Home Health Coding and OASIS Expert

Published on Thu Oct 16, 2014 PDF

Don’t miss this WOCN update.

Accurately documenting unhealed pressure ulcers on the OASIS has long been a time-consuming and confusing task, but the OASIS-C1 aims to change that. Will changing one item into two make your life easier?

Keep an Eye on these Changes

In what may be the most anticipated change in the updated assessment tool, M1308: Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage is losing a column and getting a new title. On the OASIS-C1/ICD-9, M1308 becomes “Current Number of Unhealed Pressure Ulcers at Each Stage or Unstageable.”

Taking away the term “non-epithelialized” from the item stem improves clarity and makes the item more consistent with the OASIS-C1 Guidance Manual, said Linda Krulish, PT, MHS, COS-C, president of Redmond, Wash.-based OASIS Answers during the Sept. 3 Centers for Medicare & Medicaid Services OASIS-C1 implementation webinar.

You’ll complete the new M1308 at the start of care (SOC), resumption of care (ROC), follow-up, and discharge time points.

The biggest change for M1308 is reducing this item from two columns to one.

Old way: In OASIS-C, you complete M1308’s Column 2 at follow-up and discharge to show the number of current pressure ulcers listed in Column 1 that were present at the most recent SOC and ROC.

New Way: In OASIS-C1/ICD-9, that second column disappears. Instead, you’ll only complete new item M1309: Worsening in Pressure Ulcer Status since SOC/ROC at discharge. Here, you’ll indicate the number of current pressure ulcers that were not present or were a lesser stage at the most recent SOC/ROC. 

New item M1309 will take some extra time in your training, but once you’re past the learning curve, collecting accurate data with this item will be much easier says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR — Coding Done Right in Denton, Texas. “The item goes beyond what the second column of M1308 in OASIS-C was attempting to collect,” she says.

This new item allows you to record pressure ulcers that are Unstageable due to coverage of the wound bed by slough or eschar. You’ll also be able to report new pressure ulcers or those that were previously Stage I or Stage II at the most recent SOC or ROC.

M1309 “shows if pressure ulcers are worsening,” Selman-Holman said. “This will be a clearer picture of worsening pressure ulcers.”

Take Note of These WOCN Definitions

The new and updated pressure ulcer items will also include recent guidance from the Wound, Ostomy, and Continence Nurses Society (WOCN). Staying current on clarification regarding pressure ulcers that are Unstageable due to slough or eschar as well as knowing what the term “worsening” means in OASIS integumentary logic will be key to your success in answering these items.

Unstageable: The OASIS-C1/ICD-9 item instructions for reporting pressure ulcers as unstageable due to eschar or slough in both M1308 and M1309 will be updated to reflect new WOCN guidance.

Response-Specific instructions for response d.2 (Unstageable: Known or likely but Unstageable due to coverage of wound bed by slough and/or eschar) in the revised M1308 instruct that this response “refers to pressure ulcers that the care provider suspects may be present based on clinical assessment findings, but that cannot be staged because no bone, muscle, tendon, or joint capsule (Stage IV structures) are visible, and some degree of necrotic tissue (eschar or slough) or scabbing is present that the clinician believes may be obscuring the visualization of Stage IV structures.

On the other hand: “If a Stage IV structure is visible, the pressure ulcer is not considered Unstageable,” Selman-Holman says. “It is a Stage IV even if slough or eschar is present.”

Worsening: OASIS-C1/ICD-9 item M1309 asks you to report the number of new or worsened pressure ulcers since the most recent SOC or ROC assessment. New response-specific instructions from CMS advise, “For pressure ulcers that are currently Stage II, III or IV, ‘worsening’ refers to a pressure ulcer that has progressed to a deeper level of tissue damage and is therefore staged at a higher number using a numerical scale of I-IV (the NPUAP staging system) at the time of discharge in comparison to the most recent SOC/ROC assessment.”

“Data collectors will need to understand the meaning of worsening ‘increased in numerical stage’ and combine that with the revised WOCN Wound Guidance regarding Stage IV pressure ulcers to determine whether the ulcer can be classified as a Stage IV or as Unstageable,” Selman-Holman says.

To answer M1309, CMS instructs you to “compare the current stage of the pressure ulcer to the stage of that ulcer at the most recent SOC/ROC.”

“CMS is very specific regarding its instructions, but I foresee clinicians marking ulcers as worsened when they’re larger in size, or perhaps infected,” Selman-Holman says.

You’ll also need to remember that CMS wants the number at the current stage at discharge, Selman-Holman says. 

For example: Your patient had a stage II pressure ulcer at the most recent ROC and it is now a stage III. The patient is being discharged to another service area. For M1309, row b: Stage III, the response-specific instructions indicate to “enter the number of current pressure ulcers at discharge, whose deepest anatomical stage is stage III, that were not present or were a stage I or II at the most recent SOC/ROC,” Selman-Holman says. “Because the patient’s stage II is now a stage III, the assessing clinician would enter a ‘1’ in row b.”

But it gets even trickier when the pressure ulcer is Unstageable at discharge, Selman-Holman says. In item M1309, row d is used for pressure ulcers that are currently Unstageable due to slough or eschar, Selman-Holman points out. “Worsening” in this item refers to a pressure ulcer that was either not present, or was a stage I or II ulcer at the most recent SOC/ROC and is now Unstageable due to slough or eschar. So, pressure ulcers that are currently Unstageable due to presence of slough or eschar and were Stage III or IV at the most recent SOC/ROC are not considered worsened, Selman-Holman says.