OASIS Alert

Published on Thu Oct 03, 2013 PDF

First things first: Does your patient’s wound qualify as surgical?

The OASIS integumentary items are confusing, and the surgical wound items like M1342 — Status of the patient’s most problematic (observable) surgical wound are no exception. Follow these hints from our experts to make sure you’re choosing the best responses.

1. Be sure your patient’s wound qualifies as a surgical wound according to the Centers for Medicare & Medicaid Services before answering M1342. For example, in OASIS logic, surgical wounds are those that were created by surgery and go through the integumentary system, says Judy Adams, RN, BSN, HCS-D, HCS-O, with Adams Home Care Consulting in Asheville, N.C. Surgical approaches through mucosal surfaces, vaginal approach or eye surgery are not considered surgical wounds.

There are dozens of clarifications in the CMS consolidated Q&A in Category b, Q102- 109 that differentiate whether a wound qualifies as a surgical wound, Adams says. The following table will help clarify whether some common wounds count as surgical wounds.

Caveat: This list is based on CMS Q&As Category 4 B 102-105.22. 106, 108.01-109. But the Q&As from CMS aren’t exhaustive and all inclusive. They only address specific questions clinicians have asked over time.

2. If there is anything such as a drain coming through the incision, it cannot epithelialize as long as the edges cannot come together. Therefore, even if the remainder of the incision edges are approximated, the wound is non-healing, Adams says.

3. If the incisional line was originally approximated and then opens so there is space between the two edges, the wound is now healing by secondary intention and you can consider all of the M1342 responses, Adams says. For the wound to be early/partially granulated, there must be at least 25 percent or more granulation tissue and less than 25 percent avascular tissue with no evidence of infection and the wound edges open so the wound can continue to heal. If there is less than 25 percent granulation tissue or more than 25 percent avascular tissue, or any of the other characteristics listed as non-healing, the wound is non-healing.

4. Fully granulated wounds may include wounds where the granulation has filled the wound all the way to the surface of the surrounding skin, Adams says. Wounds that in addition to the granulation, have new epithelial tissue covering any amount of the surface of the wound that is less than 100 percent closed at the edges are also fully granulated. That’s provided there is no evidence of infection, dead space, avascular tissue and the edges are not closed (curled).

5. Once a wound has been epithelialized for 30 days, it is a scar and no longer considered a surgical wound, Adams says.

6. If any one of the criteria listed in the WOCN guidance under non-healing are present, the wound is considered non-healing. Multiple characteristics do not have to be present, Adams says.

7. When evaluating the healing status of surgical wounds, consider only the surgical wound itself. The insertion sites of sutures, staples, or retention sutures are not considered part of the surgical wound. Instead, report these other wounds or lesions in M1350 — Does this patient have a skin lesion or open wound? if you are providing care, Adams says.

8. Don’t let your clinical training trip you up. CMS has modified application of the WOCN definitions for status of healing in their instructions for completing M1342, says Rhonda Will, RN, BS, COS-C, BCHH-C, of Northampton, Mass.-based Fazzi Associates. In some instances, CMS instructs the clinician to select the “best” answer and that doesn’t always match up with what you actually observe.

“To select a wound status response that says ‘not healing’ for a very normal appearing, and uncomplicated surgical wound healing by primary intention that has no signs or symptoms of infection or other characteristics of a ‘not healing’ wound is counterintuitive and for many clinicians is a moral issue,” Will says. “Completion of OASIS items does not always result in the reporting of direct observations.” Instead, the data collected by the OASIS represents clinical observations modified and molded to follow the instructions that fit the response choices given, she says.

Test Your M1342 Skills

How would you respond to M1342 in the following scenario? Your patient had surgery seven weeks ago and the physician removed the retention sutures last week. The incision has been fully epithelialized for 30 days. At the time of recertification, six of the eight insertion sites of the retention sutures are red, four are draining murky fluid, and two have crusts on the sites.

Answer: You won’t choose a score at M1342 for healing status of a surgical wound because this patient no longer qualifies as having a surgical wound, Adams says. This is because the incisional area has been epithelialized for more than 30 days. But if your agency will be providing care for the areas where the retention sutures were located, you can report them as a “yes” at M1350, she says. (Reference: CMS Consolidated Q&As 2012, Category 4b, Q.112,4,1)

Resources: To make certain you’re up-to-speed with M1342, be sure to familiarize yourself with the item guidance in Chapter 3 of the OASIS C Guidance Manual, the clarifications within the CMS consolidated Q&As and the quarterly updated OASIS questions (https://www.qtso.com/hhatrain.html), plus the WOCN guidance on answering OASIS integumentary questions (http://c.ymcdn.com/sites/www.wocn.org/resource/resmgr/docs/guidanceoasis-c.pdf). “We have certainly seen many changes and additional information related to the healing status of surgical wounds,” Adams says.