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OASIS Outcome and Assessment Information Set Wound Assessment & Reimbursement By Alex Khan RN BSN CWCN CFCN Wound Ostomy & Foot Care Consultant Slide 2 Objectives By the end of this presentation, all participants will understand: The importance of wound assessment and classification. How to appropriately document different types of wounds. How to appropriately complete sections related to wound care on OASIS form. Strategies to improve delivery of care and reimbursement. Slide 3 Overview In todays home health care market, there is a need for increased awareness about the management, treatment and documentation of wounds. Inaccurate documentation and classification of the wounds leads to : Inappropriate treatment of the wounds Delayed healing of wounds Suboptimal Medicare reimbursement Decreased quality of care delivery by the agency Dissatisfied clients Slide 4 Overview The compliance date for implementation of the International Classification of Diseases, 10 th Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) is October 1, 2013 for all covered entities. ICD-9-CM Pressure ulcer codes 9 location codes (707.00 707.09) Show broad location, but not depth (stage) www.cms.gov Slide 5 Overview ICD-10-CM Pressure ulcer codes125 codes Show more specific location as well as depth, including L89.131 Pressure ulcer of right lower back, stage I L89.132 Pressure ulcer of right lower back, stage II L89.133 Pressure ulcer of right lower back, stage III L89.134 Pressure ulcer of right lower back, stage IV L89.139 Pressure ulcer of right lower back, unspecified stage NEW FEATURES FOUND IN ICD-10-CM The following new features can be found in ICD-10-CM: Laterality (left, right, bilateral) www.cms.gov Slide 6 Issue As mandated by the Balanced Budget Act of Medicare, Home Health Reimbursement is shifted to a prospective payment system. Under this system, payment is based on the patients clinical severity, functional status, and therapy requirements. Home health agencies are required to submit a completed OASIS : Patient Assessment Form, in order to receive reimbursement for the services provided to the patient at home. Unfortunately, 9 out of 10 home health care agencies are unaware that their registered nurses are not completing the OASIS patient assessment form appropriately; affecting the agencys overall reimbursement. www.cms.gov Slide 7 Wound Care Litigation Current statistics on Verdicts and Settlements Average Reported Award 2005-2010: $4,154,592 Highest Awards 2005-2010 Dallas County, Texas: $84,425,000 Los Angeles County, California: $48,493,140 Cook County, Illinois: $25,613,42 Slide 8 Cost of Treatment Long Term Care Facilities/Hospitals What it means to you per incident: Pressure Ulcer$3,259 to $52,93 Venous Stasis Ulcer$9,695 per patient Neuropathic Ulcer $16,000 to $28,000 per incident Pressure Ulcer$3,259 to $52,93 Source: WoundVision.com Slide 9 Issue Most of the registered nurses who are responsible for completing OASIS assessment form are not familiar with current wound care classifications and staging guidelines. Wound care terminology used in the OASIS patient assessment form is geared to be completed by a wound care certified nurse, or a nurse trained in wound care. Most of the registered nurses lack in depth wound care knowledge. Home health agencies totally rely on billing companies to bill appropriately. Lack of wound care nurses involved in the assessment and billing process. Slide 10 Review of Wounds Accurate diagnosis and classification of the wound is vital. Nurses must use national grading / classification guidelines. Pressure ulcers National Pressure Ulcer Advisory Panel Diabetic Ulcer Wagners Grading Scale Venous Stasis Ulcers Partial thickness or Full thickness rule Incontinence Associated Dermatitis (IAD) fungal Infection Slide 11 STAGE-I PRESSURE ULCER Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. www.npuap.org www.woundcarenurses.org OASIS SECTION : M1300,M1302,M1306, M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS Slide 12 STAGE-II PRESSURE ULCER www.woundcarenurses.org Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. www.npuap.org OASIS SECTION : M1300,M1302,M1306,M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS Slide 13 STAGE-III PRESSURE ULCER www.woundcarenurses.org www.npuap.org Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. OASIS SECTION : M1300,M1302,M1306,M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS Slide 14 STAGE-IV PRESSURE ULCER www.woundcarenurses.org Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. www.npuap.org OASIS SECTION : M1300,M1302,M1306,M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS Slide 15 UNSTAGEABLE ULCER www.woundcarenurses.org Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. www.npuap.org OASIS SECTION : M1300,M1302,M1306,M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS Slide 16 SUSPECTED DEEP TISSUE INJURY www.woundcarenurses.org www.npuap.org Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. OASIS SECTION : M1300,M1302,M1306,M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS Slide 17 VENOUS STASIS ULCER www.woundcarenurses.org A stasis ulcer is an ulcer that develops in an area in which the circulation is sluggish and the venous return (the return of venous blood toward the heart) is poor. www.medterms.com OASIS SECTION : M1330, M132, M1334 PERTAINS TO VENOUS STASIS ULCERS Slide 18 SURGICAL WOUNDS www.woundcarenurses.org A wound that is related to surgical intervention or a surgical procedure. It included dehisced wounds also. OASIS SECTION :M1340,M1342 PERTAINS TO SURGICAL WOUNDS Slide 19 SKIN LESIONS / OTHER WOUNDS www.woundcarenurses.org All skin lesions and wounds must be reported in this section except pressure ulcers, venous stasis ulcers, and surgical wounds. OASIS SECTION :M1350 PERTAINS TO OTHER WOUNDS / SKIN LESIONS Slide 20 Wound Measurement Accurate wound assessment is a critical component of effective wound management. Wound healing is demonstrated by reduction in size, so it is important to measure it precisely. All wound dimensions must be documented in Length x Width x Depth. M1310 Pressure Ulcer Length: Longest length head to toe. M1312 Pressure Ulcer Width: Width of pressure ulcer: greatest width perpendicular to the length. M1314 Pressure Ulcer Depth: Depth of pressure ulcer; from visible surface to the deepest area. www.cms.gov Slide 21 Wound Measurement Technique www.woundcarenurses.org Slide 22 OASIS : M1020/1022/1024 Diagnosis, Symptom Control, and Payment Diagnosis List each diagnosis for which the patient is receiving home care and enter is ICD-9-CM code at the level of highest specificity. Diagnosis are listed in the order that best reflect the seriousness of each condition and support the disciplines and services provided. Are these sections filled out accurately ? www.cms.gov Slide 23 OASIS : M1032 - Risk for Hospitalization Which of the following signs or symptoms characterize this patient as at risk for hospitalization? 1 Recent decline in mental emotional, or behavioral status 2 Multiple hospitalizations (2 or more) in the past 12 months 3 History of falls (2 or more falls or any fall with injury in the past year) 4 Taking five or more medications 5 Frailty indicators, e.g., weight loss, self-reported exhaustion 6 Other Can Wounds cause hospitalizations? www.cms.gov Slide 24 OASIS : M1034 - Overall Status Which description best fits the patients overall status? (Check one) 0 The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patients age). 1 The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of patients age). 2 The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death. 3 The patient has serious progressive conditions that could lead to death within a year. Can Wounds increase the risks & complications ? www.cms.gov Slide 25 OASIS : M1240/M1242 - Pain Pain related to wounds must be assessed and documented appropriately. www.cms.gov (The Wong-Baker FACES Pain Rating Scale) Slide 26 Home Care Best Practice Model Patients with skin problems or wounds or high risk for developing wounds shall be assessed by a wound care certified nurse. Digital images of wounds to be part of the medical record. Weekly updates are recommended. Weekly measurements of wounds shall be completed and documented in the medical records. Electronic medical record (EMR) is preferred over paper charting. Contracted billing company must be evaluated for appropriate billing practices. Slide 27 QUESTIONS ??? Questions from the audience Slide 28 References www.cms.gov www.cms.gov www.woundcarenurses.org www.woundcarenurses.org www.medterms.com www.medterms.com