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M is for Miscoding

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Keep your MDS Coordinators and nursing staff up to speed in understanding the significance of accurate coding in section M and the required corresponding documentation. This presentation enables …

Keep your MDS Coordinators and nursing staff up to speed in understanding the significance of accurate coding in section M and the required corresponding documentation. This presentation enables healthcare providers to provide quality healthcare through an understanding of wound coding in relationship to skin presentation for Section M on the MDS assessment.

1. Gain an understanding of the RAI User’s Manual intent of Section M.

2. Gain an understanding of the documentation required to support Coding in Section M.

3. Develop a clear understanding of accurate coding in Section M.

4. Learn to identify the significance of care planning and utilizing an interdisciplinary approach.

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  • 1. M is for Miscoding: Relationship Between MDS and Skin HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Kim Steele, RN,WCC, RAC-CT, CHHRP-LTC Regional Consultant and Trainer
  • 2. Speaker Bio Regional Consultant and Trainer for Harmony Healthcare International, Inc. Over 28 years experience in Long-term Care and Cardiac CCU Shift Supervisor MDS and Care Plan Coordinator for 5 years Director of Nursing for 18 years Trained staff in IV-Certification, MDS 2.0, MDS 3.0, PPS, ADLs and Regulatory Compliance, Infection Control and OSHA Specialty in Wound Care and Survey Compliance for both Standard and QIS Surveys Provides education in all aspects of Therapy and Nursing Medicare Documentation Requirements, completing CAAs and Care Plan Development, Wound Assessment and Documentation Expert in NY State Medicaid/CMI Reimbursement and Documentation and training for Successfully Preparing for the NY State OMIG Audit Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  • 3. M is for Miscoding: Relationship Between MDS and Skin Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose Planners: Elisa Bovee, MS, OTR/L Diane Buckley, BSN, RN, RAC-CT Beckie Dow, RN, RAC-MT Keri Hart, MS CCC, SLP, RAC-CT Kristen Mastrangelo, OTR/L, MBA, NHA Christine Twombly, RNC, RAC-MT, LHRM Presenter: Kim Steele, RN,WCC, RAC-CT, CHHRP-LTC Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  • 4. Harmony Healthcare International, Inc. M is for Miscoding: Relationship Between MDS and Skin Disclosure Speaker: Kim Steele, RN,WCC, RAC-CT, CHHRP-LTC The speaker has no relevant financial relationships to disclose The speaker has no relevant nonfinancial relationships to disclose Copyright © 2013 All Rights Reserved 4
  • 5. Harmony Healthcare International, Inc. M is for Miscoding: Relationship Between MDS and Skin Criteria for Successful Completion Complete Sign-in and Sign-Out on Attendance Form Attendance for entire session Completion and submission of speaker evaluation form Copyright © 2013 All Rights Reserved 5
  • 6. Program Objectives The learner will be able to identify the intent of MDS 3.0 Section M The learner will be able to articulate the documentation requirements to support coding in Section M The learner will be able to state accurate coding directives for Section M The learner will be able to recognize the importance of an interdisciplinary approach to skin management and skin health Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 6
  • 7. MDS 3.0 and Section M MDS 3.0 brought major changes to how skin problems are coded - finally Many positive changes that are more in line with the clinical standards for wound documentation (NPUAP) Section M is very complex, and accurate understanding of coding instructions is crucial Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  • 8. MDS 3.0 and Section M Some pertinent changes: Skin assessment more closely aligned with NPUAP guidelines Addition of unstageable ulcers Elimination of back staging Increased detail on unhealed ulcers Date of the oldest Stage II ulcer Risk assessment for skin problems Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  • 9. MDS 3.0 and Section M Some pertinent changes (Cont.) Identifying the largest Stage III/IV or unstageable ulcer Coding of a worsening pressure ulcer Coding if ulcer is present on admission or not present on admission Replacing the RAP process with the CAA process Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
  • 10. MDS 3.0 and Section M Section M affects many areas that are important to nursing homes: Quality Measures and Survey 5 Star Quality Rating RUG-IV classification RUG-III classification (Case Mix) Most importantly, resident care! Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
  • 11. Harmony Healthcare International, Inc. 11 Skin Documentation and the Quality Measures Copyright © 2013 All Rights Reserved
  • 12. Harmony Healthcare International, Inc. 12 Skin Documentation and the Quality Measures Skin Documentation will potentially impact two Quality Measures: Percent of Residents with Pressure Ulcers That are New or Worsened (Short-Stay) Percent of High Risk Residents with Pressure Ulcers (Long-Stay) These two Quality Measures are also used to calculate the Quality Measure domain of the 5 Star Quality Rating Copyright © 2013 All Rights Reserved
  • 13. Percent of Residents with Pressure Ulcers That are New or Worsened (Short-Stay) Numerator: Short-stay residents for which a look-back scan indicates one or more new or worsening Stage 2-4 pressure ulcers (MDS items M0300 and M0800) Denominator: All residents with one or more assessments that are eligible for a look- back scan, except those with exclusions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
  • 14. Percent of Residents with Pressure Ulcers That are New or Worsened (Short-Stay) Exclusions: Missing/inconsistent data Risk Adjustments (on initial assessment): Resident-level covariate Require limited or more assistance in bed (MDS G0110) Have bowel incontinence at least occasionally (MDS H0400) Diabetes or peripheral vascular disease (MDS I2900, I0900, or listed in I8000) Low Body Mass Index =BMI between 12 -19 (as indicated by height and weight recorded in K0200) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
  • 15. Percent of Residents with Pressure Ulcers That are New or Worsened (Short-Stay) Clinical Considerations: Pressure ulcers are painful and negatively impact patient quality of life Competency check for nursing staff responsible for wound assessment Continuing education on wound assessment “Worsening” per MDS lingo is defined as moving to a higher numerical stage Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
  • 16. Percent of High Risk Residents with Pressure Ulcers (Long-Stay) Numerator: Long-stay residents who were identified as high risk and who have one or more Stage 2-4 pressure ulcer(s) (MDS item M0300) Denominator: Long-stay residents with a target assessment who were identified as “high risk” and have pressure ulcer(s) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  • 17. Copyright © 2013 All Rights Reserved 17 Percent of High Risk Residents with Pressure Ulcers (Long-Stay) Exclusions: OBRA admission or a 5-day or Return/Readmission PPS MDS Missing data Risk Adjustments (Any of the following = high risk): Comatose (MDS B0100) Impaired (extensive, dependent, 7, or 8) in bed mobility and/or transfer MDS G0110) Malnutrition or at risk for malnutrition (MDS I5600) Harmony Healthcare International, Inc.
  • 18. Percent of High Risk Residents with Pressure Ulcers (Long-Stay) Clinical Considerations: ADL coding accuracy at the source—the bedside! Invest time in ADL coding training for staff Correctly identify and code malnutrition for care planning and interventions Pressure ulcers adversely impact quality of life for nursing home residents Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18
  • 19. Skin Documentation impact on RUG-III and RUG-IV Classification The Medicare PPS system uses RUG-IV to calculate payment rates Some states calculate Medicaid payment through Case Mix RUG-III Accurate skin documentation will impact both Medicare and Medicaid reimbursement Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
  • 20. RUG-IV and Skin Documentation Accurate skin documentation can impact classification into Special Care Low Skin Problems (treatments next slide): 2+ Stage II with 2+ treatments Stage III or IV or Unstageable due to slough or eschar with 2+ treatments 2+ venous/arterial with 2+ ulcer treatments Stage II and venous/arterial with 2+ treatments Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  • 21. RUG-IV Special Care Low Skin Treatments: Pressure relieving chair or bed Turning/Repositioning program Nutrition/Hydration interventions Pressure Ulcer care Application of dressings/ointments (not to the feet) Foot infection, diabetic foot ulcer or other open lesion of foot with dressings Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21
  • 22. RUG-IV and Skin Documentation Accurate skin documentation can impact classification into Clinically Complex Surgical wounds or open lesion with treatment Skin Treatments: Surgical wound care Application of dressings/ointments (not to the feet) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
  • 23. RUG-III and Skin Documentation Accurate skin documentation can impact classification into Special Care 2+ pressure ulcers at any stage with 2+treatments Any Stage III or IV with 2+ treatments Open lesions with 1+ treatment Surgical wounds with 1+ treatment Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23
  • 24. RUG-III and Skin Documentation Pressure ulcer treatments include: Pressure relieving chair or bed Turning/Repositioning program Nutrition/Hydration interventions Pressure Ulcer care Application of dressings/ointments (not to the feet) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24
  • 25. RUG-III and Skin Documentation Surgical wound treatments include: Surgical wound care Application of dressings/ointments (not to the feet) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25
  • 26. RUG-III and Skin Documentation Accurate skin documentation can impact classification into Clinically Complex Infection of the foot with application of dressing Diabetic foot ulcer or open lesion of the foot with application of a dressing Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26
  • 27. Compliance Impact Conflicting documentation Coding accuracy Quality of Care and Pressure Ulcer citations Financial impact Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 27
  • 28. Interdisciplinary Approach Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28
  • 29. Interdisciplinary Approach Nursing Documentation Interventions Goals Dietary Documentation Interventions Goals Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29
  • 30. Interdisciplinary Approach Social Services/Activities Documentation Interventions Physician Documentation Interventions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 30
  • 31. Harmony Healthcare International, Inc. 31 Section M: Skin Conditions Intent: To document the risk, presence, appearance, and change of pressure ulcers This section notes other skin ulcers, wounds, or lesions Also includes information to capture some treatment categories related to skin injury and avoiding injury Copyright © 2013 All Rights Reserved
  • 32. Harmony Healthcare International, Inc. 32 Section M: Skin Conditions Intent (Continuation) Be certain to include in the assessment process, a holistic approach It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound Copyright © 2013 All Rights Reserved
  • 33. Harmony Healthcare International, Inc. 33 Section M: Skin Conditions Pressure Ulcer Definition: A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction RAI Manual definitions have been adapted from NPUAP, but do not follow NPUAP exactly KEY POINT: MDS must be coded according to RAI guidelines Copyright © 2013 All Rights Reserved
  • 34. Harmony Healthcare International, Inc. 34 M0100: Determination of Pressure Ulcer Risk Steps for Assessment Review the entire medical record including all forms, flow sheets and other disciplines notes (ex: nutrition, therapy, podiatry, etc.) Speak with treatment nurse, admitting nurse and direct care staff to confirm conclusions Examine the resident thoroughly checking for ulcers, scars or non-removable dressings that may be present Examine any areas that are subject to pressure (braces, oxygen tubing, bony prominences) Copyright © 2013 All Rights Reserved
  • 35. 35 M0100: Determination of Pressure Ulcer Risk For this item, check all that apply: M0100A: Resident has a Stage 1 or greater pressure ulcer, a scar over bony prominence, or non-removable dressing/device Non-dressings/devices include a primary surgical dressing, a cast, or a brace M0100B: A formal assessment has been completed Braden Scale or the Norton Scale Other tools may be used Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved
  • 36. Harmony Healthcare International, Inc. 36 M0100: Determination of Pressure Ulcer Risk M0100C: Resident at risk for pressure ulcer development is based on clinical assessment A clinical assessment could include head- to-toe physical exam of the skin as well as a thorough review of the medical record to identify risk factors See examples next slide M0100Z: If none of the above apply All residents should be assessed for risk shortly after admission Copyright © 2013 All Rights Reserved
  • 37. M0100C: Determination of Pressure Ulcer Risk Clinical Assessment Should Address (not an exhaustive list): Immobility Decreased functional ability Impaired diffuse or localized blood flow Exposure to urinary and fecal incontinence Nutrition and hydration deficits Co-morbid conditions such as: ESRD Thyroid Disease Drugs such as steroids Resident refusal of care or treatment Cognitive impairment Healed ulcer Harmony Healthcare International, Inc. 37Copyright © 2013 All Rights Reserved
  • 38. Harmony Healthcare International, Inc. 38 M0150: Risk of Pressure Ulcers M0150: Is the resident at risk of developing pressure ulcers? Coding Instructions: Code 0, no: If the resident is not at risk for developing pressure ulcers based on a review of items in M0100 Code 1, yes: If the resident is at risk of developing pressure ulcers based on information gathered for M0100 Copyright © 2013 All Rights Reserved
  • 39. Harmony Healthcare International, Inc. 39 M0210: Unhealed Pressure Ulcer(s) M0210: Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? Code based on the presence of any pressure ulcer (regardless of stage) in the past 7 days Code 0, no: If the resident did not have a pressure ulcer in the 7-day look-back period. Then skip Items M0300 – M0800 Code 1, yes: If the resident had any pressure ulcer (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period Copyright © 2013 All Rights Reserved
  • 40. Harmony Healthcare International, Inc. 40 M0210: Unhealed Pressure Ulcer(s) Coding Tips: Each ulcer should be coded only once, either a pressure ulcer or an ulcer due to another cause If the cause arises from a combination of factors of which pressure is the primary cause, then the ulcer should be included in this section as a pressure ulcer Copyright © 2013 All Rights Reserved
  • 41. Harmony Healthcare International, Inc. 41 M0210: Unhealed Pressure Ulcer(s) Coding Tips (Continued) If the pressure ulcer is surgically repaired with a flap or graft, it should be coded as a surgical wound, even if the flap or graft fails If the resident has a pressure ulcer on the last assessment and it is now healed, complete Healed Pressure Ulcers (M0900) If a pressure ulcer healed during the look- back period, and was not present on prior assessment, Code 0 Copyright © 2013 All Rights Reserved
  • 42. Harmony Healthcare International, Inc. 42 M0210: Unhealed Pressure Ulcer(s) Coding Tips (Continued) A diabetic resident can have a pressure, venous, arterial, or diabetic neuropathic ulcer The primary etiology of the ulcer should be considered Heel ulcer from pressure = PU Plantar ulcer may be diabetic foot ulcer Copyright © 2013 All Rights Reserved
  • 43. M0210: Unhealed Pressure Ulcer(s) Scabs and eschar are different physically and chemically A scab is evidence of wound healing A pressure ulcer that was staged as a 2 and now has a scab indicates it is a healing stage 2 and therefore, staging should not change Eschar characteristics and the level of damage it causes to tissues is what makes it easy to distinguish from a scab Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 43
  • 44. M0300: Current Number of Unhealed Pressure Ulcers at Each Stage Step One: Determine deepest anatomical stage Observe the base of any pressure ulcers present to determine the depth of tissue layers involved Ulcer staging is based on the ulcers deepest visible anatomical level If the pressure ulcer has ever been classified at a deeper stage it should continue to be classified at that deeper stage Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 44
  • 45. M0300: Current Number of Unhealed Pressure Ulcers at Each Stage Step Two: Identify unstageable PUs If the wound bed is partially covered, but tissue loss depth can be determined, do not code as unstageable Necrotic or eschar that obscures tissue loss depth, or the wound base covered by slough makes the wound unstageable Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
  • 46. Harmony Healthcare International, Inc. 46 M0300: Current Number of Unhealed Pressure Ulcers at Each Stage Step Three: Determine “Present on Admission” Review the medical record for history of the ulcer If the pressure ulcer was present on admission/entry or re-entry and subsequently increased in numerical stage during the resident’s stay, the pressure ulcer is coded at that higher stage, and that higher stage should not be considered as “present on admission” Copyright © 2013 All Rights Reserved
  • 47. Harmony Healthcare International, Inc. 47 M0300: Current Number of Unhealed Pressure Ulcers at Each Stage If the pressure ulcer was unstageable on admission, but becomes stageable later, it should be considered as “present on admission” at the stage at which it first becomes stageable. If it subsequently worsens to a higher stage, that higher stage should not be considered “present on admission.” Copyright © 2013 All Rights Reserved
  • 48. M0300: Current Number of Unhealed Pressure Ulcers at Each Stage If a resident who has a pressure ulcer is hospitalized and returns with that pressure ulcer at the same stage, the pressure ulcer should not be coded as “present on admission” because it was present at the facility prior to the hospitalization If a current pressure ulcer increases in numerical stage during a hospitalization, it is coded at the higher stage upon reentry and should be coded as “present on admission” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48
  • 49. Harmony Healthcare International, Inc. 49 Pressure Ulcer Staging: Stage 1 Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence Stage 1 pressure ulcers may be difficult to detect in patients with dark skin tones Pressure ulcers with suspected deep tissue injury (sDTI) should NOT be coded as Stage 1 pressure ulcers PUs due to sDTI should be coded as unstageable pressure ulcers due to suspected deep tissue injury at item M0300G Copyright © 2013 All Rights Reserved
  • 50. Harmony Healthcare International, Inc. 50 M0300A: Number of Stage 1 Pressure Ulcers Information is driven from a comprehensive full body skin assessment prior to MDS completion Coding Instructions: Enter the number of Stage 1 pressure ulcers that are currently present Enter “0”: If no Stage 1 pressure ulcers are present Copyright © 2013 All Rights Reserved
  • 51. Harmony Healthcare International, Inc. 51 Pressure Ulcer Staging: Stage 2 Stage 2: 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 Most stage 2 PUs will heal in a reasonable time frame Copyright © 2013 All Rights Reserved
  • 52. Harmony Healthcare International, Inc. 52 M0300B: Stage 2 Pressure Ulcers Coding Instructions: Identify all Stage 2 pressure ulcers that are currently present Enter “0”: If no Stage 2 are present and skip to M0300C (Stage 3) Identify the number that were present on admission/entry or reentry Identify the oldest Stage 2 PU and the date it was first noted at that stage Copyright © 2013 All Rights Reserved
  • 53. 53Harmony Healthcare International, Inc. M0300B: Stage 2 Pressure Ulcers Coding Instructions (Cont.) Identify the oldest Stage 2 pressure ulcer and the date it was first noted at that stage (Only done for Stage 2) Do NOT leave any boxes blank For Example: January 2, 2008, should be entered as 01-02-2008 If the date is unknown--dash-fill Do NOT enter date of admission if the date the Stage 2 was first noted is unknown Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  • 54. Harmony Healthcare International, Inc. 54 M0300C: Stage 3 Pressure Ulcers Stage 3: 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 Bone/tendon is not visible or directly palpable Copyright © 2013 All Rights Reserved
  • 55. Harmony Healthcare International, Inc. 55 M0300C: Stage 3 Pressure Ulcers M0300C1 Enter the number of Stage 3 pressure ulcers currently present If the number exceeds 9, then enter “9” M0300C2 Enter the number of Stage 3 pressure ulcers present on admission/entry or re-entry If a PU fails to show some evidence toward healing within 14 days the PU and the patients overall clinical status should be reassessed Copyright © 2013 All Rights Reserved
  • 56. Harmony Healthcare International, Inc. 56 Pressure Ulcer Staging: Stage 4 Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle Exposed bone/tendon visible or directly palpable Slough or eschar may be present on some parts of the wound bed, and often includes undermining and tunneling Can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible Copyright © 2013 All Rights Reserved
  • 57. Harmony Healthcare International, Inc. 57 M0300D: Stage 4 Pressure Ulcers Coding Instructions: M0300D1 Enter the number of Stage 4 pressure ulcers currently present If the number exceeds 9, enter “9” M0300D2 Enter the number of Stage 4 pressure ulcers present on admission/entry or re-entry Copyright © 2013 All Rights Reserved
  • 58. M0300D: Stage 4 Pressure Ulcers Cartilage serves the same anatomical function as bone Pressure ulcers that have exposed cartilage should be classified as Stage 4 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58
  • 59. Harmony Healthcare International, Inc. 59 M0300E: Unstageable Ulcers Due to Non-removable Dressing/Device Determine the number of pressure ulcers unstageable due to non-removable dressing/device such as a cast, orthopedic device, or dressing not to be removed per physician order M300E1 Enter the number of unstageable pressure ulcers M0300E2 Enter the number of these unstageable pressure ulcers present on admission/entry and for residents who are reentering the facility after a hospital stay, that were acquired during the hospitalization Copyright © 2013 All Rights Reserved
  • 60. Harmony Healthcare International, Inc. 60 M0300F: Unstageable Pressure Ulcers Due to Slough and/or Eschar Determine the number of pressure ulcers unstageable due to Slough and/or Eschar M0300F1 Enter the number of unstageable pressure ulcers M0300F2 Enter the number of these unstageable pressure ulcers present on admission/entry or re-entry and for residents who are reentering the facility after a hospital stay, that were acquired during the hospitalization Copyright © 2013 All Rights Reserved
  • 61. Harmony Healthcare International, Inc. 61 M0300G: Unstageable Pressure Ulcers Due Suspected Deep Tissue Injury Determine the number of pressure ulcers unstageable due to suspected Deep Tissue Injury (sDTI) M0300G1 Enter the number of unstageable pressure ulcers M0300G2 Enter the number of these unstageable pressure ulcers present on admission/entry or re-entry and for residents who are reentering the facility after a hospital stay, that were acquired during the hospitalization Copyright © 2013 All Rights Reserved
  • 62. Harmony Healthcare International, Inc. 62 Skin Definitions Deep Tissue Injury: Purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue The adjacent or surrounding areas may be painful, firm, mushy, boggy, warm or cool DTI may be difficult to detect in dark skinned tones Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Copyright © 2013 All Rights Reserved
  • 63. Harmony Healthcare International, Inc. 63 M0610: Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Unstageable Pressure Ulcer Due to Slough or Eschar Steps for Assessment: Measure length and width of all Stage 3, 4 and unstageable pressure ulcers (due to slough or eschar) Identify the surface area of each with Stage 3 or 4 or unstageable pressure ulcer due to slough or eschar pressure ulcer Length x width (in centimeters) Identify the ulcer with the largest surface area Complete M610A-C based on this ulcer Copyright © 2013 All Rights Reserved
  • 64. Harmony Healthcare International, Inc. 64 M0610: Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Unstageable Pressure Ulcer Due to Slough or Eschar M0610A: Enter the current longest point (head to toe measurement) of the largest Stage 3 or 4 or unstageable pressure ulcer due to slough or eschar in centimeters to one decimal point (e.g., 2.3cm.) M0610B: Measure the widest point (perpendicular to length) of the largest Stage 3 or 4 or unstageable pressure ulcer due to slough or eschar in centimeters to one decimal point (e.g., 2.3cm.) Copyright © 2013 All Rights Reserved
  • 65. M0610: Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Unstageable Pressure Ulcer Due to Slough or Eschar M0610C: Considering only the largest pressure ulcer or unstageable pressure ulcer due to slough or eschar, determine the deepest area of the largest pressure ulcer and record the depth in centimeters If the wound is unstageable and wound bed cannot be visualized, enter dashes Harmony Healthcare International, Inc. 65Copyright © 2013 All Rights Reserved
  • 66. 66Harmony Healthcare International, Inc. M0700: Most Severe Tissue Type for Any Pressure Ulcer Epithelial Tissue: New skin that is light pink and shiny regardless of skin pigmentation In Stage 2 pressure ulcers, epithelial tissue is seen in the center and edges of the ulcer In full thickness Stage 3 and 4 pressure ulcers, epithelial tissue advances from the edges of the wound Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  • 67. Harmony Healthcare International, Inc. 67 M0700: Most Severe Tissue Type for Any Pressure Ulcer Granulation Tissue Red tissue with “cobblestone” or bumpy appearance, bleeds easily when injured Slough Tissue Non-viable yellow, grey, tan, green or brown tissue that is soft, stringy, or mucinous in texture Slough may be adherent to the base of the wound or present in clumps throughout wound bed Copyright © 2013 All Rights Reserved
  • 68. Harmony Healthcare International, Inc. 68 M0700: Most Severe Tissue Type for Any Pressure Ulcer Necrotic Tissue (Eschar) Dead or devitalized tissue Hard or soft in texture; usually black, brown, or tan in color May appear “scab-like” Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound Copyright © 2013 All Rights Reserved
  • 69. 69Harmony Healthcare International, Inc. M0700: Most Severe Tissue Type for Any Pressure Ulcer This section addresses the changes in tissue characteristics over time that are indicative of wound healing or degeneration Steps for Assessment: Review all pressure ulcers identified to determine most SEVERE type of tissue in any wound bed Code for type present in bed/base. If mixed types, code most severe. Select only one type. Ensure coding consistency with M0300A-G (Ulcer Staging) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  • 70. M0700: Most Severe Tissue Type for Any Pressure Ulcer Coding Instructions Code 9, None of the Above: Stage 1 pressure ulcer Stage 2 pressure ulcer with intact blister Unstageable pressure ulcer related to non-removable dressing/device Unstageable pressure ulcer related to suspected DTI Harmony Healthcare International, Inc. 70Copyright © 2013 All Rights Reserved
  • 71. Harmony Healthcare International, Inc. 71 M0800: Worsening Since Prior Assessment (OBRA or Scheduled PPS) or Last Admission/Entry or Reentry Look-back period for this item is back to the ARD of the prior assessment If there was no prior assessment (i.e., if this is the first OBRA or scheduled PPS assessment), do not complete this item. Skip to M1030 This section requires the clinician to identify the number of current pressure ulcers that were not present or were at a lesser stage on prior assessment (OBRA, PPS, or Discharge) Copyright © 2013 All Rights Reserved
  • 72. Harmony Healthcare International, Inc. 72 M0800: Worsening Since Prior Assessment (OBRA or Scheduled PPS) or Last Admission/Entry or Reentry Steps for Assessment: Review previous MDS coding Review the history of each pressure ulcer (documentation) Compare the current stage to past stages to determine whether any pressure ulcer on the current assessment is new or at a higher (deeper) stage when compared to the last MDS assessment For each current stage, count the number of current pressure ulcers that are new or have worsened since the last MDS assessment was completed Copyright © 2013 All Rights Reserved
  • 73. Harmony Healthcare International, Inc. 73 M0800: Worsening Since Prior Assessment (OBRA or Scheduled PPS) or Last Admission/Entry or Reentry. Coding Instructions: Enter the number of pressure ulcers that were not present OR were at a lesser stage on prior assessment. M0800A = # of Stage 2 M0800B = # of Stage 3 M0800C = # of Stage 4 Code “0”: If no pressure ulcers have worsened OR there are no new pressure ulcers Copyright © 2013 All Rights Reserved
  • 74. Harmony Healthcare International, Inc. 74 Coding Unstageable Pressure Ulcers: If an ulcer was unstageable on admission, do not consider it to be worse on the first assessment in which it can be staged after being debrided. However, if it worsens after that assessment, it should be included in counts. If a previously staged pressure ulcer becomes unstageable and then is debrided sufficiently to be staged, compare its stage before and after it was unstageable. If its stage has worsened, code it as such in this item. Unstageable Pressure Ulcers Worsening Since Prior Assessment Copyright © 2013 All Rights Reserved
  • 75. Harmony Healthcare International, Inc. 75 Coding Unstageable Pressure Ulcers If a pressure ulcer is acquired during a hospital admission, it is coded as “present on admission” and not included in a count of worsening pressure ulcers If a pressure ulcer worsens to a more severe stage during a hospital admission, it should also be coded as “present on admission” and not included in counts of worsening pressure ulcers If a previously staged pressure ulcer becomes unstageable due to slough or eschar do not code as worsened Unstageable Pressure Ulcers Worsening Since Prior Assessment Copyright © 2013 All Rights Reserved
  • 76. Harmony Healthcare International, Inc. 76 M0900: Healed Pressure Ulcers Complete only if this is not the first assessment (OBRA or Scheduled PPS) since the most recent admission Healed Pressure Ulcer: Completely closed, fully epithelialized, covered completely with epithelial tissue, or resurfaced with new skin, even if the area continues to have some surface discoloration Epithelial Tissue: New skin that is light pink and shiny regardless of the skin pigmentation Copyright © 2013 All Rights Reserved
  • 77. Harmony Healthcare International, Inc. 77 M0900: Healed Pressure Ulcers Steps for Assessment: Complete on all residents, including those without a current pressure ulcer Look-back period for this item is the ARD of the prior assessment Review the medical record to identify whether any pressure ulcers that were noted on the prior MDS assessment have healed by the ARD (A2300) of the current assessment Copyright © 2013 All Rights Reserved
  • 78. Harmony Healthcare International, Inc. 78 M0900: Healed Pressure Ulcers If the prior assessment documents that a pressure ulcer healed between MDS assessments, but another pressure ulcer occurred at the same location, do not consider this pressure ulcer to have healed The re-opened pressure ulcer should be staged at its highest numerical stage until fully healed Copyright © 2013 All Rights Reserved
  • 79. Harmony Healthcare International, Inc. 79 M1030: Number of Venous and Arterial Ulcers Venous Ulcers: Caused by peripheral venous disease, which most commonly occurs proximal to the medial or lateral malleolus, above the inner or outer ankle, or on the lower calf area of the leg The wound may start with some kind of minor trauma, such as hitting the leg on the wheelchair The wound does not typically occur over a bony prominence, and pressure forces play virtually no role in the development of the ulcer Copyright © 2013 All Rights Reserved
  • 80. Harmony Healthcare International, Inc. 80 M1030: Number of Venous and Arterial Ulcers Venous Ulcers The surrounding tissue may be erythematous or reddened, or appear brown-tinged Edema of the lower extremity is not uncommon Venous ulcers may or may not be painful and are typically shallow with irregular wound edges, a red granular (e.g., bumpy) wound bed, minimal to moderate amounts of yellow fibrinous material, and moderate to large amounts of exudate Copyright © 2013 All Rights Reserved
  • 81. Harmony Healthcare International, Inc. 81 M1030: Number of Venous and Arterial Ulcers Arterial Ulcers: Caused by peripheral arterial disease, which commonly occur on the tips of toes, top of the foot, or distal to the medial malleolus Trophic skin changes (e.g., dry skin, loss of hair growth, muscle atrophy, brittle nails) may be also be present. LE and pedal pulses may be diminished or absent. The wound may start with some kind of minor trauma, such as hitting the leg on the wheelchair The wound does not typically occur over a bony prominence, and pressure forces play virtually no role in the development of the ulcer Arterial ulcers are often painful and have a pale pink wound bed, minimal exudate, minimal bleeding, and necrotic tissue Copyright © 2013 All Rights Reserved
  • 82. Harmony Healthcare International, Inc. 82 M1030: Number of Venous and Arterial Ulcers Coding Instructions: Pressure Ulcers coded in M0210 through M0900 should NOT be coded here Enter the number of venous and arterial ulcers present Enter “0”: If there were no venous or arterial ulcers present Copyright © 2013 All Rights Reserved
  • 83. Harmony Healthcare International, Inc. 83 M1040: Other Ulcers, Wounds and Skin Problems Coding Instructions: Check all that apply in the last 7 days If there is no evidence of such problems in the last 7 days, check Z none of the above Pressure ulcers coded in M0200 through M0900 should NOT be coded here Copyright © 2013 All Rights Reserved
  • 84. Harmony Healthcare International, Inc. 84 M1040A – C: Other Ulcers, Wounds and Skin Problems Copyright © 2013 All Rights Reserved
  • 85. Harmony Healthcare International, Inc. 85 M1040A – C: Other Ulcers, Wounds and Skin Problems M1040A: Infection of the foot (e.g., cellulitis, purulent drainage) M1040B: Diabetic foot ulcer(s) Defined as ulcers caused by neuropathic and small blood vessel complications of DM that typically occur over the plantar (bottom) surface of the foot on load bearing areas such as the ball of the foot Ulcers are usually deep, with necrotic tissue, moderate amounts of exudate, and callused wound edges M1030C: Other open lesion(s) on the foot (e.g. cuts, fissures) Copyright © 2013 All Rights Reserved
  • 86. Harmony Healthcare International, Inc. 86 M1040D: Other Ulcers, Wounds and Skin Problems M1040D: Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion) Most typically skin ulcers that develop as a result of diseases and conditions such as syphilis and cancer Do NOT code skin tears, cuts or abrasions here Copyright © 2013 All Rights Reserved
  • 87. Harmony Healthcare International, Inc. 87 M1040E: Other Ulcers, Wounds and Skin Problems M1040E: Surgical wound(s) Any healing and non-healing, open or closed surgical incisions, skin grafts or drainage sites on any part of the body Surgical debridement of pressure ulcer does not create a surgical wound A pressure ulcer that has been surgically debrided should continue to be coded as a pressure ulcer Copyright © 2013 All Rights Reserved
  • 88. M1040E: Other Ulcers, Wounds and Skin Problems M1040E: Surgical wound(s) Pressure ulcers that require surgical intervention for closure with graft or flap procedures become surgical wounds Once a pressure ulcer is excised and a graft and/or flap is applied, it is no longer a pressure ulcer, but a surgical wound It will remain a surgical wound even if the graft and/or flap fails Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 88
  • 89. M1040E: Other Ulcers, Wounds and Skin Problems Surgical wounds do not include: Healed surgical sites healed stomas or healed lacerations that required suturing or butterfly closure PICC sites or central line sites Peripheral IVs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 89
  • 90. Harmony Healthcare International, Inc. 90 M1040F: Other Ulcers, Wounds and Skin Problems M1040F: Burns(s)(second or third degree) Skin and tissue injury caused by heat or chemicals and may be in any stage of healing Do NOT include first degree burns (changes in skin color only) Copyright © 2013 All Rights Reserved
  • 91. M1040G – H, Z: Other Ulcers, Wounds and Skin Problems M1040G: Skin Tear(s) Code even if already coded in item J1900B (fall with injury) M1040 H: Moisture Associated Skin Damage (MASD) Caused by moisture rather than pressure Can be caused by incontinence, wound exudate, and perspiration Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 91
  • 92. M1040G – H, Z: Other Ulcers, Wounds and Skin Problems M1040H: Moisture Associated Skin Damage (MASD): Characterized by inflammation of the skin and occurs with or without skin erosion and/or infection Also referred to as incontinence-associated dermatitis Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 92
  • 93. M1040G – H, Z: Other Ulcers, Wounds and Skin Problems M1040H: Moisture Associated Skin Damage (MASD): Can cause other conditions such as intertriginous dermatitis, periwound moisture-associated dermatitis, and peristomal moisture-associated dermatitis Provision of optimal skin care and early identification and treatment of minor cases of MASD can help avoid progression and skin breakdown Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 93
  • 94. Harmony Healthcare International, Inc. 94 M1200: Skin and Ulcer Treatments Rationale: Appropriate prevention and treatment of skin changes and ulcers reduce complications and promote healing Coding Instructions: Check all that apply in the last 7 days Check Z: None of the above were provided, if none applied in the past 7 days Copyright © 2013 All Rights Reserved
  • 95. Harmony Healthcare International, Inc. 95 M1200A and B: Skin and Ulcer Treatments M1200A: Pressure reducing device for chair M1200B: Pressure reducing device for bed Coding Tips: Do not include egg crate cushions of any type in this category Do NOT include doughnut or ring devices in chairs Copyright © 2013 All Rights Reserved
  • 96. M1200A and B: Skin and Ulcer Treatments Definition: Pressure Reducing Device(s): Equipment that aims to relieve pressure away from areas of high risk May include foam, air, water gel, or other cushioning placed on a chair, wheelchair or bed Include pressure relieving, pressure reducing, and pressure redistributing devices Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96
  • 97. Harmony Healthcare International, Inc. 97 M1200C: Skin and Ulcer Treatments M1200C: Turning/repositioning program Includes a consistent program for changing the resident’s position and realigning the body “Program” is defined as a specific approach that is organized, planned, documented, monitored, and evaluated based on an assessment of the resident’s needs Copyright © 2013 All Rights Reserved
  • 98. M1200C: Skin and Ulcer Treatments M1200C: Turning/repositioning program The program should specify the intervention (e.g., reposition on side, pillows between knees) and frequency (e.g., every 2 hours) Progress notes, assessments and other documentation should support that the program is monitored and reassessed to determine the effectiveness of the intervention Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 98
  • 99. Harmony Healthcare International, Inc. 99 M1200D: Skin and Ulcer Treatments M1200D: Nutrition or hydration intervention to manage skin problems Must be based on an individualized nutritional assessment that determines if the resident is taking in sufficient amounts of nutrients Additional supplementation above the RDI is not proven to provide any further benefits for management of skin problems Copyright © 2013 All Rights Reserved
  • 100. Harmony Healthcare International, Inc. 100 M1200D: Skin and Ulcer Treatments M1200D: Nutrition or hydration intervention to manage skin problems The determination as to whether or not one should receive nutritional or hydration interventions for skin problems should be based on an individualized nutritional assessment. The interdisciplinary team should review the resident’s diet and determine if the resident is taking in sufficient amounts of nutrients and fluids or are already taking supplements that are fortified with the US Recommended Daily Intake (US RDI) of nutrients Copyright © 2013 All Rights Reserved
  • 101. Harmony Healthcare International, Inc. 101 M1200D: Skin and Ulcer Treatments It is important to remember that additional supplementation is not automatically required for pressure ulcer management Any interventions should be specifically tailored to the resident’s needs, condition, and prognosis (AMDA PU Therapy Companion, page 11) Copyright © 2013 All Rights Reserved
  • 102. Harmony Healthcare International, Inc. 102 M1200E: Skin and Ulcer Treatments M1200E: Pressure Ulcer Care Pressure ulcer care includes any intervention for treating pressure ulcers coded in M0300 (Current # of Unhealed pressure ulcers) Examples may include: Use of topical dressings Chemical or surgical debridement Wound irrigations Wound vacuum assisted closure (VAC) Hydrotherapy Copyright © 2013 All Rights Reserved
  • 103. Harmony Healthcare International, Inc. 103 M1200F: Skin and Ulcer Treatments M1200F: Surgical wound care Do NOT include post-operative care following eye or oral surgery Surgical debridement of a pressure ulcer continues to be coded as a pressure ulcer Surgical wound care may include any intervention for treating or protecting any type of surgical wound Copyright © 2013 All Rights Reserved
  • 104. Harmony Healthcare International, Inc. 104 M1200G: Skin and Ulcer Treatments M1200G: Application of non-surgical dressings (with /without topical medications) other than to feet Do not code dressing for pressure ulcer on the foot in this item, use Ulcer Care (M1200E) Non-surgical dressings do not include Band- Aids Do not code application of dressing to the ankle because the ankle is not part of the foot Dressings do not have to be applied daily in order to be coded on the MDS Copyright © 2013 All Rights Reserved
  • 105. Harmony Healthcare International, Inc. 105 M1200H: Skin and Ulcer Treatments M1200H: Application of ointments/medications other than to feet This may include treatments such as cortisone, antifungal preparations, and/or chemotherapeutic agents Ointments/medications may include topical creams, powders, and liquid sealants used to treat or prevent skin conditions Does NOT include ointment used to treat non-skin issues; e.g., nitropaste for chest pain Copyright © 2013 All Rights Reserved
  • 106. Harmony Healthcare International, Inc. 106 M1200I: Skin and Ulcer Treatments M1200I: Application of dressings to feet (with or without topical medications) Includes interventions to treat any foot wound or ulcer other than a pressure ulcer For pressure ulcers on the foot, use Ulcer Care (M1200E) Copyright © 2013 All Rights Reserved
  • 107. Final Thoughts… Accurate clinical assessment at the bedside leads to accurate MDS coding Nurses who do not have MDS coding responsibilities must still be aware of Section M coding instructions Proactive prevention of skin problems is the best intervention! Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 107
  • 108. Questions/Answers Harmony Healthcare Internationa 1 (800) 530 – 4413 KSteele@harmony- healthcare.com Harmony Healthcare International, Inc. 108108Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.
  • 109. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Assess your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc. 109Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

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