MDS Alert

Know how to code, document a wound that looks worse before it gets better.

Staging and coding a debrided ulcer correctly on the MDS is half the battle. But to win the survey day, you also have to know how to document these wounds.

Stage the unstageable: You can't really stage a wound that you can't visualize. The problem is that the MDS doesn't allow you not to stage a wound, notes Kathleen Thimsen, RN, ET, MSN, president of RARE Consulting Group Inc. in Belleville, IL. Thus, if "necrotic eschar is present, prohibiting accurate staging of the ulcer, code it as stage 4," until you can debride the eschar "surgically or mechanically," advises the RAI manual.

Thimsen notes that "there's no evidence saying that a wound covered by eschar is always a stage 4, but it's highly likely that it is a 3 or 4."

After you debride the wound, follow the RAI manual definitions to stage and code the wound. The manual describes a stage 3 wound as one where the "full thickness of the skin" has been lost, "exposing the subcutaneous tissues." The wound "presents as a deep crater with or without undermining adjacent tissue."

The RAI manual defines a stage 4 as being one where a "full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone."

Provide a Clear 'Before and After' Documentation Picture

Debridement can make a wound look bigger and deeper. That's because with most stage 4 wounds, "tissue death occurs at the bone," which is where the pressure has occurred, says Dale Gertsch, a physical therapist and wound care specialist in Pasadena, CA. Gertsch. "So the wound is like an iceberg where you see necrotic tissue on the top that is really much larger the deeper you go."

The problem: Surveyors who see a debrided wound that looks worse could conclude the wound has gone downhill and cite the facility, cautions Peggy Dotson, RN, a wound consultant in Yardley, PA.

Solution: Document the debridement procedure and approximate "how much tissue the clinician removed," suggests Thimsen.

Include the "wound dimensions and what you were able to visualize before and after debridement," Thimsen advises.

And remember "that size alone does not indicate progress or deterioration of a wound," Thimsen adds. "The type of tissue [in the wound], exudate, the condition of the wound edges and the peri-wound skin also reflect the wound's progress or status," she adds.

So document signs that the wound is improving--for example, you might describe how "the edges of the wound are red and healthy looking and granulation tissue has appeared at the bottom of the wound," advises Dotson.

Make Sure to Document Reason for Repeated Debridements

"Documentation is important not only from a survey standpoint, but also to head off fraud and abuse allegations," says Thimsen. Why is that? "Some wound-care consultants will do serial debridements where they remove a little tissue over several sessions and charge Medicare each time they do so," Thimsen cautions.

Yet "clinicians should not have to do several sharp debridements over a period of two weeks--if the person doing the debridement removes an adequate amount of tissue the first time."

Thus, you should document why a wound required additional debridement. Reasons might include a situation where the wound tissue deteriorates further or if the wound isn't kept moist--or if infection is present, says Thimsen.