OASIS Alert

Avoid the one response you can never list in M1334.

If your responses to the OASIS stasis ulcer question aren't spot-on, you could be risking not only clinical points, but nonroutine supply points as well. Give your approach a brush-up with the latest guidance from the Centers for Medicare & Medicaid Services (CMS).

The OASIS stasis ulcers items include:

• M1330 -- Does this patient have a Stasis Ulcer?
• M1332 -- Current Number of (Observable) Stasis Ulcer(s), and
• M1334 -- Status of Most Problematic (Observable) Stasis Ulcer.

Gatekeeper: To gain case mix points for your patient's stasis ulcers, you must answer M1330 correctly, says Judy Adams, RN, BSN, HCS-D, COS-C with Adams Home Care Consulting in Chapel Hill, N.C. Your response options include:

0 -- No [Go to M1340]

1 -- Yes, patient has BOTH observable and unobservable stasis ulcers

2 -- Yes, patient has observable stasis ulcers ONLY

3 -- Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]

If you don't answer yes (response 1, or 2), you can't go on to M1334 which determines the case mix points you're eligible for. The patient must have an observable stasis ulcer for you to report the healing status.

To answer M1332, count the number of observable stasis ulcers and select the correct response (1 -- One, 2 -- Two, 3 -- Three, or 4 -- Four or More). Remember, only stasis ulcers covered with a non-removable dressing or cast are considered unobservable.

Tallying the number of stasis ulcers for M1332 might seem straightforward, but what if the wound margins are difficult to determine?

"If areas of venous stasis ulceration are contiguous and developed at the same time, the entire area would be counted as one stasis ulcer" in M1332, CMS says in the July 2011 Quarterly CMS OCCB Q&As.

But if "the patient had a venous stasis ulcer and then later developed another venous stasis ulcer, and eventually the wound margins met," you would count it as two ulcers, "as long as it remains possible to differentiate one ulcer from another based on wound margins," CMS said.

Answering M1332 in situations like these requires good history-taking and assessment skills, said CMS's Pat Sevast during the July OCCB Quarterly OASIS Update audioconference. "Depending on the timing and progression, it may be difficult for the clinician to know that a current ulcer was once two ulcers, and/or where one ulcer ends and another begins for assessment/reporting purposes."

Bottom line: It's up to the assessing clinician to determine the number of stasis ulcers in situations where multiple ulcers may have merged together, CMS says.

M1334 asks you to describe the status of patient's most problematic (observable) stasis ulcer. Your choices include:

0 -- Newly epithelialized;

1 -- Fully granulating;

2 -- Early/partial granulation; or

3 -- Not healing.

Watch out: Although you have the option of listing 0 -- Newly epithelialized, this response is never correct because once a stasis ulcer is covered with new epithelium, it goes away, says Adams.

The OASIS-C Guidance Manual, updated in December 2010, includes the following update at M1334: "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."

Note: See the sidebar on page 115 for guidance on stasis ulcer healing status.

You'll earn case mix points for stasis ulcers based on whether they are 2 -- Early/partial granulation (8 points for all equations) or a C2 HHRG in equations 1, 2, or 3 or 3 -- Not healing (11 points for all equations) or C3 HHRG in equations 1 or 3, Adams says. Plus there are more points available for nonroutine supplies based on the number of stasis ulcers and the healing status.

Remember: If you don't mark M1330 correctly, you won't get any case mix points, Adams reminds. And, if you don't assign the correct healing status, you risk losing out on points. For example, if you mistakenly report the healing status of a stasis ulcer as early partial granulation when it actually meets the criteria for not healing, you'll lose about $367, she says.

Scenario 1: Your patient has a stasis ulcer of the lower left leg that is covered with epithelial tissue with two scabs on the distal aspect of the wound surface. How would you respond to M1334?

In this situation, the key is the presence of the scabs, Adams says. If they are truly scabs adhered through the epithelium and not just serum and dried blood on top of the wound then this would be a fully granulated wound (response 1).

It's important to look at what those scabs are, Adams cautions. If they are attached to the underside of the wound at all, then it would be a fully granulated wound because the granulation is there, but the epithelium is not intact. There is something coming through the wound that is holding it from being fully intact, she says.

Scenario 2: Your patient has bilateral stasis ulcers on her lower legs. The ulcer on the left leg has been completely re-epithelialized for the last week and the right leg is 40 percent granulated with 10 percent of slough. How would you respond to M1334?

The stasis ulcer on the left leg is healed, so it's no longer a stasis ulcer, Adams says. But the right leg has less than 25 percent slough or eschar and more than 25 percent granulation, so it meets the definition of early partial granulation (response 2).

Scenario 3: Your patient has a stasis ulcer on his right calf with wound edges open, no signs or symptoms of infection and 75 percent of the wound is covered with granulation tissue.

This wound is in early partial granulation (response 2), Adams says. This stasis ulcer isn't fully granulated because it isn't fully granulated up to the surface. Only 75 percent of the wound is covered with granulation tissue.

Another example: Your new patient came on service for care of her congestive heart failure. She also had bilateral lower extremity stasis ulcers at admission. At the discharge, the skin on the lower extremities is intact without any scabs or crust.

This patient no longer has any stasis ulcers, Adams says. So at discharge you would answer 0 -- No to indicate that the patient has no observable stasis ulcers and you would never get to M1334, she says.