OASIS Alert

It's time to re-train clinicians - again.

Once again CMS dumps a sudden change on home health agencies - and it could cost you hundreds per patient.

Bottom line: As of Sept. 1, agencies should not count a healed pressure ulcer that was Stage 1 or 2 at its worst as a pressure ulcer when answering M0445. This change could cost you up to $900 per patient.

The scenario never was logical to most clinicians: Why was the Centers for Medicare & Medicaid Services paying extra money for agencies to care for patients who had healed pressure ulcers that no longer required extra care? Well, now CMS won't - at least some of the time.

It didn't make much sense to get case mix points just because the patient once had a reddened area or a shallow break in the skin, says clinical consultant Judy Adams with Charlotte, NC-based LarsonAllen Health Care Group. Finding the inconsistency and changing it now is probably better than waiting for the HHS Office of Inspector General  to make headlines complaining about the practice, she suggests.

New Rule: "Prior guidance on healed pressure ulcers to not 'reverse stage' a Stage 1 or Stage 2 pressure ulcer no longer applies," CMS states in the new policy notice posted to its OASIS Web site. The change is based on the recent opinions of the National Pressure Ulcer Advisory Panel and the Wound Ostomy and Continence Nurses Society, explained CMS spokesperson Mary Weakland in the Aug. 24 Home Health, Hospice and DME Open Door Forum.There has been no change in payment policy at this time, although internal review is in progress, she added.
 
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. And if the healed Stage 2 ulcer left a scar, the answer to M0440 (Does this patient have a skin lesion or open wound?) would be "Yes," CMS adds.

Cost: How much this change costs an agency depends on a number of factors, experts say. If the healed pressure ulcer would have been the most problematic ulcer when you answer M0460, the 15 points you now lose could reduce the clinical domain of the case mix home health resource group by one or even two categories. This drop could cost an agency close to $900 if the patient went from a C3 to a C2, depending on the functional and service scores, explains consultant Pam Warmack with Rus-ton, LA-based Clinic Connections.

Until now, the agency could add the 15 points to the patient's score regardless of the wound's healing status, Warmack says. So the HHA caring for a patient with a Stage 2 pressure ulcer received extra reimbursement whether the ulcer was active or healed.

Another example: If a patient loses 15 points in the clinical domain, the score could drop from C3 (for a patient with 20 points) to a C0 (5 points). Before considering wage index calculations, this drop would be a revenue loss of $597, Warmack illustrates.
 
Confusion has surrounded the OASIS pressure ulcer questions since the beginning. Many agencies weren't following the previous rules, and failed to record healed pressure ulcers, experts agree. These agencies won't see much change under the new rules, but are still shortchanging themselves if they don't record healed Stage 3 and 4 pressure ulcers.
 
More clinicians are likely to be confused and upset about this new policy change because reverse staging rules seem counterintuitive, predicts clinical consultant Karen Vance with BKD in Springfield, MO. And now the reverse staging prohibition is in effect in some instances (for ulcers in the process of healing or for Stage 3 and 4 ulcers) but not others (healed Stage 1 and 2 ulcers). (See flow chart p. 84 for training assistance).

Experts warn: This change could lead clinicians to mistakenly reverse stage more serious ulcers or healing Stage 2 ulcers, which still is not allowed.

To prevent these problems, be sure clinicians understand the reason behind CMS' decision: The way Stage 1 and 2 pressure ulcers heal is different and does not increase the risk of future ulcer development. Stage 3 and 4 ulcers heal with a "permanent alteration of the underlying skin architecture" increasing the risk of future ulceration, the National Pressure Ulcer Advisory Panel announced recently.

This rationale "should make sense to clinicians," Vance notes. "There is logic in the change" and it's up to you to explain it so clinicians can get the related OASIS questions right.

Expect problems: After training your clinicians, you'll want to audit OASIS assessments for this item, recommends clinical consultant Lynda Dilts-Benson with Reingruber & Co. in St. Petersburg, FL. And the typical 10 percent chart audit probably won't be enough, she adds. Clinicians having trouble getting the item right will need individual retraining. 
 
Editor's Note: CMS' notice is at www.cms.hhs.gov/oasis/npuap.pdf.