CMS Changes Policy on OASIS Coding for Healed Stage I and Stage II Pressure Ulcers

    On August 12, 2004, the Centers for Medicare and Medicaid Services (CMS) issued a policy change regarding guidance for coding healed Stage I and Stage II pressure ulcers on the Outcomes and Assessment Information Set (OASIS) standardized patient assessment form required for all Medicare home care patients.

This change became effective September 1, 2004 and was prompted by and in response to the National Pressure Ulcer Advisory Panel's (NPUAP) consultation and opinion regarding the healing status of Stage I and Stage II pressure ulcers.

    In the NPUAP's opinion, Stage I pressure ulcers that heal to normal-appearing skin are not at increased risk for future ulcer development. Because Stage II pressure ulcers generally heal with minimal scar formation, healed Stage II pressure ulcers only slightly increase the risk for the development of another pressure ulcer in the same anatomical location. Therefore, the risk of breakdown for a healed Stage II pressure ulcer is not the same as the increased risk of future breakdown for healed Stage III and Stage IV pressure ulcers.

    Because they state, “underlying skin architecture of a healed Stage III or Stage IV pressure has been permanently altered, there is increased risk of future skin breakdown and ulceration at the site of the healed ulcer,” CMS recognizes that the practice of “reverse staging” during healing is not an appropriate method of documenting healing. The Centers for Medicare and Medicaid Services will rely on the documentation in the patient’s medical record to reflect healing. This is another reason that accurate, consistent, and regular assessment and documentation are of the utmost importance.

    The Centers for Medicare and Medicaid Services has accepted the NPUAP’s expert opinion and, as a consequence, reviewed their previous guidance policy on how to code healed Stage I and Stage II pressure ulcers. Below is the revised policy:

During the admission or subsequent comprehensive patient assessments, it is found that the patient has a healed Stage I or Stage II pressure ulcer, the responses for OASIS data items should be:

M0440: Does this patient have a skin lesion or open wound?

  • If the patient has a healed Stage I pressure ulcer (and no other pressure ulcers or skin lesions/wounds), the response should be No.
  • If the patient has a healed Stage II pressure ulcer (and no other pressure ulcers or skin lesions/wounds) the response may be either Yes or No depending on the clinician’s physical assessment of the healed ulcer site:
  • If the patient has no scar tissue from the healed Stage II pressure ulcer, the appropriate response is No.
  • If the patient has some residual scar tissue formation, the response is Yes.

M0045: Does this patient have a pressure ulcer?

  • If the patient has a healed Stage I or Stage II pressure ulcer (an no other pressure ulcers), the appropriate response is No.

The guidance for coding healed Stage III and Stage IV pressure ulcers remains unchanged under the M0450 - Current Number of Pressure Ulcers. The correct responses for documenting in this section are as follows:

  M0440 = 1, Yes, patient has a skin lesion
  M0445 = 1, Yes, patient has a pressure ulcer
  M0450 and M0460 = appropriate stage when ulcer was deepest
  M0464 = 1, fully granulating (currently best response)

    Even though it has taken several years for CMS to adopt newer pressure ulcer research into their coding and assessment tools, it is refreshing to know that the organization is open and willing to made policy adjustments when presented with evidence-based data.

    The subject of “reverse staging” is discussed in detail in the revised Guidance to Surveyors of Long-Term Care Facilities for Pressure Ulcer Requirements (F-Tag 314), the final draft of which had not been released at press time. However, while CMS recognizes that the practice is inappropriate, it is still required in the Minimum Data Set (MDS) patient assessment tool for skilled nursing facilities. Clinicians are instructed to identify the stages of pressure ulcers by describing depth in reverse order from deepest to lesser stages as a way of describing healing or ulcer improvement. Until the MDS is revised, “reverse staging” must be used. However, facilities may adopt NPUAP standards in their own clinical practice and documentation, but NPUAP standards cannot be used for coding the MDS.

    The entire revised policy for OASIS is available at: CMS Policy Change for Accurate Coding of OASIS Pressure Ulcer Items. August 12, 2004. Available at: cms.hhs.gov/oasis/npuap.pdf. Cited: September 2, 2004.