Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
Continued from the last post, lets tie all of the pieces together when coding Pressure Ulcers (Long Stay). Understanding the RAI Guidelines for completion of Section M is the third and final key to assist with managing this Quality Measure.
In order to ensure accurate coding and documentation, it is important to understand the intent of each area of Section M. Harmony Healthcare International (HHI) provides the following helpful tips to assist with this process:
- M0100 – Review data from skin care flow sheets, tracking forms, nurse notes and risk assessments. Talk to treatment nurses and direct care givers on all shifts. The most important piece to remember is to actually look at the resident. Complete a physical assessment.
- Coding: check A for Stage 1 or greater pressure ulcer, scar on any bony prominence or non-removable dressing; check B to acknowledge completion of a formal risk assessment; check C to acknowledge that risk is based upon clinical assessment (head to toe assessment, review of co-morbidities, history, etc.); check Z for none of the above.
- M0150 – Based upon all data collected, determine if the patient is at risk for skin breakdown.
- M0210 – Review all clinical documentation, interview staff and complete a physical assessment.
- Coding: code 0 for no pressure ulcers in the past 7 days; code 1 for any pressure ulcer present from Stage 1 to 4, including unstageable and DTI.
- Helpful tips:
- If a pressure ulcer is surgically repaired with a flap or graft, even if the flap or graft fails, it is coded as a surgical wound, not a pressure ulcer.
- If the pressure ulcer healed during the look back period and was not present on the last assessment, code 0.
- For the diabetic, ensure documentation supports pressure vs. diabetic ulcer and code appropriately
- M0300 – Staging is based upon deepest anatomical level. Do not backstage. Accurately staging a pressure ulcer requires some portion of the wound base to be visible. If no part of the wound base is visible, classify it as unstageable. Pressure ulcer covered with a non-removable dressing or device is coded as unstageable. Note: When coding deep tissue injury, ensure that the definition is met. Intact or Non-Intact skin, deep purple or blue color with surrounding discoloration, typically deep red. Ensure documentation reflects any ulcer present on admission.
Note: Worsening pressure ulcer is not considered present on admission. Pressure ulcer unstageable upon admission that becomes stageable is still considered present upon admission, yet is no longer coded as unstageable. Pressure ulcer present when discharged to hospital and upon return to facility at the same stage should not be coded present upon admission. A pressure ulcer that is worse upon readmission would be coded present upon admission.
- M0300A – M0300G: To code accurately, ensure completion of a head to toe assessment and detailed review of the clinical record. Enlist the assistance of the wound care nurse and/or MD as indicated, especially if determination of ulcer type is required. Note: Once a DTI or unstageable ulcer opens, it is to be classified based upon the deepest portion where the wound base is visible.
- M0610: If one or more ulcers are present, identify the ulcer with the largest surface area and record in centimeters. Keep in mind, all pressure ulcers must be measured. Depth measurement is based upon deepest visible portion of the ulcer. If the largest ulcer is unstageable, enter dashes. Note: place the patient in the most appropriate position and be consistent when obtaining measurements.
- M0700: Ensure knowledge of different tissue type definitions. Tissue characteristics must be considered. Code the most severe tissue type, even if it is a small percentage of the wound base.
- M0800: Code the number of ulcers at each stage that have worsened. Do not count pressure ulcers present upon admission/reentry. Note: An unstageable ulcer that becomes stageable is not coded as a worsening ulcer as this would be considered the first time the ulcer was staged.
- M0900: A healed pressure ulcer is defined as completely closed, fully epithelialized or resurfaced with new skin, even if the area is discolored. Look back period is prior assessment. If there is no prior assessment, skip this question.
- M1030: Be aware of anatomical location and presentation of ulcers. These ulcers are not related to pressure. There needs to be a correlating diagnosis such as peripheral vascular disease or coronary artery disease.
- M1040 A-H and Z: Any acute skin issue that is not a pressure, arterial or venous ulcer will be coded in this section. For coding the diabetic ulcer, ensure that the anatomical location is typical for this ulcer type, such as the plantar aspect of the foot or metatarsal heads. Surgical wounds do not count pressure ulcers that were surgically debrided. Moisture associated skin damage includes incontinence related dermatitis.
- M100 A-I and Z: Do not include egg-crates or donut type devices. Documentation and care planning must support the turning and positioning program. Nutrition and hydration needs to be individualized to the patient.
To summarize, always refer to the MDS 3.0 RAI User’s Manual for clarification. To most accurately classify any ulcer, it is critical to know the etiology and cause. The MDS 3.0 is truly a resident based tool but always include visual resident assessment for coding section M. Remember, it is not just about filling in the boxes. Use the information gathered to develop to comprehensive, detailed and patient specific care plan.
Stay tuned and we will continue to define and refine Quality Measures in our weekly blog posts. Harmony Healthcare International (HHI) is available to provide onsite analysis and associated medical record reviews to help you improve your Quality Measure Scores. Please contact Harmony Healthcare International by clicking here or calling our office at 1.800.530.4413.
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