OASIS Alert

Hint: Know the difference between primary and secondary intent healing.

Documenting wounds on the OASIS is complex and full of intricacies. Make sure your responses are accurate with the latest guidance on reporting problematic surgical wounds.

OASIS item M1342 asks you to identify the status of the patient's most problematic (observable) surgical wound. New guidance from the Centers for Medicare & Medicaid Services helps you choose the best response.

Your response options for M1342 -- Status of the patient's most problematic (observable) surgical wound are:

0 -- Newly epithelialized;

1 -- Fully granulating;

2 -- Early/partial granulation; and

3 -- Not healing.

This item identifies the degree of healing present in the most problematic, observable surgical wound.

Key: Before you can select an answer for this item, you'll need to ask two questions.

If your patient has only one observable surgical wound, that wound is automatically the most problematic, according to CMS' response-specific guidance for this item. Remember, all surgical wounds are considered observable unless they are covered by a dressing or cast that cannot be removed.

When there is more than one surgical wound, you must use your clinical judgment to determine which is "most problematic." It may be the largest surgical wound, the one most resistant to treatment, or an infected surgical wound. You may find other measures to base your decision upon, depending on the specific situation, CMS says.

The responses you can select for M1342 vary depending upon the way the surgical wound is healing.

Wounds healing by primary intention heal through a process of epithelialization (regeneration of the epidermis across a wound surface). These wounds are closed by sutures, staples, or adhesive tape.

Wounds healing by secondary intention heal through granulation. A patient with a wound healing by secondary intention may have a drainage system or his wound may be packed with gauze.

Surgical incisions healing by primary intention do not granulate, so the only appropriate responses for these wounds would be 0 -- Newly epithelialized or 3 -- Not healing, CMS advises in new response-specific instructions for M1342 in the January 2011 update to the OASIS-C Guidance Manual.

"If the wound is healing solely by primary intention, observe if the incision line has re-epithelialized," CMS instructs. "If there is no interruption in the healing process, this generally takes within a matter of hours to three days." If the wound doesn't show full epithelial resurfacing such as a scab adhering to underlying tissue, the correct response to M1342 would be 2 -- Not healing for a wound healing by primary intention.

Wounds with incisional separation are healing by secondary intention, CMS says in the update. For these wounds, the clinician must determine the status of healing, which could be 3 -- Not healing, 2 -- Early/partial granulation, 1 -- Fully granulating, and eventually 0 -- Newly epithelialized, CMS says.

When answering M1342, consider a surgical site closed primarily (with sutures, staples, or a chemical bonding agent) as a surgical wound until re-epithelialization has been present for approximately 30 days, CMS says. This timeline holds true unless the wound dehisces or presents signs of infection. After 30 days, the surgical wound is generally described as a scar, and would not be reported in M1342.

Select response 0 -- Newly epithelialized for implanted venous access devices and infusion devices when the insertion site is healed, Northampton, Mass.-based Fazzi Associates instructs in the OASIS C Best Practice Manual.

Get the Latest M1342 Answers

CMS has been answering questions regarding dialysis shunts and surgical wound rules, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

In the CMS OASIS Q&As related to M1342, the answer to Q105.3 states that an implanted venous device is considered a surgical wound until it has been epithelialized completely for 30 days at which time it becomes a scar. But, the next sentence of the answer says that the site is considered a surgical wound as long as the device is in place.

CMS has clarified how to respond in this situation with the following response, Selman-Holman says. "An implanted venous access device is considered a current surgical wound as long as it is implanted in the patient's body."

CMS goes on to say "When first implanted, the incision is the surgical wound. The assessing clinician will follow the 12/09 WOCN guidance to determine the healing status of the incision. Once it is fully epithelialized, the site (due to the implanted device) will remain a current surgical wound with a status of 'Newly epithelialized' for as long as it is present in the patient's body, unless it later develops complications. This guidance clarifies and supersedes CMS OASIS Q&A Category 4b, Q105.3."

In other words: "The dialysis shunt is a surgical wound, but the 30 day rule does not apply. The dialysis shunt is considered a surgical wound as long as it is in place," Selman-Holman says.

Tip: At follow-up, skip M1342 item if the patient no longer has surgical wounds(s).

Editor's note: See the Reader Question on page 41 for another M1342 update from CMS.