MDS Alert

Working this decision-making tree will be fruitful.

Time heals all wounds--or many of them--if it's nursing time combined with the right treatments.

The problem: Providing optimal wound care requires adequate money. And undercoding a resident's wounds and care in Section M will pull the RUGs out from under your wound-care program.

The solution: Answer these five questions to help you capture the highest possible payment for residents with skin ulcers, lesions and treatments.

Question No. 1: Does the resident have skin ulcers caused by pressure or circulatory problems? "Two ulcers of any stage (pressure or circulatory-related) [at two sites] coded in M1 plus two treatments in M5 [see p. 122] puts the person in Special Care, if he has an ADL score of at least 7," says Jane Belt, MS, RN, RC, consulting manager of Plante & Moran Clinical Group in Columbus, OH. A single stage 3 or 4 pressure ulcer recorded in M2 plus two or more treatments in M5 will also qualify a resident with an ADL of 7 or higher for Special Care.

Question 2: Does the resident have a surgical wound? A surgical wound (M4g) with one or more treatments will put the resident into Special Care if he has the requisite ADL score.

But "more often than not" the facility doesn't code the treatments, says Marilyn Mines, RN, RAC-C, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.

Seattle-based MDS expert Nathan Lake, RN, agrees: "If a resident has a surgical wound and you remove the sutures or provide irrigation or dressings, you want to capture that in the lookback. It doesn't have to be a major [surgical] incision."

A surgical wound includes "healing and non-healing open or closed incisions, skin grafts or drainage sites on any part of the body," Mines says. You wouldn't count healed surgical sites, stomas, lacerations requiring suturing or butterfly closures. Also, don't count a debrided skin ulcer as a surgical wound.

Surgical wound care (M5f) would include "any intervention for treating or protecting any type of surgical wound," including:

• topical cleansing
• wound irrigation
• application of antimicrobial ointments
• application of dressings of any type
• suture removal
• warm soaks or heat application.

Tip: The care team should evaluate whether a surgical wound requires a treatment, Mines advises.

3. Does the resident have an open lesion that qualifies for coding at M4c, such as a cancer-related lesion? A resident with a lesion coded at M4c and one or more treatments will RUG into Special Care, if he has an ADL score of at least 7. The treatments include "application of dressing" (M5g) or ointments (M5h) except to the feet in either case. Don't code skin lesions at M4c that are coded elsewhere in Section M. Also don't code skin tears or cuts at M4c.

4. Does the resident have an open lesion on his foot? Open lesions, including "cuts, ulcers, fissures" coded at M6c, and a dressing with or without topical medications (M6f) will RUG a resident with an ADL score of at least 4 into Clinically Complex. M6f includes "dry gauze dressings, dressings moistened with saline or other solutions, transparent dressings, hydrogel dressings--and dressings with hydrocolloid or hydroactive particles."

Also: A foot infection (e.g., cellulitis, purulent drainage) coded at M6b and a dressing in M6f qualifies a resident for Clinically Complex.

Key point: Always evaluate the cause of a foot ulcer.

For example, if the resident's toe has a diabetic ulcer caused, in part, by rubbing against an ill-fitting shoe, then also stage and code it as a pressure ulcer in M1 and M2, Mines advises.

Survey survival tip: The revised 314 survey guidelines say it's imperative to assess every open area to determine the cause ...quot; for example, pressure or circulation, Belt suggests. "A physician should also examine the wound" to investigate the cause. Some residents may require a Doppler study to identify arterial circulatory problems, Belt says.

Obtain an Accurate Extensive Count Determination

5. Does the resident with an skin ulcer or lesion and treatment(s) coded in Section M also qualify for extensive services (based on IV fluids for hydration/nutrition, IV medication, suctioning, tracheostomy or ventilator and an ADL score of at least 7)? Coding the skin ulcer(s) or lesions and treatments in Section M could affect the Extensive count determination, say reimbursement experts.

Reap the extra $$: Suppose a resident with an ADL score of 7 qualified for Extensive Services because he received IV pain medication. He has a Stage 3 decubitus ulcer with two or more treatments. Because the resident also qualifies for Special Care based on the ulcer and treatments, his RUG score would be SE2 rather than SE1, notes Diana Johnson, RN, BSN, a consultant with Health Dimensions Group in Minneapolis.