OASIS Alert

You set the criteria for most problematic.

When it comes to answering M1320 (Status of most problematic pressure ulcer), the Centers for Medicare & Medicaid Services offer plenty of guidance, but you'll still need to use your clinical judgment to select the right answer. The following pointers may help guide the way.

1. It's up to you to choose the criteria for "most problematic." It could be the largest pressure ulcer, the one at the most advanced stage, the most difficult to access for treatment, or one in the area most difficult to relieve pressure. If there is only one pressure ulcer, that one is automatically the most problematic.

2. The most problematic pressure ulcer may be of a lower stage, says Judy Adams, RN, BSN, HCS-D, COS-C, with Adams Home Care Consulting in Chapel Hill, N.C. For example, suppose your patient has a pressure ulcer of the heel that was stage I but has advanced to stage II and appears to be getting worse. He also has a stage III pressure ulcer of the sacrum that is healing nicely, beginning to fill in, granulate, and get some epithelium over it. You might mark the stage II pressure ulcer as the most problematic, and that's OK, she says.

Tip: If your patient has more than one pressure ulcer, remember to clearly indicate in the clinical record which one you are describing at M1320, Adams says.

3. Stage II pressure ulcers reported at M1320 are always 3 -- Non-healing. That's because stage II pressure ulcers don't granulate and newly epithelialized stage II pressure ulcers are considered healed and no longer considered to be a pressure ulcer so they aren't counted in this item, says Ann Giles, RN, BSN, HCS-D, COS-C, director of ICD-9 coding & OASIS review services with Biloxi, Miss.-based

PPS Plus Software.

4. Deep tissue injuries reported in M1320, whether suspected or confirmed are marked as 3 -- Nonhealing. Deep tissue injuries do not granulate and would not be covered with new epithelial tissue, CMS says in the OASIS-C Guidance Manual. Rather, a suspected deep tissue injury can take one of two paths to heal. It either opens up and begins to go through the healing process, so that it becomes a stageable pressure ulcer, Adams says. Or it resolves without opening up, but while it is present it is considered nonhealing.

5. An intact serum-filled blister resulting from pressure should be reported as a stage II pressure ulcer, Adams says. When reporting such an ulcer in M1320, you would select 3 -- Non-healing because the fluid-filled blister prevents it from healing.