Staging & Documenting Pressure Ulcers in the Wound Care Clinic

  Despite prevention efforts by multidiscipline healthcare teams, pressure ulcers persist among the geriatric patient population. For many of these individuals, treatment in the outpatient wound clinic will follow discharge from a hospital or skilled nursing facility, or occur while receiving inpatient care within a long-term care (LTC) facility.

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  When a patient arrives to the wound clinic from another facility, it is imperative to ensure that clinical healthcare information is documented and communicated appropriately in order to maximize outcomes and remain compliant with regulations set forth by the Centers for Medicare & Medicaid Services (CMS), which, in turn, should help assure proper financial reimbursement.

  When it comes to pressure ulcers, one’s documentation as it pertains to the staging of individual wounds will significantly affect compliance and eventual payments. Referring to the National Pressure Ulcer Advisory Panel (NPUAP) classification system¹ can be an effective means of maintaining wound-staging accuracy and fostering efficient communication across all care settings. However, CMS staging definitions differ in LTC. Differentiating the correct diagnosis of chronic wounds from other conditions and determining that they are indeed pressure ulcers also holds implications for treatment plans as well as CMS regulations and reimbursement. This manuscript reviews pressure ulcer assessment and staging as it relates to the NPUAP and offers guidance on CMS regulations (as well as modifications) that impact outpatient wound clinics.

Pressure Ulcer Assessment & Staging

  Most patients who are referred to the wound clinic from an LTC setting typically present with full-thickness pressure ulcers that have failed to heal for at least 30 days. While there has been discussion in the literature regarding superficial and full-thickness skin injury (and how this may translate into a revised classification system for pressure ulcers²), most clinicians in acute care and outpatient wound centers throughout the US and Canada are currently using the NPUAP pressure ulcer categories/staging definitions.¹ (See Table 1.)

  Remember, NPUAP category/stages should only be used to describe pressure ulcers, not other skin injuries/wounds such as skin tears;³ arterial, venous, or neuropathic ulcers; or neuroischemic/diabetic or other foot ulcers that have their own unique and distinct classification systems. The NPUAP staging system is based on the type of tissue affected or seen in the wound bed rather than the depth of the wound in centimeters. Stages I and II pressure ulcers are considered by NPUAP to be superficial injuries or wounds. When pressure/shear forces result in non-blanchable erythema of intact skin over a bony prominence, the appropriate designation is stage I.

  A stage II classification is given when the epidermis is no longer intact and the pressure-related erosion (loss of superficial epidermis with an epidermal base) or ulcer (complete loss of epidermis with a superficial dermal base) is shallow and there is no slough on the wound bed. Stage II pressure ulcers can also present as an open or ruptured blister with serous fluid. Remember, there are many skin problems that can present as a blister, including wounds in patients living with epidermolysis bullosa, burns, and herpes. Assessing the cause of the blister and the etiology correctly is paramount before staging and documenting can occur. And, of course, in order to be staged with the NPUAP classification system, the cause of the wound must be due to pressure.

  Stage III and IV pressure ulcers have full-thickness tissue loss, but are differentiated when bone, joint, muscle, or tendon is/are not visible or palpable (stage III) and is/are visible or palpable (stage IV). According to a 2012 position statement by the NPUAP, if cartilage is visible, the pressure ulcer should be classified as stage IV.⁴ When the wound bed is no longer visible due to slough or eschar, the pressure ulcer should be classified as “unstageable.” Suspected deep tissue injuries (sDTIs) are pressure ulcers that present as purple or maroon intact skin or blood-filled blisters. A recent retrospective study⁵ of 77 hospitalized adult patients living with sDTIs found that 66.4% completely resolved or were progressing toward resolution while only 9.3% deteriorated into full-thickness pressure ulcers. The remaining sDTIs remained intact. More research is needed to accurately assess the evolution and characteristics of sDTIs.

Difference Between CMS & NPUAP Pressure Ulcer Staging

  CMS has adapted, but not adopted, the NPUAP pressure ulcer categories/staging definitions that are summarized in Table 1. The major difference relates to the staging of pressure ulcers that present as blisters. CMS regulations direct the clinician to assess the surrounding or adjacent blister tissue for signs of deep tissue injury. The blister margin assessment should be independent of the blister fluid composition of blood, serum, pus, or any combination of these contents. If the criteria for sDTI are discovered, the pressure ulcer is classified as sDTI, even if the blister fluid is not bloody. Conversely, if there is no associated skin change evidence of sDTI in the soft tissue surrounding the blister, the pressure ulcer must be designated as stage II, even if the blister fluid is bloody.⁶ Clinicians need to be aware of this difference in CMS regulations, especially if the patient is referred from an LTC facility.⁷ An LTC facility has to code accordingly to CMS regulations as a stage II because it is a pressure ulcer with a blood-filled blister with no signs of deep tissue injury. It is not incorrect staging; the LTC facility is following the directions in the CMS resident assessment instrument (RAI) manual to code it as a stage II.

Etiology & Documentation

  The first step to achieving consistent documentation is to correctly identify wound etiology. In the sacral area, there are several common skin problems that require differential diagnosis, including skin tears,³ moisture-associated skin damage (MASD),^8,9 gluteal cleft,¹⁰ or friction injuries. There are four types of MASD, two of which can be misdiagnosed as pressure ulcers — incontinence-associated dermatitis^8,9 from stool and/or urine and intertrigo related to perspiration in the gluteal cleft.¹⁰ All types of MASD are more severe when friction is a co-factor. Making the correct differential diagnosis is important to develop and implement the appropriate treatment plan for improved patient outcomes as well as for CMS compliance.

  The technique for measuring pressure ulcers as indicated by CMS may differ from that of the NPUAP. CMS’ RAI manual for LTC states that a “disposable measuring device or a cotton-tipped applicator” should be used. Based on the research recommendation of the NPUAP, CMS directs clinicians to assess wound area by multiplying the longest length of the wound (head to toe) by the greatest width perpendicular to this length.⁶ For pressure ulcers that are open, depth should be assessed by using a moist cotton applicator that is carefully inserted into the deepest part of the wound. For LTC residents, CMS also directs clinicians to code tissue types using a numerical scale that includes four of the NPUAP Pressure Ulcer Scale for Healing (PUSH) Tool rankings for tissue type.⁶ (To access this tool, visit www.npuap.org.) However, clinicians in the outpatient wound clinic may want to document other pressure ulcer characteristics not yet included on MDS 3.0. This documentation can include the type of exudate (serous, sanguineous, purulent, or combinations). For exudate amount, consider using “none,” “light,” “moderate,” or “heavy” from the NPUAP PUSH tool describers. Other characteristics include presence of undermining/tunneling, periwound skin condition, and pain associated with pressure ulcers. The 2014 NPUAP, European Pressure Ulcer Advisory Panel (EPUAP), and Pan Pacific Pressure Injury Alliance’s Prevention and Treatment of Pressure Ulcers: Quick Reference Guide also offers helpful reccommendations.¹¹

  In December 2013, CMS posted the Final Rule for calendar year 2014 regulation (CMS-1601-FC). This rule explains how outpatient clinics are reimbursed through the Hospital Outpatient Prospective Payment System.¹² To maintain continuity of care, outpatient wound clinic staff members should be aware of CMS regulations that govern LTC so that documentation can be consistent during patient referrals and transfers. A full discussion of CMS regulations is beyond the scope of this article. Clinicians are advised to visit CMS online (www.cms.gov) to obtain the official regulations in their entirety.

Elizabeth A. Ayello is a faculty member with Excelsior College School of Nursing, Albany, NY, and course coordinator of the IIWCC-NYU at NYU Langone Medical Center, NY. R. Gary Sibbald is professor of medicine and public health, University of Toronto. Barbara Delmore is program manager for the Wound and Ostomy Nursing Service at NYU Langone Medical Center. Sarah Lebovits and Komal Saggu are members of the wound and ostomy nursing service at NYU Langone Medical Center.

References

1. National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer staging/categories definitions. Accessed online: www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories.

2. Sibbald RG, Krasner DL, Woo KY. Pressure ulcer staging revisited: Superficial skin changes and deep pressure ulcer framework.© Adv Skin and Wound Care. 2011;24(12):571-80.

3. LeBlanc K, Baranoski S, Christensen D, et al. International skintear advisory panel: A tool kit to aide in the prevention, assessment, and treatment of skin tears using a simplified classification system.© Adv Skin and Wound Care. 2013; 26(10):459-76.

4. NPUAP position statement. Pressure ulcers with exposed cartilage are stage IV pressure ulcers. Accessed online: www.npuap.org/wp-content/uploads/2012/01/Cartilage-Position-Statement1.pdf.

5. Sullivan R. A two-year retrospective review of suspected deep tissue injury evolution in adult acute care patients. Ostomy Wound Manage. 2013;59(9):30-39.

6. CMS MDS 3.0 RAIManual. Accessed online: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html.

7. Ayello EA, Levine JM, Roberson A. CMS Updates on MDS 3.0 Section M: Skin Conditions-Change inCoding of Blister Pressure Ulcers. Adv Skin and Wound Care. 2010;23(9):394,396-397.

8. Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage: Overview and pathophysiology. JWOCN. 2011;38(3):233-241.

9. Black JM, Gray M, Bliss DZ, et al. MASD Part 2: Incontinence-associated dermatitis and intertriginous dermatitis. JWOCN. 2011;38(4):359-370.

10. Mahoney M, Rozenboom B, Doughty D. Challenges in classification of gluteal cleft and buttocks wounds. JWOCN. 2013;40(3):239-245.

11. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: Quick reference guide. Emily Haesler (Ed.) Cambridge Media: Perth Australia, 2014. Accessed online: www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA.pdf. Last accessed 6 October 2014.

12. CMS Details for Regulation NO: CMS-1601-FC. Accessed online: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1601-FC-.html.