OASIS Alert

Prepare for ulcer coding conflict between OASIS, ICD-9 guidance.

Coding for ulcers is never easy, but recent clarification from the Centers for Medicare & Medicaid helps lay to rest one common question. Can you describe a healed stasis ulcer as newly epithelialized?

The answer is no, according to the OASIS-C Guidance manual, updated in December 2010. The latest version of the manual includes the following new information at M1334 (Status of Most Problematic [Observable] Stasis Ulcer):

"Once a stasis ulcer has completely epithelialized, it is considered healed and should not be reported as a current stasis ulcer. The response option "Newly epithelialized" should not be selected for a healed stasis ulcer, as a completely epithelialized (healed) stasis ulcer is not reported as a stasis ulcer on OASIS."

This clarification clears up a matter that has caused confusion since OASIS-C went into effect, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, director of coding with Foundation Management Services in Denton, Texas.

M1500 (Symptoms in Heart Failure Patients) used to say that if heart failure was not coded in M1010, M1016, or M1020/M1022/M1024 on the last assessment the clinician had to answer M1500 'NA,' Twombly points out. Changes in the updated guidance give you the ability to answer yes even if heart failure wasn't coded among the top 6 diagnoses last assessment, she says.

Response-specific instructions for this item now read "Select Response options 0, 1, or 2 if the patient has a diagnosis of heart failure, regardless of whether the diagnosis is documented elsewhere in the OASIS assessment."

The January 2011 Quarterly CMS OCCB Q&As also offer new guidance for completing M1500:

Question: Our nurse was notified by family that her patient, who has a diagnosis of heart failure, was admitted to the hospital due to increased shortness of breath (SOB) due to congestive heart failure (CHF). The patient had not exhibited signs or symptoms of heart failure since the start of care (SOC). Because the family chose not to call the agency, no visit was made to assess the patient for signs and symptoms of CHF on the day he went into the hospital. How do we answer M1500 (Symptoms in Heart Failure Patients) and M1510 (Heart failure follow-up) in this situation?

Answer: When M1500 is answered at transfer or discharge, "1 -- Yes" is the appropriate response if the patient had a diagnosis of heart failure and exhibited symptoms of heart failure at or since the previous OASIS assessment. In your scenario, the patient had a diagnosis of heart failure and the record review revealed that the patient experienced SOB. The SOB resulted in a qualifying hospitalization since the previous OASIS assessment.

When completing the transfer OASIS, the clinician would answer M1500 "1 -- Yes", even though the agency did not have the opportunity to assess the symptoms during a visit. When answering M1510, you report the actions your agency took in response to the heart failure symptoms. If no actions were taken, response "0 -- No action taken" would be appropriate. Include an explanation of your "No" response in the clinical record.

Not all of CMS's updates provide clear-cut guidance. A new bullet at M1324 (Stage of Most Problematic Unhealed [Observable] Pressure Ulcer) seems to contradict ICD-9 coding instruction, Twombly says.

The new response-specific instructions at M1324 advise "Until suspected deep tissue injury (DTI) evolves and opens, the stage will be considered "NA," as the wound bed cannot be visualized."

But the official ICD-9 coding guidelines advise you to assign code 707.25 (Pressure ulcer, unstageable) for "pressure ulcers that are documented as deep tissue injury but not documented as due to trauma."

"There is a new conflict there," Twombly says.