Medicare Compliance & Reimbursement

HHAs should prepare for scrutiny of this high-dollar OASIS coding revision.

There will be no more free lunch when it comes to counting healed pressure ulcers on OASIS.

That's the message the Centers for Medicare & Medicaid Services is sending with a new policy change to how home health agencies should code healed pressure ulcers on OASIS.

Effective Sept. 1, HHAs should not count healed Stage 1 or Stage 2 pressure ulcers in M0440 (Does this patient have a Skin Lesion or Open Wound?) and M0445 (Does this patient have a Pressure Ulcer?), CMS instructs. So unless the patient has other qualifying ulcers, clinicians should respond "No" to both questions when the patient has healed pressure ulcers that were Stage 1 or 2 at their worst.

"Prior guidance on healed pressure ulcers to not 'reverse stage' a Stage 1 or Stage 2 pressure ulcer no longer applies," CMS explains in the notice posted to its OASIS Web site.

The prohibition on reverse staging for Stage 1 and 2 ulcers does still hold true while the wound is healing, however. During healing "a stage 2 pressure ulcer does not become a stage 1 pressure ulcer; it remains a stage 2 pressure ulcer until it is healed," CMS says.

The change's reimbursement impact could pack a wallop. An OASIS item not mentioned in CMS' missive, M0460 (Stage of Most Problematic [Observable] Pressure Ulcer), especially could cost agencies big. "Under the old rule ... a patient with a Stage 1 or 2 ulcer would receive 15 points at M0460" if the healed ulcer was the most problematic (i.e., probably the only) one, explains clinical consultant Pam Warmack with Clinic Connections in Ruston, LA. "These 15 points are applied regardless of the healing status of the ulcer, since the question does not ask the healing status but only the stage," Warmack tells MLR.

Now, HHAs could lose 15 points for multiple episodes of care, Warmack summarizes. And while 15 points doesn't sound like much, it can knock a patient's clinical domain level down one or even two categories, which can add up to a whopping $900 per patient.

Likewise, in M0440 the patient could lose 21 points in the clinical domain score, although only if she has a burn or trauma diagnosis.

For example: Losing 15 points could put a serious dent in agencies' reimbursement. A patient who has 41 points (C3) could drop to 26 points (C2) for a loss of $887 depending on the functional and service scores, Warmack explains. And a patient who drops from 20 points (C2) to 5 points (C0) could rack up a loss of $597, before wage index calculations.

"Assessment accuracy results significantly affect reimbursement," Warmack warns. And with this much money potentially on the line, you [...]