OASIS Alert

Claim your rightful ulcer reimbursement while you still can.

If you've been confused about healed pressure ulcers, you're not alone - but an answer to your questions may finally be at hand.

One of the most difficult areas for clinicians to understand in conducting an OASIS assessment has been the series of questions about pressure ulcers, experts say. 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," says Chapel Hill, NC-based senior consultant Judy Adams with LarsonAllen Health Care Group.

Clinicians are concerned about how to answer these questions when a patient who is known to have had pressure ulcers is admitted to home care with those pressure ulcers healed.

With the Centers for Medicare & Medicaid Services keeping a close watch for fraud and abuse and overpayments, agencies are cautious. Is it proper to receive extra points and reimbursement from marking the patient as having two or more Stage 3 or 4 pressure ulcers, when these areas are healed and require no extra care, they wonder.

Yes, consider this a bonus similar to the one agencies receive when a patient has extensive personal care needs, but family members or others provide the needed care, suggests National Association for Home Care & Hospice VP of Regulatory Affairs Mary St. Pierre. At least for the moment, "once a pressure ulcer, always a pressure ulcer" rules the day.

And don't be confused when you must choose between the OASIS instruction from CMS to assess the patient's condition on that day - or 14 days before for some questions - and the prohibition on reverse staging of pressure ulcers.

Even if the ulcers healed five years ago and never recurred, the agency can receive the extra payment, CMS says. "We haven't changed the policy," a CMS spokesperson assured St. Pierre. "When we have the opportunity to modify OASIS, we will most likely add an option to include 'fully epithialized' or healed. I expect the grouper will look to that and downcode payment for the healed ulcer," the spokesperson added.

It's most probable that any such changes affecting case mix and payment won't take effect until 2005, though, St. Pierre tells Eli.

TIP: CMS has included a specific example outlining the correct answers to the healed ulcer scenario in its new Internet-based training module (see story, "Training"). If you know a patient had a previous healed pressure ulcer and you know what stage it was at its worst, you mark that stage on the new OASIS assessment, CMS instructs.

For example, if the ulcer was a Stage 3 in a previous episode, but when the patient is admitted for the current episode the ulcer remains healed, you would answer the questions as follows, CMS says:

M0445 = 1 (yes)                    M0450(a) = 0

M0464 = 1

M0450(b) = 0                         M0450(c) =1

M0450(d) = 0                         M0460 = 3

But for OASIS accuracy, "document in the clinical record when a pressure ulcer you're reporting in M0450 is healed," instructs OASIS expert Linda Krulish, president of Redmond, WA-based Home Therapy Services. Of course, you document more details of active pressure ulcers as well, but because of the OASIS assessment's limitations, supporting documentation is important for providing an accurate picture of a patient with healed ulcers, she adds.

Additional response-specific instructions from CMS to keep in mind when assessing pressure ulcers include: