OASIS Alert

Do you know which treatment turns a pressure ulcer into a surgical wound?

Answering M1320 (Status of most problematic pressure ulcer) is complicated enough. Add in suturing, grafting, and debridement and things only get murkier. Four tips help you know what to do when faced with these common pressure ulcer treatments.

Suturing a pressure ulcer closed isn't common, says Judy Adams, RN, BSN, HCS-D, COS-C with Adams Home Care Consulting in Chapel Hill, N.C. Sutures aren't a preferred method of treatment due to limited efficacy, she says. But suturing the edges together is occasionally done in an attempt to close a stage III or IV pressure ulcer.

If your patient has a pressure ulcer that has been sutured together, you'll answer M1320 with "NA -- No observable pressure ulcer," Adams says. For the purposes of OASIS data collection, CMS treats this situation as a pressure ulcer with a dressing that cannot be removed, Adams explains.

Caution: Make certain the pressure ulcer wasn't closed with a surgical procedure such as a skin advancement graft, rotation flap, or muscle flap, Adams says. Pressure ulcers treated with these procedures will have different M1320 answers.

Skin grafts to pressure ulcers are a less desirable treatment than muscle flaps, but they are still occasionally done. In this procedure, a skin graft is sutured in place over the pressure ulcer and the skin graft serves as a "tissue bandage" over the wound, Adams says.

Because skin grafts are full-thickness grafts, they are usually performed on stage III or IV pressure ulcers, Adams says. "It would be very unusual but not impossible for a skin graft to be done on a stage II pressure ulcer," she says.

How you'll report a pressure ulcer treated by a skin graft in M1320 depends upon whether the site is covered by a dressing.

If there is a physician's order not to remove the pressure ulcer dressing until the first doctor's appointment, you'll choose NA, Adams says. If the bed of the pressure ulcer is not visible, but the skin graft is intact with no signs or symptoms of infection, breakdown or rejection, choose 0 -- Newly epithelialized, she says.

Example: Your patient had a skin graft placed on a pressure ulcer of the sacrum six months ago. The wound has no signs of complications. You would answer 0 -- Newly epithelialized for this patient, Adams says. As the skin graft heals, it may contract a bit and become darker, but a skin graft is considered epithelial tissue, she says.

Debridement cleans out eschar, slough, and bad tissue to promote healing of a pressure ulcer. After debridement, the pressure ulcer remains a pressure ulcer for OASIS purposes, Adams says.

To answer M1320 for a pressure ulcer treated with debridement, look to the Wound Ostomy Continence Nurses Society (WOCN) guidance on OASIS-C integumentary items found here: www.wocn.org/pdfs/GuidanceOASIS-C.pdf. This document offers guidelines for completing all of the wound-related OASIS items.

Each visiting nurse should carry a copy of this eight page guidance, suggests OASIS expert, Ann Giles, RN, BSN, HCS-D, COS-C, director of ICD-9 coding & OASIS review services with Biloxi, Miss.-based PPS Plus Software. Guidance from the Centers for Medicare & Medicaid Services instructs clinicians to reference the WOCN guidance when answering OASISC integumentary items, so it's important to have this information at hand, Giles says.

When a pressure ulcer has been treated with debridement, you'll probably score it at least a 2 -- Early/partial granulation at M1320, Adams says. But if the wound is not fully granulated, it may be more appropriate to list 3 -- Non-healing, she says.

When a patient has a muscle graft to a pressure ulcer, the wound becomes a surgical wound for the OASIS integumentary items, Adams says. So, you wouldn't consider these wounds when answering M1320.

But what if the muscle graft breaks down, resulting in a new pressure ulcer?

If the muscle flap had healed completely and then began to break down due to pressure, you would have a new pressure ulcer to report and you would base your M1320 answer on the WOCN guidance, Adams says.

But if the flap had never healed completely, it would be considered a complication of a surgical wound and you wouldn't consider it for inclusion at M1320. Instead, you would report it at M1342 -- Status of most problematic (observable) surgical wound.

Note: While OASIS logic considers a pressure ulcer treated with a muscle graft to be a surgical wound, ICD-9 coding logic still calls it a pressure ulcer. So you would still list a pressure ulcer code for patients who have received this treatment.