Integumentary refers to an organ system consisting of the skin, hair, nails, and exocrine glands. The skin is the largest organ in the human body. In OASIS-D there are nine M items (M1306, M1307, M1311, M1322, M1324, M1330, M1334, M1340 and M1342) dealing with pressure ulcers/injuries relating to this system. This blog will define these nine M items and provide preliminary guidance regarding each one.
Dealing with Resource Discrepancies
Before reviewing each M item, it is essential to know what resources are out there that can be used by Home Health agencies (HHAs). CMS has adopted the guidelines from the Wound, Ostomy and Continence Nurses Society (WOCN), whichwere developed to facilitate the classification of wounds.
Today, many home health agencies are using the NPUAP (National Pressure Ulcer Advisory Panel) guidelines in their clinical practice and documentation instead. Discrepancies exist between the two guidelines as the definitions do not perfectly align at each stage. When encountering these discrepancies, it is best that a HHA use and rely on the guidelines adopted by CMS.
- M1306 deals with patients who have at least one unhealed pressure ulcer/injury at Stage II or higher or designated as unstageable. It does not deal with Stage I, healed Stage II or closed Stage III and Stage IV pressure ulcers/injuries.
Once the pressure ulcer has fully granulated and the wound surface is completely covered with new epithelial tissue, it is considered healed. However, note that the tensile strength of the skin overlying a closed full thickness pressure ulcer is only 80 percent of normal skin tensile strength; therefore, agencies should ensure preventative measures are put into place that will mitigate the re-opening of a closed pressure ulcer.
- M1307 identifies the oldest Stage II ulcer that is present at the time of discharge and is not fully epithelialized (healed). This item takes into consideration the length of time the ulcer remained unhealed while receiving care from the HHA. It also identifies patients who develop Stage II ulcers while under the HHA’s care.
The HHA should not reverse the stage of a pressure ulcer as way to document healing. This method does not accurately characterize what is physiologically occurring as the ulcer heals.
- M1311 identifies the number of unhealed pressure ulcers/injuries at each stage (Stage II, Stage III and Stage IV), except Stage I. However,those observed on assessment are designated asu At time of discharge, this item also identifies if each pressure ulcer/injury present on the discharge assessment was observed at the same stage at the time of the most recent SOC/ROC.
When designating a pressure ulcer/injury as “healed” vs. “unhealed”, it is the same as referring to it as “closed” vs. “open”. However, unstageable pressure ulcers/injuries, whether covered with a non-removable dressing, eschar and/or slough, would not be considered healed.
- M1322 deals with the number of Stage I pressure ulcers/injuries.
When dealing with M1322, it is critical to review past medical records, and ask physicians, caregivers and family first before coding. The HHA needs to determine if the redness can be attributed to a previous Stage III or Stage IV pressure ulcer/injury.
- M1324 is concerned about the most problematic unhealed pressure ulcer/injury that is stageable.
This M item excludes any pressure ulcer/injury that cannot be staged due to a non-removable dressing/device, coverage of wound bed by slough and/or eschar, or deep tissue injury. Also, any pressure ulcers/injuries that have healed should not be considered. The HHA should use the response that most accurately describes the stage of the most problematic stageable pressure ulcer/injury as per the definitions of each stage detailed in M1311. NA should be used if the patient does not have any pressure ulcers or only has unstageable pressure ulcers.
- M1330 deals with stasis A stasis ulcer is an ulcer that develops in an area in which the circulation is sluggish, and the venous return is poor. One of the most common locations for a stasis ulcer to develop is the ankle.
It is key to differentiate stasis ulcers from other types of skin lesions because they DO NOT include arterial lesions or ulcers. Once a stasis ulcer has completely epithelialized, it is considered healed and should not be reported as a current stasis ulcer.
- M1332 identifies the number of stasis ulcers that are observable.The responses for this item range from one to four or more.
- M1334 is concerned with the most problematic stasis ulcer that is observable. A stasis ulcer can be categorized as the most problematic because it is the largest, the most resistant to treatment, and/or infected.
It is critical that a HHA utilize the WOCN guidelines when determining the most problematic, observable stasis ulcer.
- M1340 identifies the presence of a wound resulting from a surgical procedure.
If there are no surgical wounds that are identified, the clinician can skip to item M1400.
- M1342 covers the status of the surgical wound. According to WOCN guidelines,a surgical site closed primarily (with sutures, staples, or a chemical bonding agent) is a surgical wound until re-epithelialization has been present for approximately 30 days, unless it has dehisced or shows signs/symptoms of infection.After 30 days, it is generally described as a scar and is no longer reported as a surgical wound.
A dehisced wound or one healing by secondary intention is considered“not healing” when the amount of a vascular tissue is ≥25 percent.An important thing to note is that the presence of staples does not mean the surgical wound is not healing. Steri-strips are skin closures and are not considered a dressing or device.If the steri-stripsenable sufficient visualization of the wound, appropriate healing should be reported by the HHA.
There is so much more to know about the M items related to integumentary. Whether you need coding, consulting and/or training, our team offers the services that can best help you sift through the industry’s constant changes and hence, often confusion. To learn more, please contact us at [email protected] or 866-428-4040.Read More