Section M: Pressure Ulcers

Section M: Pressure Ulcers


We’ve received a lot of questions from those
of you here in the room as well as those of you who are participating online. And we will work to get written answers to
those questions. That document will be posted following the
training. So if your question wasn’t answered today,
and you have submitted it, it’s not that we just don’t want to answer your question, it’s
that we need to maybe confer back with some colleagues, always keeping in mind that we’re
looking across four settings and want to make sure that there’s consistent guidance amongst
those settings. So we’ll go with that. So we are going to begin Section M with talking
about the quality measures. And I had a question earlier about why some
changes were made. So I will address that question as well. So very quickly, let me just welcome those
of you who are on the web stream. I do want to mention that during Section M,
we are going to use some of those supportive materials that are in your packets if you’re
here in the room or are in that folder online. We’ll be using specifically the case study
and the excerpts of the Section M item set. These are the objectives of the section. We are going to talk about the intent of Section
M. We’ll look at the rationale of the look-back period. We’ll look specifically at M0300 and M0800,
although I’ll talk about M0210 as well. You are going to be looking at coding some
scenarios. But before we do that, we’ll start by looking
at the quality measures. And the question I received from one of my
colleagues during one of the breaks was, why did the specs change? You may have noticed within the last, I don’t
know, several days, that there’s been a new posting of the specs. And the quality measure specs for this item
now, you are going to see that we use M0300 rather than M0800. And the reason for that is, it really corrected,
kind of leveled the playing field with the other settings. Think about in the other settings, the intent
of this is to compare how did they come in, and how are they at the end of the session? So in this SNFs when you use M0800, you are
having that look-back scan. You’re capturing anytime a pressure ulcer,
maybe they had a pressure ulcer develop in the facility. So it’s new pressure ulcer, or maybe that
pressure ulcer was a stage 2 in advance to the stage 3, but at the end of that SNF PPS
stay they are free of pressure ulcers. If you’re using the information from M0800
and capturing all of those assessments over the whole course of the stay, you would capture
that change versus these two points in time. So in order to make it consistent with the
other settings, this allowed us to capture simply those two points in time. So let’s talk about what “this” is, what this
change is. So the SNF denominator here is the number
of complete resident Medicare Part A stays. That’s defined as the 5-day PPS Assessment
and the discharge. So that’s the piece that really led to this
change of not using all those intervening assessments. And that could be a standalone Part A PPS
or a Part A combined with the OBRA discharge, except those that meet the exclusion criteria. The SNF numerator is the number of complete
resident Medicare Part A stays that the resident — the assessments indicate the resident has
had a change, one or more new or worsened pressure ulcers. And you can see on the slide here that now
those new or worsened pressure ulcers are going to be captured with M0300B, C, or D
looking at the item, do they have the pressure ulcer and the present on admission items? And we’ll walk through these closely. And we are only looking at 2, 3 and 4. So that’s consistent with that short stay
measure that we’ve known all along, right. We don’t consider 1s, and we don’t consider
unstageables in this item. Then let’s look at our exclusions. Missing data, residents with missing data
are going to be excluded if that data are missing on the discharge assessment. And residents who die are going to be excluded
from the measure as well. If there’s no initial assessment that would
capture this covariate item, that will also be excluded. So what are the covariates? There is a risk adjustment here, and it is
the covariates. They are collected at the initial assessment. And I think that that’s a key point here and
that is, that has been the case right along these covariate items are captured on that
first assessment that you do. And these are that the resident has bed mobility
where they require limited assistance or greater, bowel incontinence at least occasionally and
how frequent does someone have to be incontinent of bowel to be occasionally? One, do you all agree? Isn’t frequently two or more? Yeah. And then diabetes or PVD you would capture
that in Section I. Or low BMI, that’s calculated within the specifications
based on how you code the height and weight for the resident. So before we look at the select items in Section
M, let’s review the intent of this section. In Section M the items document the risk,
presence, appearance and change in pressure ulcers. Other skin ulcers and wounds are also captured
in this section and are documented in Section M as are some treatments. It’s not all inclusive. There certainly may be treatments or issues
that are not captured on Section M. And clinicians need to be sure to recognize and evaluate
risk factors and need to identify and evaluate skin areas at risk for constant pressure. And a complete assessment is an essential
first step in preventing pressure ulcers and effectively treating those if the resident
does have any skin issues in a holistic resident-centered approach to assessment and care planning is
certainly a must. When you’re determining wound etiology, determining
the wound etiology is going to be critical one for treatment of the resident, but two
for accurately coding the MDS. So we have an item M0210, and that’s not included
here on the slides. But I think it’s important to consider M0210
on the MDS as a gateway item into the rest of Section M. And M0210 you’re simply asked,
does the resident have one or more unhealed pressure ulcers at stage 1 or higher? If you say no, you skip all the way down to
M0900. But if you say, yes, you continue right on
down to M0300. And that’s where we’re going to really begin
our discussion about these items today, and that is M0300. With this item, we’re going to be first determining
the deepest anatomical stage for pressure ulcers. We’re going to be sure not to backstage. We do consider current and historical levels
of tissue damage. It’s certainly important to capture that information
in the medical record documentation when they’re being admitted into you. Really what stage? What’s the historical information about that
ulcer? We’re going to observe and palpate any pressure
ulcer to determine the true depth of tissue damage. And ulcers are staged based on the deepest
level of tissue damage that is either visible or palpable. If the ulcer’s depth is obscured by slough,
or eschar, the ulcer is going to be unstageable. And more information is going to be outlined
in step two about documenting unstageable ulcers, including those related to slough
or eschar. Those are non-removable dressing or device,
or with suspected deep tissue injury. The historical information about the ulcer
available in the medical record must inform staging. Because ulcers can’t be back-staged. If the ulcer was classified as a higher numerical
stage than it currently appears, that higher stage is what will be coded on the MDS. And there’s no question that a solid system
to ensure careful documentation and tracking of pressure ulcers helps to ensure accuracy
in coding Section M, but importantly helps to ensure accuracy in clinical follow-up and
appropriate care for the resident. So step 2 focuses on those unstageable pressure
ulcers. We’re going to identify those and if slough
or eschar prevents the clinician from visualizing or palpating the wound bed, that ulcer would
be classified as unstageable. However, if slough or eschar is present but
the true depth of the ulcer can be determined, it should be staged appropriately. So years ago I cared for a lady who had a
extremely contracted arm, left or right I’m not sure which, and she had a very small pressure
ulcer right over her tendon here in her antecubital area here. And it was covered with tons and tons of slough. But if you looked really close there was a
shiny white tendon that you could see. I wouldn’t necessarily measure to get the
true depth of that wound. But I sure could see an underlying structure
evident in the base of that. So how am I going to stage that wound? 4. Right. I see that underlying structure, so I don’t
necessarily — it’s not a percentage of slough or eschar that you say, it’s obscured or not
obscured. It’s what clinically are you seeing in there? If you can see that underlying structure,
as we could for that lady, remember the doctor at the time was a wound care center said that’s
a tendon, Jen. I was like oh, it was really, really pretty
dramatic. You want to consider each individual case
and make the determinations appropriately. We may have pressure ulcers that are intact
but appear as suspected deep tissue injury. And these also would be coded as unstageable,
not as stage 1s. And if the pressure ulcer can’t be assessed
because of a non-removable dressing or device, it also would be coded as unstageable. And next we’re going to determine for each
ulcer whether or not that pressure ulcer was present on the time of admission, entry or
re entry, and not acquired while the resident was in the care of the nursing home. Again, we’re going to consider the current
and the historical levels of tissue involvement. And in order to make this determination, we’re
going to review the history of the ulcer, including the location and stage of the ulcer
at the time of admission,entry or re entry , and looking back into the medical record
that you received about that resident and really gathering the historical information. And there’s lots of kind of — they’re not
really coding tips, they’re more of the instructions here. But I do want to draw your attention to a
few that were revised or added as we look through these next several steps here. And I’m going to share with you what it says
on the slide. But then I do want to have a little discussion
kind of surrounding each one of these, and really kind of try to bring those alive in
a clinical example. So if we have a pressure ulcer that was present
on admission, entry or re entry and it subsequently increases 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
present on admission. So here’s our example. The resident comes into your facility and
they have a stage 2 pressure ulcer. And at that time you’re going to code your
MDS would say what? Stage 2, present on admission. The next MDS you’re doing for that resident,
between those periods of time it advanced to a stage 3 pressure ulcer. So now it’s a stage 3 pressure ulcer, not
present on admission. Okay. So when they come in, you’ve got a stageable
ulcer. It gets worse. That higher stage is captured on the MDS. It’s not considered present on admission. If a pressure ulcer was unstageable on admission,
entry or re entry, and then later becomes numerically stageable, it’s going to be considered
present on admission at the stage that first becomes numerically stageable. If it’s subsequently increases, again that
won’t be coded as present on admission. So let’s talk about this one a little. We have a resident who comes in with an ulcer
that’s completely obscured with slough. You can not see anything in the base of that
wound. The slough is debrided. And we have a stage 3 pressure ulcer. That stage 3 pressure ulcer is a stage 3 present
on admission. But now the ulcer becomes covered with slough
or eschar again. And now you debrid it again. Now it’s a stage 4. Is it a stage 4 present on admission? No. Once it’s stageable once, and now it declines,
it’s not present on admission. Okay. How about if a resident has a pressure ulcer
that was originally acquired in the facility? I want draw your attention to this coding
tip or direction number five is a revised one. So this is revised in the draft of the RAI
User’s Manual. If a resident who has a pressure ulcer, was
originally acquired in the facility, is hospitalized and returns with that pressure ulcer at the
same numerical stage, the pressure ulcer should not be coded present on admission, because
it was present and acquired at the facility. So this is, your resident comes in with absolutely
no skin problems. They then develop a stage 2 pressure ulcer
in your facility. That is a stage 2 not present on admission. They go out to the hospital and come back
with the very same stage 2 pressure ulcer. It is still not present on admission. Okay. And this is a significant change from how
we coded this item. And it’s really much more consistent with
the clinical picture of the resident, right. Stage 2 that happened in your facility, they
go to the hospital, that stage 2 still happened in your facility. Number six is an added tip. So the next instruction we’re going to go
over is brand new. And that is, if the resident who has a pressure
ulcer that was present on admission, not acquired in the facility is hospitalized, and returns
with that pressure ulcer at the same numerical stage, it is still coded as present on admission. I thought I’d hear a thunderous round of applause. (Applause) Yeah, yeah. It clinically represents the true picture
of the resident, right. That resident came in with that pressure ulcer. They went to the hospital, comes back with
the same pressure ulcer, because it was originally acquired outside the facility, it is going
to still be present on admission. All right. So this is our resident that came in with
a stage 2. They do go the hospital. They’re out for a few days. They come back, same stage 2. It was present on admission before, it’s present
on admission now. Yes? Yes, excellent. And number seven here was updated as well. And that is, if the resident who has a pressure
ulcer is hospitalized and the ulcer increases in numerical stage during that hospitalization,
the ulcer will be coded as present on admission at the higher stage for re entry. And this coding tip or instruction here was
updated as well. And let me share with you a clinical example
for this. Your resident leaves the nursing home with
a stage 2 and goes to acute care. Upon return to the nursing home, that stage
2 is now a stage 3. This stage 3 is going to be considered present
on admission. Okay. There’s been a couple of great examples and
some, I don’t know if you want to call them flowcharts or what we would call them here
in the RAI User’s Manual that have been added. So this little graphic you see on the top
of the slide actually appears if the manual now. So let’s take a look at these. Our example is that Ms. K is admitted to the
facility without a pressure ulcer. But during her stay she develops a stage 2
pressure ulcer. This is a facility-acquired pressure ulcer. It’s not present on admission. She was hospitalized and comes back with the
exact same stage 2. This pressure ulcer is originally acquired
in the nursing home and it won’t be considered present on admission when she comes back. The graphic really helps to document the decision
making here. And I encourage you to use these graphics
as you’re helping your staff and others understand the coding of these items. So in this scenario, Ms. K came in without
a pressure ulcer. She acquired one in the nursing home. She went back, she went to the hospital. She came back with that pressure ulcer at
the same stage. Again it was originally acquired in that nursing
home. And therefore, it’s not going to be considered
present on admission. But then we have Ms. J, another example. And she is — sorry, Mr. J, he is a new admission
to the facility and admitted with a stage 2 pressure ulcer. The pressure ulcer is considered present on
admission because it wasn’t acquired in the facility. The resident arrived to the nursing home with
it. He’s hospitalized and he comes back with the
same stage 2, unchanged from the prior admission or entry. And the pressure ulcer is still considered
present on admission because it was originally acquired outside of your nursing home. Again the graphic here helps to document the
decision making regarding coding. Mr. J came in with a stage 2 initially. Again it wasn’t facility acquired to start
with. He went to acute care. And he returned with the same stage 2 pressure
ulcer. He continues to have an ulcer that’s present
on admission. You all good? Excuse me. Now let’s take a look now at each item on
M0300 beginning with M0300A, stage 1 pressure ulcers. Before I do go through these stages though,
I want to stress that the definitions in the manual have been adapted. CMS adapted not adopted, okay. So there was some minor changes, adaptations
from the NPUAP or National Pressure Ulcer Advisory Panel’s 2007 pressure ulcer staging
guidelines. Those are what is currently used in the RAI
User’s Manual. We know the staging definitions have been
recently updated again. But what you are coding this MDS on has to
be the MDS definitions. So you may have instances where documentation
is a little bit different for MDS versus what you might have on your pressure ulcer staging
sheet. But you’re documentation should tell the story
as to why you’re MDS looks the way it is. So the clinical picture around that assessment
is what’s going to support that coding. And again, I can’t stress enough, follow these
instructions, these RAI Manual instructions for coding. So what is a stage 1 pressure ulcer? It’s defined in the RAI User’s Manual as an
observable pressure-related alteration of intact skin, intact skin being a keyword there. And the indicators when compared to adjacent
or opposite areas of the body, you may have changes in skin temperature where it’s warmer
or cooler. It maybe a tissue consistency. It might be a little bit boggy, a little bit
firmer. It maybe sensation. Your patient or resident may have a itch or
a little bit of soreness in the area. They may also have that defined persistant
redness. And we know in folks with darker skin tones,
that if we’re looking for red areas we’re never going to find stage 1s, right. We need to be educating staff for looking
at changes in skin color. It might be purple, it might be a little bit
redder, a little bit more of a blue color. But we generally aren’t going to find pink
areas on folks with darker skin. So stage 1s are intact and changes in temperature,
consistency, sensation or color. And these all might be signs of that stage
1 skin damage. For a stage 2, M0300B is where the assessor
is going to document stage 2 pressure ulcers. In addition to coding the number of pressure
ulcers and the number of those pressure ulcers that were present on admission, the date of
the oldest stage 2 pressure ulcer is going to be captured as well in M0300B. So what is a stage 2? It’s defined as a partial thickness, loss
of dermis, presenting as a shallow open ulcer with a red or pink wound bed without slough. It may be an intact or open or ruptured blister. I want to draw your attention to that phrase
“without slough”. If an ulcer is coded as a stage 2, and then
I look through your MDS and I get down to M0700 where you’re defining the most severe
tissue type and I see slough, I’m going to say there might be a problem here, right. So we’re going to go back and say what is
really going on? So I think Section M for me as someone who
looks at MDS, looks at consistency items, I think Section M is an absolutely ripe opportunity
to look at consistency in coding. We know that certain stages are going to present
with certain tissues. We know that there’s not going to be slough
or eschar in a stage 2, right. We know there’s going to be epithelialization
here. We’re really not going to see — oh my God
it just went out of my head, granulation. Thank you from the field there. We’re not going to see that granulation tissue,
right. That’s not how stage 2s heal. So we’re going to look at consistency across
these items, and really take that opportunity for staff education from a clinical standpoint
and from a MDS coding standpoint to say, what are you really looking at here when you’re
assessing that wound? In M0300C are stage 3 pressure ulcers. We’re going to document those there in C.
Stage 3 pressure ulcers are full thickness tissue loss. Subcutaneous fat may be visible. But underlying structures such as bone, tendon
or muscle are not exposed. In other words, you’re not able to visualize
them or directly palpate those underlying structures. Slough may be present but it doesn’t obscure
the true depth of tissue loss. These ulcers may have undermining or tunneling. And in stage 4s, they’re documented in M0300D. And these ulcers are also full thickness tissue
loss with exposed bone or tendon that can be seen or be directly palpated. Again, slough or eschar may be present. These wounds often include undermining or
tunneling. So what’s the key definition between 3 or
4? They’re both full thickness wounds. The key difference is that presence of an
underlying structure. It’s not depth, per se. It’s depth of soft tissue damage such that
we’re getting to these underlying structures. But it’s not the centimeters or millimeters
of damage, but the depth of the damage into the actual tissues. When you think about a stage 4 on someone’s
ear, it can be pretty shallow right, very shallow where maybe they have it on their
thigh or buttock and it’s a much, much deeper area, but it’s really a stage 3. So we’re really helping individuals who are
coding this, and who are assessing resident’s pressure ulcers really to get them to understand
it’s the structural changes that we’re seeing in that wound that really leads us to stage
one way or another. In M0300E we’re looking at unstageable ulcers
due to non-removable dressings or devices. So for some reason you can’t see the ulcer. As a nurse, these always made me nervous,
right. I didn’t like these much at all. So what are some examples of non-removable
dressings and devices? Primary surgical dressing, casts or other
orthopedic stuff that can’t be removed. So I would say we’re not getting a whole lot
of these hopefully. We tend to be able to visualize those wounds,
even if we’ve got maybe a longer use dressing that comes off once or twice a week. We can still take that opportunity to evaluate
and assess the wound. And then we have unstageable ulcers captured
in M0500 that are unstageable related to slough and/or eschar. And slough or eschar are both defined in the
RAI User’s Manual. Both of these are dead tissue. They’re devitalized tissue. When we look at slough, it is yellow, tan,
gray, green, brown. It’s usually stringy or clumpy. It maybe adherent to the base of the wound,
kind of all across. You may also have little clumps of this. For eschar, that usually can be soft in nature,
but it tends to be that harder kind of leathery substance that is black, brown or tan in color. It may look like a scab, but certainly very
different from a scab. These are very firmly adherent to the base
of the wound and often the sides or edges of the wound as well. So again, both of these are well defined in
the RAI User’s Manual and the bottom line is they’re both non-viable tissue, no question
about it. M0300G, these are unstageable pressure ulcers
related to suspected deep tissue injury. And let’s take a look at this definition. I want to draw your attention here to one
particular word in the second line. Suspected deep tissue injury is defined in
the RAI User’s Manual a purple or maroon area of discolored intact skin. I want to draw your attention to that word
intact skin, due to damage of underlying soft tissue. The area may be preceded by tissue that’s
painful, boggy, warmer, cooler, compared with the adjacent tissue. Do note again that issue that it is intact. So it is your turn for a polling question. Miss. N was admitted for a pressure ulcer on her
right ischium on March 3, 2016. The ulcer was obscured with slough on admission. The physician debrided the ulcer on March
14th. A full thickness ulcer without exposed bone tendon
or muscle was revealed. How will the pressure ulcer be staged in M0300 on the combined admission
and 5-day assessment with an ARD of March 10th. Will it be A, unstageable related to SDTI. Will it be B, stage 3? Will it be unstageable related to slough or
eschar? Or will it be a stage 4 as in D. Take just
a moment. The poll is open. You can go ahead and click in your answer. All right. Just a couple more seconds there guys. All right. We have unstageable is the predominant answer. Let’s see which one is right. Unstageable. So why is this unstageable and not a stage
3 on the assessment ARD of March 10th? Hasn’t been debrided yet. It’s going to be debrided on the 14th. So on that 14-day assessment we are going
to have a stage 3. Oops. I guess I just gave you the answer to the
next question. (Laughter) Let me see if you were listening. Looked like you were listening. So following debridement, do you all agree
with that stage 3? Sorry to give away the top secret. (Laughter) Thank you for the 11 of you that
voted, and the 10 or so of you that were listening. Appreciate that. (Laughter) Okay. It is a stage 3. All right. Great job, guys. But there’s one more question. Following debridement will that pressure ulcer
be considered present on admission? Go ahead and take your polling. A is yes, or B is no. I see lots of responses. You guys are doing great for this late in
the day. I really appreciate your stamina. It must be a bunch of folks that work in nursing homes; Right? — You’re hearty souls. Doing great. All right. 100% of you say it’s present on admission. Well done. Remember that these slides with these correct
answers are going to be posted on the website for you. I see somebody taking a picture. I should have mentioned that for you earlier. Again, I know Mark mentioned it earlier. But they will be available. Good job there. Let’s look at M0800. Now keep in mind that the new revised quality
measure is all based on M0300 for this SNF QRP. This MDS item M0800 is a fantastic opportunity
to look at consistency in coding to look at what really happened in tracking changes. We’re capturing in this item M0800, we’re
looking at worsening of pressure ulcers since the last assessment. For purposes of this item, I want to stress
to you that we’re looking at worsening in numerical stage. So if you go in there and you have a kind
of shallow stage 3 now you have a really deep stage 3, clinically you’re like, yikes! That’s not looking so good. But for MDS coding, we’re looking at the increase
in numerical stage that’s really impacting the coding of this item. There’s no question that tracking of changes
of pressure ulcers is consistent with good quality care and certainly appropriate. So why are we doing this item? When a pressure ulcer newly develop or worsen,
reevaluation of the interdisciplinary care plan should occur with the goal of ensuring
that prevention and management measures are appropriate for the care of that resident. Sorry, I was a slide behind there. But rationale when planning for care, this
item is all about helping to trigger a plan for care, making sure that we’re reevaluating
when there is a change. So I mentioned earlier that worsening for
this item equates to progressing to a higher stage. In other words, there’s a deeper level of
tissue damage than the previous assessment. When there’s no evidence of skin breakdown,
the MDS is going to reflect 0 pressure ulcers here. What’s the look-back period for this item? It is to the ARD of the prior OBRA or scheduled
PPS. If the assessment is being completed for the
first time, so it’s the first assessment for that resident, this item is not completed. So let’s look at the steps for assessment. We begin by reviewing the history of each
pressure ulcer, specifically that we’re looking to how it currently appears to past stages
to determine whether that ulcer increased, is new or increased in numeric stage compared
to the last assessment or since admission, entry or re entry. And it allows — again we’re comparing — we’re
looking at that medical record documentation and really considering what’s going on with
these ulcers, you know, the status of this resident. For each stage we’re counting the current
ulcers that are new or have increased in stage since that last assessment. Remember we’re considering ulcers that are
stage 2, 3 or 4 only here. And then we’re going to enter the number of
ulcers that were not present, or were present on a lesser numerical stage on a prior assessment. And if there’s no ulcers, we’ll Code 0 in
that. So some coding tips, clearly having a system
in place that ensures documentation of pressure ulcers over time including changes in ulcer
status makes coding this item easier. More importantly it makes clinical care more
appropriate for that resident. And ulcers are considered worsening if a numerically
staged ulcer increases in numeric stage. There’s some additional coding tips with scenarios
that I’ll review and again try to offer some kind of clinical scenarios to support these. The first is if a pressure ulcer was unstageable
on admission, entry or re entry, don’t consider it as worsened on the first assessment that
if it’s stageable. So if your resident comes in with a resident
that’s unstageable due to slough or eschar and the provider debrides it, then it’s a
stage 3 is revealed, it is not new or worsened. Are we going to consider that a present on
admission though? What do you think? So they come in with a unstageable. It’s debrided. Now it’s a stage 3 present on admission? Yes. Excellent. If a pressure ulcer was numerically staged
and becomes unstageable due to slough or eschar, do not consider this pressure ulcer as worsening. The only way to determine if the pressure
ulcer has worsened is to remove enough slough so that the wound bed can be visualized. And once that’s happened that it can be visualized
or palpated, then the wound is staged and the determination of worsening is made. So an example of this, you may have a resident
who has a stage 3 ulcer. It then becomes covered with slough. That stage 3 that becomes covered with slough
is a great example of clinically, yikes, right. Clinically it’s worsened. But for this item, you’re only coding 2s,
3s, and 4s. So that covered with slough ulcer is not going
to be captured here. But once it’s debrided you see it’s a stage
4 ulcer. Now it is new or worsened. Now it’s reflected here at stage 4, new or
worsened. Is it present on admission? No. Correct. Great job guys. If a pressure ulcer was numerically staged
and becomes unstageable and again, subsequently debrided, so you can numerically stage it,
you’re going to compare the numeric stage prior to it becoming unstageable and after. And then you’re going to consider that when
you’re coding it. So if the ulcer’s current stage has increased
you’re going to consider that as worsened. So that’s the stage 3 becomes unstageable,
debrided, now it’s stageable again at a stage 4. It’s new or worsened. And if two pressure ulcers merge, you don’t
consider them as worsened. Again clinically you might be saying, yikes
what’s going on here? We now have one giant ulcer instead of two
little ulcers. Although the surface area may have increased,
overall size of that ulcer, it’s not increased in numeric stage, and only once it is increased
in numeric stage is it considered new or worsening. So two stage 2s merge, they become one big
stage 2. It’s not new or worsening. Two stage 2s merge and become a stage 3, it
is new or worsening. Okay. And then if a pressure ulcer is acquired during
the hospital stay, it’s stage will be coded on admission and considered present on admission
or entry or re entry. It’s not going to be coded in this item. If it worsened in the SNF subsequently, it
will be captured. And if a pressure ulcer increases in numeric
stage during a hospitalization, its stage is going to be considered present on admission. And again, it won’t be coded in this item. And the clinical team will certainly recognize
that there’s been a change in the status and act accordingly with the clinical assessment. So I have a coding scenario for you. This is not a polling question. This is a opportunity to work with Ms. J’s
discharge assessment coding that for skin. So in your packets that you have if you’re
in the room and in the supporting materials that are posted online if you’re participating
remotely, there are a couple of things that you will need, are the excerpt of Section
M. So it’s like one page that just says M0300 and M0800. And you’ll also need the case study that you
used for the ADL exercise earlier today. You will use that same case study. I’m going to give you a little bit less than
10ish minutes. And then we’ll debrief this. So, my watch right now says about 12 minutes
until 4:00. Come back about 5 of 4:00 and we’ll debrief
from this. So work together at your tables. Talk amongst yourselves. I’ll see you in a few. »» Okay, guys, it seems like most of you
guys are wrapped up here. Everybody good? You need more time? No. Okay. We’ll let’s go ahead and debrief on what we
saw for Ms. J. Remember we’re coding her discharge assessment here. So how would you code M0300 the current number
of pressure ulcers at each stage? What do you think for stage 1s? 0. How about stage 2s? 0. Stage 3s? 1. And just why are we coding it that way? May 9 she had that purple area she was admitted
with. But then it was noted earlier to be a full
thickness wound without bone, tendon or muscle visible or palpable. How about stage 4s? 0. How about the other three items that are here? 0 — oops I went the wrong way. 0, 0, and 0. You all agree. Well done. So is this ulcer at stage 3, is it present
on admission for her? Yes, she was admitted with an unstageable
ulcer. The first time that ulcer became stageable
it was stage 3 and it’s healing up. And she’s going to be leaving our facility. Great. And then how about M0800 worsening in pressure
ulcer? How did you code this item? I hear lots of 0s. Do you agree? 0 stage 2, stage 3 and stage 4. Nothing got worse during her stay. They only improved. So with that, I’m going to ask if there’s
any questions related to Section M? If there are, come on up and ask them. Otherwise we’re going to just pull the folks
who are going to be coming up to answer questions together. And we will be back in 10 or so minutes to
answer questions if you have them at the mic or if you’ve already submitted them. Thank you guys very much.

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