Home Health Coding and OASIS Expert

Don’t miss this Unstageable update.

The biggest and most anticipated change on the OASIS-C1 is the move from the two-column M1308 — Current number of unhealed (non epithelialized) pressure ulcers at each stage to a new set of two pressure ulcer questions. Take a closer look at new pressure ulcer item M1309 — Worsening in pressure ulcer status since SOC/ROC to avoid answering this item incorrectly.

New OASIS item M1309 asks you to document the number of pressure ulcers that are new or have worsened since the most recent Start or Resumption of Care assessment. One key to answering this item accurately is to understand what worsening means in this context. “The definition of worsening is particular to this item,” 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.

Definition: “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,” CMS says in the Response Specific Instructions for the new item.

Take note: Unstageable has a new description. Previous descriptions indicating that if the wound bed can be seen and the stage determined as a Stage III or IV then the ulcer is not Unstageable are gone and new guidance is in their place, 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 new guidance for determining when a pressure ulcer is Unstageable is this: “Pressure ulcers that the care provider suspects may be present based on clinical assessment, 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.”

This means if there is eschar and/or slough but Stage IV structures can be seen, then you should stage the ulcer at Stage IV, Selman-Holman says. If those Stage IV structures can’t be seen, then it’s Unstageable. Notice there is no option for determining that it is a Stage III, she points out.

Establish the Basics

You’ll answer M1309 only at discharge. Enter a number in rows a-d to indicate the number of new or worsened Stage II, III, IV, or Unstageable pressure ulcers your patient has. Try taking a three-step approach to answering this item.

Step 1: If your patient has no pressure ulcer for the stage specified by a particular row, enter a “0.”

Step 2: If your patient currently has any Stage II, III, or IV pressure ulcers, review the history of each pressure ulcer. Determine whether the pressure ulcers are new or if they existed at the time of the most recent SOC/ROC assessment. If the pressure ulcers existed at the most recent SOC/ROC assessment, compare the current stage to the stage that was reported previously.

Tally the number of pressure ulcers at each stage that are new or have increased in numerical stage since the most recent SOC/ROC assessment and record the numbers in the appropriate rows.

If there are no new or worsened pressure ulcers for a particular stage, enter “0” in the corresponding row. For example, if the pressure ulcer was a Stage III at ROC and is still a Stage III at DC, you would answer “0” in row b.

Step 3: Determine whether the patient has any pressure ulcers that are currently Unstageable due to coverage of the wound bed by slough or eschar. “Pressure ulcers that are Unstageable due to slough or eschar are those in which the wound bed is not visible due to some degree of necrotic tissue or scabbing that the clinician believes may be obscuring the visualization of bone, muscle, tendon or joint capsule (Stage IV structures),” CMS says in the Response-Specific Instructions for M1309.

Exception: If you can visualize any Stage IV structures, do not count the pressure ulcer as Unstageable. In this case, it’s a Stage IV even if slough or eschar is present, CMS says.

If your patient does have any pressure ulcers that meet the definition of Unstageable for this item, you’ll need to review the record to see whether the pressure ulcer existed at the most recent SOC/ROC assessment. If the Unstageable pressure ulcer didn’t exist or was previously a Stage I or II, you’ll report it in row d. 

Enter “0” if your patient has no Unstageable pressure ulcers at discharge, or if all current Unstageable pressure ulcers were III, IV, or Unstageable at the most recent SOC/ROC assessment.

Try Your Hand at these M1309 Scenarios

Now that you know the ins and outs of completing M1309, why not put your skills to the test with two scenarios Krulish shared during the CMS audioconference?

Scenario 1: You are completing Mrs. Sanchez’s discharge comprehensive assessment. While assessing her skin, you determine she has two pressure ulcers. One is a Stage IV on her left buttock, and is 50 percent covered in slough, with observable muscle. The other is on her left elbow and is completely covered with eschar. You review her chart and find that at SOC the left elbow was a Stage II and the buttock ulcer was a Stage III.

How would you respond to M1309 — Worsening in Pressure Ulcer Status since SOC/ROC?

Scenario 2: You are completing Mr. Stone’s discharge comprehensive assessment. When assessing his skin, you discover a Stage II pressure ulcer on his right heel and a suspected deep tissue injury on his left heel. When you review the chart, you discover that he had no pressure ulcers at SOC.

How would you respond to M1309 — Worsening in Pressure Ulcer Status since SOC/ROC? 

Scenario 1 Answer: Mrs. Sanchez’s Stage IV pressure ulcer was a Stage III at SOC. This pressure ulcer advanced in numerical stage since SOC, so you’ll report it with a “1” in row C.

Mrs. Sanchez’s Unstageable pressure ulcer was a Stage II at SOC and now, at DC it’s Unstageable due to complete coverage of the pressure ulcer by eschar. Report this pressure ulcer with a “1” in row d.

Mrs. Sanchez doesn’t have any Stage II or Stage III pressure ulcers, so you’ll answer rows a and b with “0.”

Scenario 2 Answer: Mr. Stone’s Stage II pressure ulcer wasn’t present at SOC, so you’ll report it with a “1” in row a. His suspected deep tissue injury wasn’t present at SOC either, but these wounds don’t count in M1309. You’ll answer “0” for rows b, c, and d for this patient.