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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. Objectives. By the end of this presentation, all participants will understand: The importance of wound assessment and classification.
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OASISOutcome and Assessment Information SetWound Assessment & Reimbursement By Alex Khan RN BSN CWCN CFCN Wound Ostomy & Foot Care Consultant
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.
Overview In today’s 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
Overview • The compliance date for implementation of the International Classification of Diseases, 10th 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
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
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 patient’s 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 agency’s overall reimbursement. www.cms.gov
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
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.
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 – Wagner’s Grading Scale • Venous Stasis Ulcers – Partial thickness or Full thickness rule • Incontinence Associated Dermatitis – (IAD) fungal Infection
STAGE-I PRESSURE ULCER OASIS SECTION : M1300,M1302,M1306, M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS 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.woundcarenurses.org www.woundcarenurses.org www.npuap.org
STAGE-II PRESSURE ULCER OASIS SECTION : M1300,M1302,M1306,M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS 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.woundcarenurses.org www.woundcarenurses.org www.npuap.org
STAGE-III PRESSURE ULCER OASIS SECTION : M1300,M1302,M1306,M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS 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. www.woundcarenurses.org www.woundcarenurses.org www.npuap.org
STAGE-IV PRESSURE ULCER OASIS SECTION : M1300,M1302,M1306,M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS 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.woundcarenurses.org www.woundcarenurses.org www.npuap.org
UNSTAGEABLE ULCER OASIS SECTION : M1300,M1302,M1306,M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS 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.woundcarenurses.org www.woundcarenurses.org www.npuap.org
SUSPECTED DEEP TISSUE INJURY OASIS SECTION : M1300,M1302,M1306,M1308,M1320,M1322,M1324 PERTAINS TO PRESSURE ULCERS 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. www.woundcarenurses.org www.woundcarenurses.org www.npuap.org
VENOUS STASIS ULCER OASIS SECTION : M1330, M132, M1334 – PERTAINS TO VENOUS STASIS ULCERS 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.woundcarenurses.org www.woundcarenurses.org www.woundcarenurses.org www.medterms.com
SURGICAL WOUNDS OASIS SECTION :M1340,M1342 PERTAINS TO SURGICAL WOUNDS A wound that is related to surgical intervention or a surgical procedure. It included dehisced wounds also. www.woundcarenurses.org www.woundcarenurses.org www.woundcarenurses.org
SKIN LESIONS / OTHER WOUNDS OASIS SECTION :M1350 PERTAINS TO OTHER WOUNDS / SKIN LESIONS All skin lesions and wounds must be reported in this section except pressure ulcers, venous stasis ulcers, and surgical wounds. www.woundcarenurses.org www.woundcarenurses.org www.woundcarenurses.org
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
Wound Measurement Technique www.woundcarenurses.org www.woundcarenurses.org
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
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
OASIS : M1034 - Overall Status Which description best fits the patient’s overall status? (Check one) 0– The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient’s 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 patient’s 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
OASIS : M1240/M1242 - Pain Pain related to wounds must be assessed and documented appropriately. www.cms.gov (The Wong-Baker FACES Pain Rating Scale)
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.
QUESTIONS ??? Questions from the audience
References • www.cms.gov • www.woundcarenurses.org • www.medterms.com