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.
 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
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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
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
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
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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.
(The Wong-Baker FACES Pain Rating Scale)
www.cms.gov
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
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www.cms.gov
www.woundcarenurses.org
www.medterms.com