Unlearning: to put out of one’s knowledge or memory or to undo the effect of or discard the habit of. This is what we have to do with most everything we have been so diligent about doing with pressure ulcer documentation on OASIS for 16 years. Major changes are set for the Integumentary section of the OASIS-C2 and it is feared that many won’t get the message before January 1, 2017.
As always, clarification has been issued regarding the National Pressure Ulcer Advisory Panel (NPUAP) guidance:
- Agencies may adopt the NPUAP guidelines for clinical practice and documentation. Default to CMS OASIS Instructions if discrepancies exist between NPUAP guidelines and the OASIS scoring instructions.
The HUGE issue for OASIS-C2 that MUST be UNLEARNED is the documentation guidelines for Stage 3 and Stage 4 Pressure Ulcers. Prior to January 1, 2017 agencies have been educated that if a patient has ever had a Stage 3 or Stage 4 Pressure ulcer that it was to be documented as such on the OASIS, even if the ulcer was currently “closed”. Not only are we NOT doing this with OASIS-C2, the language has been updated – now you can acknowledge “closed” or “open” ulcers by referring to them as “healed” or “unhealed”. So what constitutes “healed” –
–Once the pressure ulcer has fully granulated and the wound surface is completely covered with new epithelial tissue, the wound is considered to be closed, and will continue to remodel and increase in tensile strength. For the purposes of scoring the OASIS, the wound is considered healed at this point, and should no longer be reported as an unhealed pressure ulcer.
This means that even if the patient had a Stage 4 Pressure ulcer, at some point, that had bone exposed, etc. and it is now completely covered with epithelial tissue it is “healed” and NOT reported as a pressure ulcer on the OASIS-C2. If the patient has that same pressure ulcer re-open during the course of the episode, it would then be recorded as a Stage 4 Pressure ulcer on the next OASIS-C2 document. Case- Mix Weight is, in part, determined by the pressure ulcer M items. This will mean a significant case-mix weight cut when the ulcers are “healed”. Keep in mind that even if the patient has an Other Follow Up OASIS completed, due to change in condition or even a Resumption of Care, during that same episode, the reimbursement does NOT change for that episode. ONLY with the Follow Up/Recertification OASIS for a subsequent episode would the case-mix weight and payment for the subsequent episodes be affected.
The old M1308 is BACK and is now M1311. This OASIS-C2 item is to document pressure ulcers, by stage, that are present at the SOC/ROC and then acknowledging at Follow Up and Discharge the ulcers that are present and the ones of those that were present at SOC/ROC. This item also brings two NEW points of instruction.
1. A pressure ulcer treated with a skin graft (defined as transplantation of skin to another site) should not be reported as a pressure ulcer and until the graft edges completely heal, should be reported as a surgical wound on M1340.
2. Pressure ulcers that are known to be present but that are Unstageable due to a dressing/device, such as a cast that cannot be removed to assess the skin underneath, should be reported as D1 (Unstageable). “Known” refers to when documentation is available that states a pressure ulcer exists under the non-removable dressing/device. **Prior instruction included that you could document if you “suspected” that there was one under the dressing.
The last item of note is M1313 to be completed at Discharge. This item is to identify the number of current pressure ulcers that were not present or were at a lesser stage at the most recent SOC/ROC. Basically, trying to determine if this patient has pressure ulcers at Discharge that they did not have before or that got worse during your agency’s episode of care. This item is confusing enough that they even include an algorithm to assist in completion.
If you are a HPS Alliance Member there will be a free teleconference on November 18, 2016 to cover all the changes.