Kathy: Welcome to the Home Health
Virtual Training Program, Part 1.
My name is Kathy Roby, and I will be presenting
Section M: Skin Condition.
First, a few words about my background.
I have been in home health as a clinician,
a clinical manager, an administrator, and an educator.
For the last 15 years, I've been
a quality consultant assisting home health
and hospice providers to improve the quality
and the outcomes of care.
Our objectives for this presentation are
to describe the coding updates for Section M items,
and to summarize the implications of the Section M updates.
The intent of the items in Section M
are to assess the presence of pressure ulcers,
stasis ulcers, and surgical wounds.
There have been a number of changes in Section M.
As a brief overview, the references
to the National Pressure Ulcer Advisory Panel,
NPUAP, have been updated
to the National Pressure Injury Advisory Panel, NPIAP
Throughout this section.
a clarification of consistent data
sources has been provided.
Physical assessment and observation
are the preferred approaches.
Patient and caregiver reports or medical records,
including physician or allowed practitioner orders
and input may be used.
Home health providers are encouraged to refer to Appendix D
of the OASIS-E manual for a description
of the changes from OASIS-D to OASIS-E,
to ensure that you have a complete understanding
of the revisions to these items.
Additional changes to Section M include these.
Updated response specific instructions
for the following items.
M1307, The Oldest Stage 2 Pressure Ulcer
that is present at discharge.
M1311, The Current Number of Unhealed Pressure Ulcers
or Injuries at Each Stage.
M1330, Does this patient have a Stasis Ulcer?
M1340, Does this patient have a Surgical Wound?
Coding instructions have been updated.
M1324, The Stage of the Most Problematic
Unhealed Pressure Ulcer
or Injury that is Stageable.
And update to instructions for surgical wound assessment.
M1342, The Status of the Most Problematic
Surgical Wound that is Observable.
This is a screenshot of M1307,
The Oldest Stage 2 Pressure Ulcer
That Is Present at Discharge.
For this item, we look first
at the definitions to the right.
Number one was present
at the most recent SOC/ROC assessment.
Number two, developed since
the most recent SOC/ROC assessment.
You would enter your date in the boxes provided
and select the appropriate number
and place it in the code box on the left.
The specific instructions for this item have been updated.
We do not reverse stage pressure ulcers as a way
to document healing as it does not accurately characterize
what is physiologically occurring as the ulcer heals.
For example, over time, even though a Stage 4 pressure ulcer
has been healing and contracting so that it is less deep,
wide, or long, the tissues that were lost,
muscle, fat, and dermis,
will never be replaced with the same type of tissue.
Clinical standards require
that this ulcer continue
to be documented as a Stage 4 pressure ulcer
until it has healed or becomes unstageable.
This is a screenshot of M1311, The Current Number
of Unhealed Pressure Ulcers or Injuries at Each Stage.
This item identifies the number of pressure ulcers
or injuries at each stage,
two, three, and four, and designated as unstageable
that are observed on assessment.
This item is assessed at start of care,
resumption, and discharge from the agency.
Again, this is a snapshot of this assessment.
It's important to read the descriptors for A
through F carefully, enter the current number
of unhealed pressure ulcers or injuries
at each stage in the box to the left.
This is a screenshot of M1311 at discharge.
Again, read the description of each item carefully
and enter the current number of unhealed pressure ulcers
or injuries at each stage in the box immediately
to the left of that statement.
What is the rationale behind the coding
of this item?
In M1311, it is important to recognize
and evaluate each patient's risk factors
for developing skin ulcers,
wounds, or lesions, and to identify
and evaluate all areas at risk of constant pressure.
A complete assessment of the skin is essential
to an effective pressure ulcer injury prevention
and skin treatment program.
It's imperative to determine the etiology of all wounds
and lesions, as this will determine
and direct the proper treatment and management of the wound.
The specific response instructions
for M1311 have been updated.
The general standard of practice for patients starting
or resuming care is that patient assessments
are completed as close to the actual time
of the SOC/ROC as is possible.
These instructions have been updated
to allow for when the assessing clinician is unable
to complete a full skin assessment at the first visit.
The assessing clinician may collaborate
with a second clinician who completes
that first clinical assessment
within the required assessment timeframe.
In addition, the Response Specific Instructions
for stages two and three pressure ulcers have been updated.
Please note the enhancements are highlighted in blue text.
For B1, a previously closed Stage 3 pressure ulcer
that is currently open again, should be reported
as a Stage 3 pressure ulcer,
unless currently presenting
at a higher stage or unstageable.
For C1, a previously closed Stage 4 pressure ulcer
that is currently open again should be reported
as a Stage 4 pressure ulcer, unless currently unstageable.
An important concept in accurately coding M1311
is understanding how to determine present
at the most recent start of care or resumption of care,
so let's review that definition now.
Again, this content in blue has been added for clarity.
If the patient has a pressure ulcer that was documented
at SOC/ROC, and at discharge,
is documented at the same stage,
it would be considered as present
at the most recent SOC/ROC,
even if during the episode
the original pressure ulcer healed and reopened.
Let's move on now to M1324, The Stage
of the Most Problematic Unhealed Pressure Ulcer
or Injury That Is Stageable.
This is a screenshot of this item.
In the gray box, it tells us
that M1324, The Stage of the Most Problematic
Unhealed Pressure Ulcer
or Injury That Is Stageable, excludes pressure ulcer
or injury that cannot be staged
due to a nonremovable dressing or device,
coverage of the wound bed by slough and/or eschar,
or a deep tissue injury.
Remember that Stage 1 pressure injuries,
although closed, intact skin,
would not be considered healed.
This is a screenshot of M1330.
Does This Patient Have a Stasis Ulcer?
This item identifies patients
with ulcers caused by inadequate venous circulation
in the area affected, usually the lower legs.
This lesion is often associated with stasis dermatitis.
For this item, you will again enter the number in the box
to the left for the response
that most accurately describes this patient.
When coding this item, response number three is selected
if the patient has unobservable stasis ulcers only.
M1330, these are response specific instructions.
Unobservable stasis ulcers are reported stasis ulcers
that cannot be observed,
because of a dressing or device,
such as a cast or Unna boot, that cannot be removed.
Information may be obtained from the physician
or patient caregiver regarding the presence
of a stasis ulcer underneath the cast or dressing.
Unobservable stasis ulcers are defined as reported,
but covered by a nonremovable dressing
or device such as a cast or an Unna boot.
Collaboration with others is permitted.
Note that if you have coded M1330 as three,
you will move directly to M1340.
M1340 is, Does This Patient Have a Surgical Wound?
This is a screenshot of this item
where we are asked to determine if
there is a surgical wound.
For coding this item, the Response Specific Instructions,
does the patient have a surgical wound, have been updated.
For coding this item, the agency clinician may use
any skin assessment conducted
during the assessment timeframe.
This is a screenshot for M1342.
The Status of the Most
Problematic Surgical Wound That Is Observable.
This item identifies the degree
of healing present in the most problematic
observable surgical wound.
So the definition, again,
reads, M1342 is the Status
of the Most Problematic Surgical Wound That Is Observable.
Again, you will look at the definitions on the right,
select zero through three
that most closely describes your patient
and enter the code in the box to the immediate left.
M1342 speaks to the most problematic surgical wound.
But most problematic is determined
by the clinician's professional evaluation
of the individual's overall wound status.
And may be based on factors including
but not limited to healing status,
such as an ulcer that is infected or resistant to treatment,
size, may be the largest ulcer,
location, may be difficult to access for treatment.
Again, remember, this is based on the professional judgment
of the assessing clinician.
Surgical wounds, healing by
primary intention, do not granulate.
Therefore, the only appropriate responses are zero,
newly epithelialized or three, not healing.
A surgical incision is not automatically coded
as Response 3 solely due to the presence of staples.
These are important concepts regarding wound assessment
that I would like to reinforce.
Again, healing by primary intention does not granulate.
Therefore, the only appropriate response is zero or three
and a surgical incision
is not automatically coded as not healing if
there are staples present in the wound.
Surgical wounds with incisional separation will heal
by secondary intention.
Surgical wounds, healing
by secondary intention, do granulate.
Therefore, in addition to meeting the definition for zero,
newly epithelialized, or three,
not healing, these secondary intention wounds may also fit
the definitions for Response 1, fully granulating,
or Response 2, early partial granulation if appropriate.
In conclusion, during this presentation,
we have reviewed the changes
to item guidance language in Section M.
We have summarized the coding updates for pressure ulcers
or injuries, stasis ulcers, and surgical wounds.
We've covered a great deal
of information in this presentation.
If you would like to submit a question regarding
this presentation, please send it
to PACTraining@EconometricaInc.com by August 31st, 2022.
Again, that email is on this slide.
As a reminder, a practice coding workshop
will be held in September.
We strongly encourage you to attend.
Selected questions from those submitted will be answered
in a Q&A session during the September,
2022 virtual live event.
Thank you for reviewing this presentation with us,
and we look forward to your coming to the coding workshop.