), 22 points for not healing (box 3).

As with M0460, you must use your clinical and professional judgment to determine which stasis ulcer is the worst, if there is more than one, Weakland noted. WOCN guidance will help determine status.

Surgical Wounds

M0482 (Does this patient have a Surgical Wound?). No points.

Unlike pressure ulcers, fully healed surgical wounds are no longer counted.

A muscle flap performed to surgically replace a pressure ulcer is a surgical wound, not a pressure ulcer any longer, the OASIS Manual Chapter 8 says. But a skin graft is not the same -- the pressure ulcer treated with a graft stays an ulcer, although the skin graft site could be a new surgical wound, Weakland pointed out.

Likewise, a debrided pressure ulcer is still an ulcer, not a surgical wound, she added.

M0484 (Current Number of [Observable] Surgical Wounds). No points.

When a wound completely heals along part of its length, but leaves two unhealed areas on either side, each of those areas is counted as a separate wound, Weakland confirmed.

M0486 (Does the patient have at least one Surgical Wound that Cannot be Observed due to the presence of a non-removable dressing?). No points.

Again, this applies only to wounds covered by non-removable dressings or casts, not wounds that are healed, Weakland said.

M0488 (Status of Most Problematic [Observable] Surgical Wound). Adds seven points for early/partial granulation (box 2), 15 points for not healing (box 3).

When using your clinical judgment to determine the most problematic surgical wound, factors such as drainage, color, odor, location and size, and the color of wound bed should be considered, Weakland suggested.

As with M0464 and M0476, WOCN guidance will help you determine the status.

Editor's Note: The WOCN guidance and information on viewing the session are at www.cms.hhs.gov/oasis/hhtrain.asp.