OASIS Alert

Identify and address these hard-to-heal wounds.

If you don't know what kind of ulcer you're caring for, you'll likely encounter  problems with wound healing.

OASIS assessment wound questions M0445 through M0488 have you assess and code pressure ulcers, stasis ulcers and arterial ulcers, but not diabetic ulcers. However, for patient care--and survey success--you still need to identify diabetic ulcers and include them on the plan of care.

Ulcers 101: To have a diabetic neuropathic ulcer, the patient must have a documented diagnosis of both diabetes mellitus and peripheral neuropathy, notes Elizabeth Ayello, PhD, RN, a nursing professor at Excelsior College in Albany, NY. But documentation labeling an ulcer diabetic doesn't tell you enough.

What to do: Ask the physician to define the underlying etiology of the ulcer, advises Rena Shephard, RN, MHA, president of RRS Healthcare Consulting in San Diego. "For example, is it ischemic and then affected by pressure and diabetes-related factors such as decreased sensation?" Shephard notes that "any time a person has an ulcer, you need to carefully assess what role pressure may have played in causing the wound or in affecting how it heals."

Tip: If you suspect an arterial ulcer in a patient with diabetes, suggest the prescribing clinician order a transcutaneous oximetry to assess the patient's microcirculation, advises Michael Miller, DO, a wound expert in Terre Haute, IN.

Beware shoe fit problems: If a patient with diabetes and peripheral neuropathy has an ulcer on the foot caused by tight shoes, "the ulcer may be both a pressure and diabetic ulcer," advises Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.

Code the Diabetic Ulcer in M0230/M0240

Use ICD-9-CM codes in M0230/M0240 to identify a foot ulcer diagnosed as a diabetic ulcer in a person with diabetes and diabetic peripheral neuropathy. When the cause of the ulcer is due to a diabetic neuropathy, assign the diabetic code 250.6X (Diabetes with neurological manifestations) followed by the code for the ulcer of the lower extremity (707.10-707.19), advises Ann Zeisset, RHIT, CCS, CCS-P, practice manager, American Health Information Management Association.

Emphasize care planning: The care plan for a person with a diabetic neuropathic ulcer should first and foremost focus on glycemic control and nutrition, including monitoring A1c levels and timing the Accuchecks appropriately, says Kathleen Thimsen, RN, ET, MSN, president of RARE Consulting Group Inc. in Belleville, IL.