OASIS Alert

You're not the only one chronically confused about skin ulcers and accurate answers count.

The prospective payment system adds 17 points toward reimbursement if the patient has two or more stage 3 or 4 pressure ulcers healed or not.

M0440 through M0488 on the OASIS assessment ask about  "integumentary status. "Although clinicians are better at sorting out the answers to these questions than they were a year ago, accuracy still is a challenge, experts agree. "I'm seeing problems more with newer staff now," says Pam Warmack with Clinic Connections in Ruston, LA. "Our seasoned veterans are becoming much better at it," she adds.

Even so, chart reviews still reveal an awful lot of inconsistency in wound documentation, reports consultant Melinda Gaboury of Nashville, TN-based Healthcare Provider Solutions.

Head off problems by asking yourself:

1. Is the ulcer really a pressure ulcer or is it a stasis ulcer? Differentiating between these skin lesions is important to demonstrate professional competence and to avoid downcoding and compliance problems, explains Warmack. These ulcers can look the same but both the cause and treatment differ, she adds.

In answering M0445, ask yourself if the patient would have developed the ulcer if there had been no pressure on the spot, Warmack suggests. If not, it is a pressure ulcer. "But if the patient would have developed it anyway, then pressure didn't cause it, and you need to go instead to M0468 to answer the questions for a stasis ulcer,"she explains.Reimbursement points may differ significantly, she notes.

2. Have I staged the pressure ulcer correctly? Once an ulcer is a stage 4 pressure ulcer, it is always a stage 4 pressure ulcer, experts stress.It never goes back to a lesser stage, even as it heals.

Pressure ulcers "are staged to classify the degree of tissue damage observed," according to the Wound Ostomy and Continence Nurses Society.  Agencies can improve consistency in pressure ulcer staging by using the resource surveyors and medical reviewers use the WOCN Society Guidance on OASIS Skin And Wound Status M0 Items found at www.wocn.org/pdf/WOCNOASISGuidance.pdf.

3. Has a previously documented pressure ulcer disappeared? Because a staged pressure ulcer remains at its most severe stage even when it heals, if a patient is admitted with a pressure ulcer, she must be recertified or discharged with one also even if it's completely healed, Gaboury advises.

The National Pressure Ulcer Advisory Panel describes healing as "progressively more shallow depth of an ulcer," as the ulcer is replaced with scar tissue rather than with muscle or subcutaneous tissue, explains Chapel Hill, NC-based senior consultant Judy Adams with Larson Allen Health Care Group.

Part of the confusion may come from the fact that four OASIS questions address the pressure ulcer. M0445 asks if there is a pressure ulcer and M0450 identifies the number at each stage. Then M0460 asks for the stage of the most problematic observable pressure ulcer and M0464 asks for the status of the most problematic observable pressure ulcer. "At this time M0464 is the only way to show healing or positive changes in pressure ulcers in OASIS," Adams says.

4. Has the pressure ulcer been surgically debrided? This procedure removes dead tissue from the ulcer, but doesn't change it to a surgical wound, Warmack advises. A pressure ulcer that was there prior to the surgery remains a pressure ulcer and claiming it is a surgical wound will incorrectly increase the reimbursement points, she says.

5. Has the pressure ulcer been surgically repaired with a flap or graft? If so, it becomes a surgical wound. A graft changes the nature of the wound and the healing process, Warmack explains,so it is defined more accurately as a surgical wound.