MDS Alert

Mistake: Wound’s depth won’t give you correct staging answer.

Your staging of pressure ulcers will be on the top of surveyors’ list in the 2015 MDS-focused surveys. Here are a few crucial tips to avoid drawing surveyors’ ire to your MDS coding of pressure ulcers.

Tip #1: When to Select DTI Vs. Unstageable

A wound that has bruising discoloration, usually purple in color, and that usually has the skin intact is a suspected deep tissue injury (DTI), according to Dr. Bardia Anvar, president of Skilled Wound Care in Los Angeles. “You could also use this classification for a blood-filled blister. DTIs can then become any stage wound.”

An unstageable pressure ulcer, on the other hand, “is usually a wound that you cannot tell how deep it is — it can be down to fat, muscle, tendon, or bone,” Anvar explained. “And this is because there is either slough, necrosis, eschar, or other tissue breakdown that obscure the depth of the wound.”

But if the slough, necrosis or eschar is removed and you can partially see that the wound is down to muscle or bone, you can restage the wound to a Stage 4 pressure ulcer, Anvar said.

Tip #2: Don’t Look at the Wound’s Actual Depth for Staging 

Although you must document measurements of the width, length and depth of pressure ulcers in Section M, “the actual depth of the wound does not dictate the stage,” warned Japa Volchok, DO, CHC, of Vohra Post-Acute Physicians in Miami, in a recent presentation. 

“Depending on the anatomic location on the body, the depth of the wound can vary dramatically,” Volchok noted. Tissue covering areas like the ankle or hands can be pretty thin, while an area like the heel or back can have significant subcutaneous tissue before you reach the level of muscle or fascia.

Right way: “The anatomic structures that are involved, such as muscle, tendon or bone, are what determines the stage of the wound,” Volchok said. If the bed of a wound is obscured by necrotic tissue, you would code it as unstageable. But if you see fascia, muscle fibers and bone or other underlying structures like tendons present in the base of the wound, for instance, you would categorize the wound as a Stage 4 pressure ulcer.

A Stage 1 pressure ulcer involves intact skin, while a Stage 2 would present as a shallow ulcer with an area of open epidermis, or as an intact or ruptured blister, Volchok noted. A Stage 3 pressure ulcer involves full-thickness tissue loss (epidermis and dermis), extending to the subcutaneous tissue but not below it.

Tip #3: Avoid ‘Backstaging’ Healing Pressure Ulcers

You likely know that “backstaging” or “reverse-staging” is a big no-no on the MDS 3.0. But how should you properly code a healed or healing pressure ulcer?

One common question is about coding a debrided pressure ulcer on the MDS. After a resident’s pressure ulcer is debrided, you might be tempted to no longer stage it and instead report it as a surgical wound, but this would be wrong.

“A pressure ulcer that has been surgically debrided remains a pressure ulcer and isn’t considered a surgical wound,” said Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS, co-founder of the Wound Care Education Institute in Plainfield, Ill, in an FAQ document for the Wound Care Advisor.

But what about a pressure ulcer that is repaired with a surgical flap? “If a muscle flap, skin advancement flap, or rotational flap is performed to surgically replace a pressure ulcer, the area is considered a surgical wound and is no longer a pressure ulcer,” Sardina said. “If the flap fails, continue to code the area as a surgical wound until it’s healed.” 

If a pressure ulcer heals, completely epithelializing over, but later reopens at the same site, you should list the ulcer at the previous staging diagnosis, Sardina stated. “Remember that pressure ulcers heal to a progressively more shallow depth. They don’t replace lost muscle, subcutaneous fat or dermis before they reepithelialize.”

“Instead, the full-thickness ulcer is filled with scar tissue composed primarily of endothelial cells, fibroblasts, collagen and extracellular matrix,” Sardina continued. So a Stage 4 pressure ulcer therefore cannot become a Stage 3, Stage 2 or Stage 1.

Resource: Check out the National Pressure Ulcer Advisory Panel (NPUAP) excellent illustrations of pressure ulcer categories/staging at www.npuap.org/resources/educational-and-clinical-resources/pressure-ulcer-categorystaging-illustrations/.