Section M: Skin Conditions Updates

Section M: Skin Conditions Updates


»» Good morning, everyone. SNF training for me is always like old home
week, we all know each other. Tom had stressed I’ve been in this a longtime. You guys have all been in it a long time with
me. So Good morning. I am going to talk to you about Section M.
Those of you who know me know this is my favorite section of the MDS and something I’ve been
talking about again for a long time. In this presentation we are going to look
at the updates. Deb mentioned a lot of the changes that have
occurred with Section M. Many of the changes involve removing those items, which is neat. We don’t usually have lots of things removed
but we did this year in Section M. You’ll also see that definitions have been updated
to reflect changes in the 2016 National Pressure Ulcer Advisory Panel or NPUAP pressure injury
staging system. As in earlier versions of the manual these
definitions are adapted, so they’re not exactly the same as they are with the NPUAP. You’ll also note the integration of the word
“pressure injury” rather than just pressure ulcer in the manual and the item set. I do want to just draw your attention to a
couple of things. In your packets, if you’re an online participant
it’s your packet that is Section M, Skin Conditions updates. In addition to the Power Point you have the
practice coding scenarios Section M without Answers is what it’s called. For those of you who are here in the room
with us you have that in your packet as well. What it allows you to do is have the coding
scenarios in front of you before you actually, as you’re doing the polling so you’re able
to look at that. So that should actually be in the folder that
you received when you came in so you should able to use that. We do have quite a few polling questions in
this section. I encourage you to get involved with those. I also am very happy to entertain questions
when the section ends. In each of our presentations today you’ll
find an acronym list. We certainly aren’t going to read those to
you. But they are embedded within the Power Point. Then also within your packet you’ll find a
comprehensive list of all the acronyms that were used in the sessions. So feel free to pull that out and refer to
it. And that is available in the Introduction
Packet if you’re an online participant. So what are we going to talk about in this
section? I’m going to explain the intent of Section
M and discuss some updated coding guidance. There’s lots of practice scenarios. And then we’ll also, I’ll explain to you the
cross-setting pressure ulcer measure, which is, Changes in Skin Integrity Post-Acute Care:
Pressure Ulcer/Injury and how that measure is calculated. You’ll notice that the slides for this section
of the training include updated guidance rather than complete coding guidance. So for example, I’m going to look at the steps
for assessment with you in a little bit. And you’ll see that there are just excerpts
of the steps. This would be a huge set of slides if we included
everything there. I’ll refer back to pages and things that you’ll
be able to take these back and use them when that manual becomes available so you can more
fully understand Section M. Here are our objectives for the training. After the session I hope that you’ll all be
able to identify the intent of Section M, articulate the purpose of the new wording
and any implications that that has for coding. You’ll be applying coding scenarios; we have
quite a few. And that you’ll recognize the elements of
that cross-setting pressure ulcer measure. So let’s start with looking at the Section
M, Intent. There has been one change in the intent of
Section M, and that is the addition of the word “injuries” to the first sentence. So where it states “the items in this section
document the risk, appearance, and change of pressure ulcers/injuries.” And then CMS does go on to stress in that
intent the importance of identifying and evaluating risk factors as well as evaluating areas at
risk for pressure. Next the intent stresses the importance of
a complete skin assessment and a holistic approach that informs the plan of care for
the resident. And the final bullet on this slide is a very
important one. Clinicians must accurately identify wound
etiology. This is vital to ensuring accurate documentation
including on the MDS. And more importantly it’s vital to directing
the resident’s plan of care. Let’s take a look at the item changes, and
there are quite a few. Similar to what’s been in the manual before,
CMS acknowledges that there is a wide array of terms to describe skin alterations that
are due to pressure. And these go from long ago terms like decubitus
ulcer and bedsore to pressure ulcer and pressure injury among others. So regardless of what the documentation is
in the medical record, using any of these terms, clearly anything, an alteration in
the skin due to pressure is going to be captured in Section M as such. Another important point is the change of pressure
ulcer to pressure ulcer/injury. And that was made to better describe the presentation
of tissue injury as open ulcers versus tissue injuries that present as intact skin. This stresses that regardless of the term,
as I mentioned before used in the medical record, you should be coding appropriately
in Section M for pressure. And you’ll note on this slide the addition
of the word “injuries” in several areas on the item set. And let’s look at that a bit more closely. Stage 1 pressure injuries and DTIs are termed
“pressure injuries” as they are closed. Stage 2-4 and unstageable ulcers due to slough
or eschar are generally open so they are termed as pressure ulcers. Unstageable do to a non-removable dressing
or device could be either. So these are referred to as pressure ulcers/injuries. Additionally, non-staged specific references
are ulcer/injuries such as in M0150, when the item set asks about risk of pressure
ulcer/injury. In M0300E, the item was updated to include
“device” in the bolded text in the first part of the item following the letter E. And in
M0300G, the phrase “suspected deep tissue injury in evolution” was changed to “deep
tissue injury”. And Deb already mentioned to you that several
items have retired. So the date of the oldest Stage 2 pressure
ulcer, the dimensions of the unhealed Stage 3 or 4, or Pressure Ulcer covered with eschar
and the most severe tissue type have all been retired because they’re not used in any of
CMS’s programs. And it was deemed as additional burden on
providers to collect that information. Additionally, M0800, Worsening in Pressure
Ulcer Since Prior Assessment, and M0800, Healed Pressure Ulcer items are being removed because
the present on admission items that you code on the Discharge Assessment will be able to
identify which of the pressure ulcers have increased in numerical stage or become unstageable
and whether or not an ulcer is healed. So essentially those M0300 items capture that
information that those two items were providing. There have also been several changes in coding
guidance. Let’s take a look. With removal of several items from Section
M, some definitions and guidance were moved to other Section M locations. Any remaining instructions that did not apply
to items were removed. And skip patterns have been updated to reflect
the removed items. There have been two changes in the pressure
ulcer risk factor definition. These include the addition of injury so that
the concept being defined as pressure ulcer/injury risk factor and microclimate was added as
an example of a risk factor. This was also added in the list of external
risk factors in the discussion of the item rationale. Microclimate was defined in a program presentation
by Dr. Laura Edsberg. It was a 2015 NPUAP presentation where Dr.
Edsberg defined microclimate as “temperature, humidity and airflow at the patient support
surface interface.” There’s certainly an expanding body of information
regarding microclimate. What is evident is that microclimate has a
significant influence on an individual’s risk for pressure ulcer or injury. As in previous slides, the bold italicized
font on these slides indicates new additions to definitions or other guidance. And the phrase “intense or prolonged” pressure,
that was added to describe the pressure. We understand that it’s not only prolonged
pressure, but intense pressure for a short time can also lead to pressure injury. This change is consistent with that clinical
concept. The last sentence that states the “the pressure
ulcer/injury can present as intact skin or an open ulcer and may be painful” was also
added. Additionally the phrase “and/or friction”
was removed. It used to say pressure in combination with
shear or friction. Keep in mind again that this definition is
adapted from the 2016 NPUAP definition. So that has been kind of realigned to be more
clinically in line with that definition. As I mentioned the term microclimate has been
added to the item rationale for the determination of pressure ulcer/injury risk. And microclimate influences the susceptibility
of skin and soft tissue to the effects of pressure and shear. It’s important that nursing home teams are
cognizant of that risk factor and take steps to care plan appropriate interventions and
put those interventions in place to address the issues related to microclimate. There were several updates to M0210’s Planning
for Care section. The reference to the staging system was updated
to reflect the NPUAP’s 2016 staging system that was used as the basis for the definition. Injury was added in a couple of places. Additionally the importance of visual appearance
and forming staging decisions can’t be overstated. So the description of a staging system now
includes the phrase “visual appearance and/or” anatomic depth of soft tissue damage. Excuse me. On this slide appears a completely new planning
for care tip that reinforces the need to reevaluate the plan of care with a new or worsening pressure
ulcer – excuse me- to ensure that the most appropriate plan of care to treat the pressure
ulcer/injury as well as to prevent additional ulcers is in place along with those again
preventative measures to keep the rest of that resident’s skin healthy. The first coding tip on this slide states
that if two pressure ulcers/injury occur on the same bony prominence and are separated
at least superficially by skin, then count them as two separate ulcers. Stage each and measure each, and again document
them separately. You may recall the last coding tip on this
slide. The manual previously stated if a resident
had a pressure ulcer/injury that healed during the look-back period of the current assessment
but was not documented — there was no documented pressure ulcer in the prior assessment, Code
0. But that tip has been updated. And I think this is a pretty significant change
in the guidance. That now it says, so that second part of the
tip that stated there was no documented pressure ulcer on the prior assessment Code 0 was removed. So now the tip is exactly what you see here
on the slide. If a resident had a pressure ulcer/injury
that healed during the look-back period of the current assessment do not code the ulcer/injury
on the assessment. So what part of that went away? The requirement to have to have it coded on
the prior assessment. That to me is a big change. I think that was a tip that folks often struggled
with for a lot of years. Now it’s a little more simple. You all doing good? Still with me? Yep. Okay. So the three steps for completing M0300A-G
likely look very familiar to you. First determine the deepest anatomical stage. Then identify unstageable pressure ulcers. Then determine which of those ulcers or injury
were present on admission. The definition for “on admission” has not
changed. It means as close to the actual time of admission
as possible. Your facility protocols and clinical practice
guidelines likely inform what that time means in your facility. Is that fair? Yeah. Each of these steps has been updated. And let’s take a look to see what those updates
are. In an effort to spare you some incredibly
wordy slides, we just made a note that manual instructions 3 and 4 under Step 1, which we’re
referring to back staging and reverse staging, were added. And I am going to just share those tips with
you. You can take a listen to those. And again, I welcome questions on these when
we’re done with the presentation. So the first tip which is number 3, again
that’s been added under that first step which is identify the deepest anatomical stage,
states that pressure ulcers do not heal in reverse sequence. That’s not news. Right? That is, the body does not replace the types
or layers of tissue. For example, muscle, fat and dermis are not
replaced as that ulcer heals, that were lost during pressure ulcer development before they
re-epithelialized. Stage 3 and 4 pressure ulcers fill with granulation
tissue. This replacement tissue is never as strong
as the tissue that was lost and hence this area is more prone to breakdown forever. Right? I think clinically we all acknowledge that. The fourth tip is even longer, and it’s got
a ton of clinical information in it. And again I’ll just share that with you. Clinical standards do not support reverse
staging or back staging as a way to document healing. As it does not accurately characterize what
is occurring physiologically as the ulcer heals. For example, over time even though a Stage
4 ulcer has been healing and contracting such that it is less deep, wide and long, the tissues
that were lost and that is muscle, fat, dermis, will never be replaced with the same type
of tissue. Previous standards using staging reverse staging
or back staging would have permitted identification of such a pressure ulcer as a three and then
a two, then a one, then we would say it was healed. But clinical standards now require that this
ulcer continue to be documented as a Stage 4 until it is completely healed. And nursing homes can document the healing
of pressure ulcers using descriptive characteristics of the wound, that is the depth, the width,
the presence or absence of granulation tissue and the like, or by using a validated pressure
ulcer healing tool. Once the pressure ulcer is healed, it’s documented
as a healed pressure ulcer at its highest numerical stage, for instance a healed Stage
4 ulcer. For care planning purposes, the healed Stage
4 ulcer would remain at increased risk for future breakdown or injury and would require
continued monitoring or preventive care. That’s quite a tip, quite a mouthful. What’s the biggest risk factor for that patient
or resident for having a pressure ulcer? Having had a previous one. Right? We know, number one, top of the heap that
we’re worried about those residents. The definitions for epithelial and granulation
tissue were also added in this section. So epithelial tissue is new skin that is light,
pink and shiny even in persons with darkly pigmented skin. In a Stage 2 ulcer, epithelial tissue is seen
as the center and at the edges. Then in Stage 3 or 4, so full thickness wounds,
that epithelial tissue advances from the edges as that wound fills in. And granulation tissue, nurses are the only
people that say, oh look, it’s all red and bumpy. Doesn’t that look great! That’s what granulation tissue is. It’s red tissue with that cobblestone or bumpy
appearance. It bleeds easily when they’re injured. Your patient’s families are like, why are
you happy it’s bleeding? We’re like because a week ago there was no
blood flow. Yay, it’s doing great! Again, we want to see that. We want to see those nice healthy wounds. Instruction 2 under step 2 was added to reinforce
the point that the ulcer should be clean prior to staging. If after its cleaned the anatomical structures
remain obscured such that the clinician can’t determine the extent of the soft tissue damage,
the ulcer’s unstageable. So what if your ulcer is 80 or 90% covered
with slough but you can see a tendon. Is that stageable? Sure, right. You can see an underlying structure. It’s a Stage 4. Doesn’t mean you can measure it fully. Doesn’t mean you don’t have some stuff going
on there. But you can see the base of that ulcer. You see that structure. Instructions 6 under step 2 provides additional
information that in order to code a pressure ulcer/injury as unstageable due to non-removable
dressing or device, it must be “known” that there’s a pressure ulcer/injury under that
device and it must appear in the documentation. There are some new instructions regarding
determining present on admission. And again, this is where I would note that
there’s a pretty significant change. I shouldn’t use the word “significant change”
in MDS training. (Laughter) Yikes! That was a bad one. Manual instruction 4 under step 3 if the pressure
ulcer/injury was present on admission or entry, or re-entry and becomes unstageable due to
slough or eschar during the resident’s stay, the pressure ulcer is coded in M0300F and
should not be coded as present on admission. So what did we do in the past? We said we have a Stage 3 or 4. It becomes unstageable. You wait and see what happens once it becomes
stageable again to compare. Have these declined or what’s going on under
there? We’ve always said, but we know if it’s covered
with eschar or slough it’s clinically worse, right. We’re worried about it. Now the MDS aligns with that. If it’s a Stage 3 or 4 or any ulcer that was
stageable now it’s unstageable due to slough or eschar, it will not be coded as present
on admission. Okay. Likewise if a resident with a pressure ulcer/injury
goes to the hospital and returns with an unstageable pressure ulcer/injury or an ulcer/injury of
a higher stage, you would code it present on admission. So if you discharge your resident, they have
a Stage 3 pressure ulcer. They go to the hospital. They come back a week later — excuse me — now
that Stage 3 pressure ulcer is covered with slough. You can’t stage it. Now it is an unstageable present on admission. Okay. Then you’ll determine, once again you can
unroof that, you can see what’s underneath that. Then you can determine that stage as appropriate. What did do I there? I think I went backwards. Sorry. Okay. Manual instruction 9 under step 3 that addresses
numerically staging ulcer that becomes unstageable and subsequently is debrided that it can be
staged and is a higher stage, again consider it not present on admission. And this is that example. This is not a new instruction. This was just moved. And again it’s worth mentioning. Similarly, this tip is not a new tip. It was just moved. And that is, instruction 10, under step 3
that addresses when two pressure ulcers merge. In the case of two pressure ulcers that were
present on admission merging, continue to count the single larger ulcer as present on
admission unless it increases in stage or becomes unstageable due to slough or eschar. Again, nothing new with that. So the present on admission items, and those
are M0300B2-G2 address whether the pressure ulcer/injuries were present on admission or
acquired or worsened during the stay. When we say subsequent assessment, it could
mean another PPS assessment. It could be a Discharge Assessment. It’s important to note however when we look
at that QM later on in this section, that the QM now is only going to be comparing that
admission to the Discharge Assessment. So where we used to look at what happened
on the 5-day? Okay, compare to it the 14, compare to it
the 30, the 60, that’s not happening anymore. It’s really this kind of two points in time
now. You’ll see that when we review that measure
at the end of this session. Per page M8 of the RAI Manual if the pressure/injury
was present on admission or entry and becomes unstageable due to slough or eschar during
the resident’s stay, it’s going to be coded M0300F. And it is not coded as present on admission. And then, manual page M9 is the reference
for if the pressure ulcer was numerically staged and becomes unstageable and subsequently
debrided sufficiently to be numerically staged compare it to the numerical stage before and
after it was unstageable. Again it’s increased. Code this pressure ulcer as not present on
admission. So again we’re looking at subsequent assessment
or Discharge Assessment. And if that is not coded as present on admission,
it’s new or worsened. If it is coded as present on admission, it’s
not new or worsened. So basically, facility-acquired equals worsened
or worsening in stage. So let’s look at a present at admission scenario. This is not one that you have for polling
yet. We’re just going to talk through this one. But we have a lot of polling to come on this
section. So Mrs. J came into our SNF with a Stage 4
pressure ulcer on her left hip. When the pressure ulcer is reassessed at discharge
it’s entirely covered — hopefully it was reassessed before discharge too — but it’s
entirely covered with eschar and the wound bed can not be assessed. Mrs. J is discharged with an unstageable pressure
ulcer due to slough or eschar. So Mr. J had a Stage 4. During her SNF stay the ulcer became completely
covered with slough or eschar. How do you code this in M0300? Let’s take a look. On the Admission Assessment, so this is when
she first came in. We have nothing in stage 1s, 2s, 3s. So when you’re coding 0, like in M0300B1 or
C1 you code a 0, you’re going to skip down to the next item because you aren’t going
to address present on admission if you don’t have that ulcer. Then in M0300D1, number of Stage 4 pressure
ulcers, we’re going to code it as 1 on her admission. And one of those was present on admission. And then we aren’t coding anything in the
unstageables on her 5-day PPS. But then on her discharge, we’re coding nothing
in M0300B1, C1, or D1. Notice that we don’t have the opportunity
to code M0300A. That isn’t going to be on your Discharge Assessments
anymore, okay, the PPS Discharge Assessment. How do you find out all of that stuff on what
the changes are in what item set? On the link that Deb provided on that last
couple of slides when she provided where all the item sets and things were, there is a
Change Table for the MDS item sets that are coming in October 2018. So you can actually go through the item set
type and know which items are going to appear on which item set. What most of you probably do is what I do,
print out a comprehensive right, because it has everything. You learn and use that. But this way you can figure out what’s going
to be there and which item sets, and can plan kind of accordingly. Okay. So in this, in D1 here the number of Stage
4 pressure ulcers we are coding it as 0. Because remember, that ulcer became unstageable. So here we code that item unstageable pressure
ulcers due to slough or eschar as a 1. And it is not present on admission. And remember, it became unstageable during
her stay. So here’s our rationale at admission. She had that Stage 4 on her left hip. We code the Admission Assessment as one Stage
4 ulcer. And that one ulcer was present on admission. But then the Stage 4, it became unable to
numerically stage it during her stay. So on discharge, the Discharge Assessment
is coded as 0 for D, where we code Stage 4s. And we are going to then skip D2. And we are going to capture that ulcer in
M0300F1 as on the Discharge Assessment as an unstageable. And then we will count that as not present
on admission. Just a reminder, this newly added instruction
is going to be on page M8 of your manual. And that is if the pressure ulcer/injury was
present on entry or reentry and becomes unstageable due to slough or eschar during the resident’s
stay it’s coded in M0300F and should not be counted as present on admission. Okay. Let’s go ahead and look down through some
coding instructions. Again we’re only focusing on changes here,
not every single instruction that appears in the manual. And this item, M0300A it’s been updated to
refer to pressure injuries, the word “currently” was added in the coding instructions. Otherwise it’s unchanged for that Stage 1. A new coding tip has been added to the coding
instructions for M0300B that reinforces that Stage 2 pressure ulcers do not have granulation
tissue, slough or eschar. When these are present in previously staged
Stage 2 the ulcer has now become a full thickness ulcer. Remember that Stage 2 pressure ulcers are
partial thickness wounds. When they progress such that there is granulation,
or any of that underlying tissue, you’ve now moved on to a full thickness
wound. There are two entries under planning for care
associated with M0300C. These stress the importance of considering
tissue characteristics of pressure ulcers when determining treatment options. And note that these characteristics are also
indicative of whether the wound is on the right track so to speak in healing or getting
worse. There are quite a few new coding examples
for Stage 3s as well that have been added to the RAI User’s Manual. So you certainly can use those in your training
of your staff. (phone ringing) That’s okay. Can’t believe you admitted it was you. I would have been like, whose phone is that? (Laughter) She’s honest. Honest girl. All right. A coding tip has been added for M0300D that
addresses the importance of assessing tunneling and undermining. So what do we think about tunneling? It’s kind of like a sinus track, like a shoot
off of that wound. Where undermining, I think of it as kind of
you’ve got your skin intact. You’ve got that tissue underneath. It’s kind of like a little cave in there. It’s that kind of larger section. We usually talk about undermining as we might
measure it at the clock. We would say from 12:00 to 5:00, right. Where tunneling is usually a tunnel at 1:00
or something like that. So it’s very different characteristics. So like other wound measurements, you’re measuring
tunneling and undermining. You’re no longer capturing the wound measurements
on the MDS. And you certainly don’t capture the tunneling
or undermining. And again these aren’t coded on the MDS but
they need to be assessed, monitored and treated. Like the other pressure ulcer measurements
and characteristics, these issues need to be included in the overall assessment as to
whether the wound is healing or degenerating, or whether it’s staying the same and maybe
something needs to change. Visual inspection of the wound bed is necessary
for accurate staging. Pressure ulcers that have eschar or slough
present such that you can’t assess the anatomic depth of the soft tissue can’t be visually
inspected or palpated, so the wound’s going to be classified as unstageable. Keep in mind you’re looking at what are those
underlying structures? What’s going on in that wound? The bold italicized portion of this coding
tip was added to stress if the pressure ulcers that are covered with slough or eschar and
again the bold part “and the wound bed can not be visualized” they’ll be coded as unstageable. Once enough non-viable tissue is removed to
allow inspection of the tissue damage then you can go ahead and stage that wound. Remember under the new guidance, stage 1-4
pressure ulcers/injuries that develop slough or eschar would be considered worsened. So let’s take a look at some other updates. These are updates to M01040. The updates effect three of the items, M01040D,
open lesions other than ulcers, rashes or cuts, and M01040G, skin tears, and M01040H,
moisture -associated skin damage. The coding tip has been added and showed on
the screen in bold gives examples of what we might code in M01040D. Examples include other wounds, boils, cysts
and blisters. There was also in addition to the second coding
tip to stress that abrasions aren’t coded here. This tip is important where it says do not
code rashes, abrasions, cuts or lacerations. It says these aren’t recorded on the MDS but
are captured in the plan of care. I think one of the mistakes that folks particularly
if they’re new to MDS make is they try to fit everything into somewhere on the MDS. Right, if you look at your hygiene item, they
try to take like the entire part of — like AM. care or whatever and cram it all in there. And they should be just sticking with what’s
the coding instructions. So the MDS is a pretty big assessment. It’s 50-ish pages now. It captures a lot of information. But everything about your patient or resident
condition isn’t crammed into that assessment. Don’t let your staff and let the folks you
work with feel the need to fit it somewhere. Some things simply don’t fit on the assessment. Does that make sense? I just discussed this tip under M01040D. It was also added to M01040G skin tears, cuts,
lacerations, abrasions aren’t coded in this item either. But they’re going to be coded in the plan
of care. And then there were some additions to moisture-associated
skin damage. The first bullet had the statement, can cause
other conditions such as – “removed.” So we used to say maceration and includes
other conditions such as, blah, blah, blah, and list all of those. That’s been removed. Additionally there was the addition to the
note that MASD or moisture-associated skin damage is also called maceration. The definition has also been updated there. Moisture-associated skin damage is superficial
skin damage, that’s important, caused by sustained exposure to moisture, such as
incontinence, wound exudate or perspiration. There was an addition to the first coding
tip shown on this slide that stresses the role of moisture and moisture-associated skin
damage and pressure ulcer risk. Remember microclimate, temperature, and humidity. The next coding tip will help clinicians in
identifying moisture-associated skin damage. Moisture-associated skin damage without skin
erosion is red or bright red in color most often. The skin around it maybe hypopigmented, so
lighter. Moisture-associated skin damage usually has
irregular edges and it’s generally blanchable. The skin may be inflamed. So what about moisture-associated skin damage
with skin erosion? This may be hyper or hypopigmented. Tissue is usually blanchable, again edges
are irregular. There may be inflammation, but there won’t
be necrosis. Moisture-associated skin damage is a superficial
or partial thickness skin injury. If there is a combination of pressure and
moisture-associated skin damage, code the skin damage as pressure. And I will tell you in my years of being a
consultant, I worked with a lot of folks with G-level pressure ulcer or worse deficiencies
who said, oh, they’ve got some moisture-associated skin damage. We’ll put a little of this nice cream on. And a week later the doctor comes in and says
well there is some moisture but there’s also some pressure. Right? Now they get all their pressure protocols
going. So there’s been a delay in the care. So I think the bottom line to me is accurate
etiology early. Right? Don’t wait. Don’t assume it’s moisture associated skin
damage. Don’t not move ahead with the appropriate
care of that resident in the hope to avoid a pressure ulcer. We’ve got to get on top of it quick. And if there is an area of a full thickness
wound that extends beyond the subcutaneous tissue or beyond or there’s necrosis, don’t
code it as moisture-associated skin damage, instead code it in M0300 as a pressure ulcer. We also have M1200G application of non–surgical
dressings with or without topical medications other than to the feet. That’s a very minor change. Let’s take a look. We added wound closure strips. I’m not reading you the whole tip. There it is. No other changes to it. Wound closure strips are also known as what? Steri-Strips, yep. Okay. You ready for some fun? Time for you guys to do the work instead of
me. Again to make it easier for you to participate
in those scenarios, you can refer to that document in your packet labeled Section M,
Skin Conditions Updates Practice Coding Scenarios. You should have that example looking something
along — like this. For those of you online you should be able
to access it in this section’s electronic folder as well. For those of you in the audience you should
be able to find that in your packets. Everybody finding it? Okay. Let’s go. So this is when you need your phones and that
Slido app. Ephraim back there at the table in the yellow
shirt is the Slido king. If you have any questions see him. He’s really done a lot of awesome work on
our project. You guys can thank him for all the neat interaction
and stuff. Yay, Ephraim. You ready to go? Got your Slidos ready? Cool name, Slido! All right. A resident develops a Stage 2 pressure ulcer
while at the nursing facility. The resident is hospitalized due to pneumonia
for 8 days and returns with a Stage 3 in the same location. How would you code M0300C1 and M0300C2 on
the 5-day PPS? So would you code M0300C1 — I’m sorry. How would you code M0300C1 on the 5-day PPS? So the number of Stage 3 pressure ulcers. Is it O for A? B, 1? Or would you enter a dash? Go ahead. And again you can join on that Slido app. And just take a moment and enter your response. I think they’re pulling it up on the screen
right now. Bear with us. Talk amongst yourselves. (Laughter) Sorry, Ephraim. I jinxed you. Well, I think I’m just going to just ask you
for a show of hands. How many say it’s A? How many say B? Woohoo. Okay. The answer is B. All right. And how would you code M0300C2 on the 5-day
PPS assessment? This is the number of these Stage 3 pressure
ulcers — that, oops — that were present on admission. So number of these ulcers that were present
on admission. Is it A, 0? B, 1? Is it C, enter a dash? Again, we’ll do a show of hands while we’re
getting our software cooking here. How many of you say A, 0? How many of you say B, 1? Yeah. Excellent. All right. Perfect. We did have folks that are online who are
clicking along with that. Great. Okay. All righty. Our rationale for that item, the resident
had the pressure ulcer in that same anatomical location prior to transfer to the hospital. But because the pressure ulcer increased in
numerical stage to a Stage 3, it’s going to be coded as a Stage 3 present on admission
or entry. Your coding tip to support this is on your
manual page M9 where it says if a resident had a pressure ulcer/injury, is hospitalized
and the ulcer increases in numerical stage or becomes unstageable due to slough or eschar,
it will be coded as present on admission on re-entry. All right. Next scenario. A resident is admitted to a nursing facility
with a short-leg cast to the right lower extremity. He had no visible wounds on admission but
arrives with documentation that a pressure ulcer exists under the cast. Two weeks after admission to the nursing facility
the cast is removed, and following the removal of the cast the right heel is observed and
assessed as a Stage 3 pressure ulcer which remains until the subsequent assessment. So whether that subsequent assessment is the
14-day or at admission, whatever it is, how would you code M0300C1 on the subsequent assessment,
number of Stage 3 pressure ulcers? Would you code it as A, 0? B, 1? Or C, enter a dash? And go ahead and take a moment. Those of you who are online or in the room
we’re glad to have you participating. It’s really cool that the online folks can
participate in the polling too with this. All right. We still have a couple more coming in. But it does look like it’s a pretty strong
vote for 1, right. We’re going to code M0300C1 on the subsequent
assessment as 1. And how many of these ulcers are you going
to code in M0300C2 on the subsequent assessment? So coding the number of these Stage 3 pressure
ulcers that were present on admission, entry or re-entry? Would you code A, 0? B, 1? Or C, enter a dash? Go ahead and take just a moment there and
enter your answers? Would you code — what is the number of these
Stage 3 pressure ulcers that were present upon admission/entry or re-entry? We got lots of folks still clicking in. And it does look like an overwhelming majority
are saying 1. So that pressure ulcer, the resident was admitted
with a documented unstageable because of the non-removable dressing or the device. They has a cast. When they removed that cast the Stage 3 pressure
ulcer was assessed. I was the first time that ulcer was assessed
and that it had been numerically staged. So it is coded at that stage, the Stage 3
present on admission/entry or re-entry. Next scenario, Mr. M who was admitted to the
nursing facility with eschar tissue covering both heels as well as a Stage 2 pressure ulcer
on the coccyx. The pressure ulcers were reassessed before
the subsequent assessment. The Stage 2 on the coccyx had healed. The left heel eschar had become fluctuant
and showed signs of infection, had to be debrided at the bedside was subsequently numerically
staged as a Stage 4. The right heel eschar remains stable and dry
and it remained unstageable. So how many Stage 4 pressure ulcers will you
code? How would you code M0300D1 on the subsequent
assessment? Would you code A, O? B, 1? Or C, enter a dash? It looks here like the overwhelming majority
says that they’re going to capture 1 ulcer. And you guys are right on with that. And then how would you code M0300D2 on the
subsequent assessment? This is the number of these Stage 4 pressure
ulcers that were present upon admission/entry or re-entry. Would you code it 0? Would you code it B, 1? Would you code it C, enter a dash? How many were present upon admission/entry
or re-entry? We have the majority here saying 1, but a
lot of folks are saying 0 as well. Let’s look at the answer and see what we come
up with here. The correct answer is 1. And let’s talk about the rationale for that. Oh, wait a minute, what am I doing here? Sorry about that. Okay. So again, one of these ulcers with slough
or eschar was present upon admission or re-entry. Let’s look at the rationale. So we’re going to code one ulcer as a Stage
4. We’re going to code one ulcer as unstageable. Both are going to be present on admission. Remember the Stage 2 on the coccyx has healed. So Mr. M was admitted with an unstageable. One of the heels was subsequently debrided
and that first numerical stage is a Stage 4. Thus that’s going to be coded as present on
admission at that Stage 4. Again the other healed ulcer remained covered
with eschar. Our next one, a resident’s admitted to the
nursing facility with a blood-filled blister on the right heel after assessment of the
surrounding tissues it’s determined to be DTI. Three weeks after admission the right heeled
blister is drained and conservatively debrided at the bedside. After debridement the heel is staged — the
ulcer on the heel is staged as a Stage 3 pressure ulcer. On the subsequent assessment it remains a
Stage 3. So how would you code M0300C1 on the subsequent
assessment? So this is the number of Stage 3 pressure
ulcers. Would you code it A, 0? B, 1? Or C, enter a dash? And the lion’s share of folks are saying B
here. We’ve still got a few votes coming in. But you are right. Oh, whoops. Too fast. It is B, 1. And then how many — how would you code M0300C2
on the subsequent assessment? The number of these Stage 3 pressure ulcers
that were present upon admission/entry or re-entry? Would you code it A, 0? B, 1? Or C, enter a dash? Lots of folks are still voting. I’ll give it just another moment or two. Okay. It looks like most of folks have said B, and
that is the correct answer. And let’s look at the rationale. So this resident had an unstageable pressure
ulcer due to deep tissue injury. Then that was subsequently debrided. So the first time it’s debrided and staged
it is a Stage 3. So remember the person was admitted with unstageable. The first time it becomes stageable. It’s going to continue at that stage as present
on admission. Now what if two weeks later it goes to a Stage
4? Present on admission? No. You got it. Good job. Okay. And then we have Mr. H. He was admitted with
a known pressure ulcer/injury due to a non-removable dressing. Ten days after admission the surgeon removes
the dressing and a Stage 2 pressure ulcer is identified. Two weeks later that pressure ulcer’s a full
thickness ulcer. It’s now staged as a Stage 3. And it remains a Stage 3 at the time of the
next assessment. So how are we going to code M0300C1 on the
subsequent assessment, number of Stage 3 pressure ulcers? Will we code it A, 0? B, 1? Or C, enter a dash? And it looks like about 94% of you all say
that it’s B, 1. So then with this one Stage 3 pressure ulcer
how would you code it in M0300C2 on the subsequent assessment? The number of these Stage 3 pressure ulcers
that were present on admission/entry or re-entry? Would you code it A, 0? B, 1? Or C, enter a dash? You still have quite a few votes coming in. Give it just a moment or two. Okay. It looks like most of you are saying 0. And that’s correct. Let’s take a look at the rationale. So our person or resident came in with an
unstageable because it was covered with a dressing or device. Then the device or the dressing was removed
and we see a Stage 2 pressure ulcer. And then prior to our next assessment it actually
worsens to a full thickness wound. And it’s now considered a Stage 3. All right. Let’s talk for just a moment about the cross-setting
pressure ulcer measure called Changes in Skin Integrity Post-Acute Care: Pressure
Ulcer/Injury QM. You can find the data specifications for this. The document is called Final Specifications
for SNF QRP Quality Measures and Standardized Resident Assessment Data Elements. This measure was finalized in the fiscal year
2018 SNF Final Rule with the implementation of October 1, 2018. Just a couple of months away. I can’t believe I’m saying October is a couple
of months away. My word. (Laughter) Before you know it we’ll be wearing
snowsuit instead of flip-flops. This measure meets the IMPACT Act requirement
to address skin integrity and changes in skin integrity. It’s a cross-setting measure that reports
residents who since admission have had a new or worsened Stage 2-4 pressure ulcer or an
unstageable pressure ulcer due to slough or eschar non-removable dressing for DTI. So what’s the big change there from our current
pressure ulcer measure? Any thoughts on that? We’re including the unstageables, right. That’s a big change. Another big change is now where we’re looking
at from the timeline. And I mentioned to that earlier. So M0300 items will be used to calculate this
QM with data collection beginning October 1, 2018. We actually already collect all of these data. It’s not a change for us. There’s some minor changes where we’ve added
device and things like that too. But otherwise you guys are familiar with these
items. And do remember that there is some pretty
significant new coding guidance related to the unstageables. Dash use, I want to just mention. A dash is an accepted value for these items. However, we would expect dash use is pretty
infrequent. I would think it would be pretty unusual that
you wouldn’t know your patient’s skin status. What might be an example of it? The person’s in your nursing home for like
10 minutes and goes back to the hospital or something. But otherwise, I would think you would know
what these items are. So let’s look at the numerator and denominator. The numerator is residents who have a complete
Medicare Part A stay for which the Discharge Assessment indicates one or more new or worsened
Stage 2-4 pressure ulcers or unstageable pressure ulcers due to slough or eschar, and non-removable
device or dressing, dressing or devise or DTI compared to admission. So its two points in time now guys, that first
assessment and the Discharge Assessment. The SNF denominator is the number of Medicare
Part A SNF stays in the selected time window for residents ending during that time window
except those who meet exclusions. Who is excluded? Residents who have missing data or if the
resident dies. If you dash these items they are excluded. But if I’m looking at your MDS as an auditor
or something and you’ve got a lot of dashes, I’m saying what is going on in your world
here that you can’t complete these items. That would be a giant red flag to me. There are some risk adjustments. These are pretty similar to what the risk
adjustments were in the other measure. The first is functional mobility. This is a change. We’re now using GG0170C, which is lying to
sitting on the side of the bed for the covariate for this. So think about covariates are, these four
things are issues with that resident, they’re resident-level issues that increase the likelihood
of them having a pressure ulcer. It’s not an exclusion. These guys don’t come out of the numerator
or denominator. It kind of levels the playing field based
on resident’s risk. So we’re looking in functional mobility. If folks are dependent, need substantial or
maximal assist, if the resident refused or it’s not applicable or not attempted, that
is going to be the credit for the covariate. Bowel incontinence, if the resident’s occasionally,
frequently or always incontinent of bowel that is a covariate, that’s a 1, 2,3. That’s consistent with how it’s always been
with the pressure ulcer measure. The next is PVD or PAD, so peripheral vascular
or peripheral arterial disease which are I0900 and I2900 is diabetes. If either of those are checked that is a covariate. Then BMI, the BMI doesn’t appear in your MDS
but it is calculated with the height and weight. So the covariate is if the BMI is less than
19, equal or less than 19. What about the time window for this? It’s calculated using a rolling 12-month window. If a resident has more than one stay during
that time each stay is eligible for inclusion. That’s an important fact. That’s an important point. More details are available in those QM specs
that I just mentioned. So what did we accomplish in this little over
an hour together? We looked at the updated coding guidance and
some examples as well as the cross-setting pressure ulcer measure. Keep in mind that’s expanded now from 2-4
pressure ulcers, stage 2, 3s and 4s to include those unstageables. And that measure is meeting the IMPACT Act
requirement. So it’s time to test your Slido skills with
some ideas for your Action Plans. So in your folders you have an Action Plan. And there’s a part of that Action Plan for
each section. So it looks like this. If you’re online, it is in that introductory
folder. So there’s an example there that’s related
to Drug Regimen Review. You certainly can think about that. So if you could, go ahead and pop in an idea
or two in Slido. Let’s see who has the fastest typing skills
on those little phones and can share their ideas for Slido. We decided when we prepared this training
that many of you guys have been doing this as long as many of us have. And your ideas for the Action Plan were at
least as good if not better than ours. We thought we would look to you instead of
you all looking to us. So please share those ideas. Are we pulling up Slido? Educate new staff on new MDS changes. Use a mannequin for demonstration in training. Training for wound care guidelines for all
wound nurses. I would argue to expand those training for
all nurses, because the wound nurse leaves and whoever comes on the floor, automatically
all the other nurses wound care brains are sucked out of their head. Right? We want everybody to know. Does the discharge MDS — we have a question
there. I’m going to hold on that one. But put it in with the Questions if you will
instead of the Ideas. So lots of ideas. Again reviewing the intent, rationale, the
steps for assessment. There’s lots of new coding tips that you’re
going to see in Section M. And you’re going to see a much shorter Section M than you’re
used to. I must say some of my favorite items retired,
the things I’ve loved to train on. So I had a bit of a sad time, but realized
they’re not being used. So hopefully you’re capturing those measurements
and things in your clinical information. So I am about to get the hook. I was just told I have two minutes remaining. So if there are any questions, the one is,
does the discharge MDS include the standalone NPE? So the NPE, I do not think — actually I’m
going to look to Deb Weiland. Can you help me with that, Deb? I don’t understand what we’re asking here
I guess. Does the discharge MDS include the discharge
MDS? Anyway, see us on the break if we can help
with that. And with that, I think Tom’s going to come
see us. I want to thank you guys for your attention. I appreciate it. I’ll see you guys tomorrow at the end of the
day.

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