Section M: Skin Conditions (Pressure Ulcer/Injury)
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Section M: Skin Conditions (Pressure Ulcer/Injury)


»» Today we’re going to cover this morning
skin conditions. the nice thing about this, since this is just
around breakfast time is there’s no pictures. (Laughter)
Usually when you hear you’re going to be teaching a program on skin, people are like ah, over
lunch? I’m like, yes. So let’s start off and what we have here,
there we go. We have our acronym list. That is always important. You know we end up having our own alphabet
soup. I’m sure you have one in your own organization. We have one certainly for here so that we
have what I call a shared mental model and we all understand what we’re talking about. The objectives for today is we are going to
describe the cross-setting pressure ulcer/injury quality measures. And I know we’ve taught on this in the past
but there tends to be continued questions, not only in the IRF setting but in all of
the healthcare settings around this. And I think sometimes it’s people wanting
to kind of accept the answers, or the ideas, or the suggestions that we’ve put forward
on how to code these. So we keep getting a lot of the same repeat
questions. So I’ll try to address some of those questions
as I go through today. And we hope to be able to have everyone applying
the coding instructions accurately and work with the coding scenarios. To that end, I think it’s Handout 6. You’ll have some coding scenarios that we’re
going to work on. So you might want to take those out so that
you can look at those. So the intent for today is we’re going to
document the presence, appearance and change in status of pressure ulcers/injuries
based on a completion and ongoing assessment of the patient’s skin, guided by clinical
standards. It is to promote effective pressure ulcer/injury
prevention and skin management program for all patients. And just to level set, what is a pressure
ulcer? Well, it is a localized injury to the skin
and/or underlying tissue. It’s usually is over a bony prominence. It is as a result of intense and/or prolonged
pressure. And I think that that’s probably one of the
most important things that you need to understand. There needs to be pressure involved in the
injury for it to be a pressure ulcer. And people forget that. So when they’re looking at you know, maybe
something on a mid-calf with no brace or anything like that, and just because it’s an open area
they want to stage it as a pressure ulcer. They think everything needs to be staged. So when you’re teaching, just a good opportunity
there to reinforce that. Or pressure in combination with sheer, the
pressure ulcer/injury can present as intact skin or as an open ulcer, and it may be painful. So changes in skin integrity. For this measure, an ulcer/injury is considered
new or worsened at discharge if the Discharge Assessment shows a Stage 2-4 or unstageable
pressure ulcer/injury that was not present on admission at that stage. So this is an important slide. This is the definition for the measure. We’ll go through the numerator and
denominator next. So the numerator, stays in the denominator
in which the Discharge Assessment indicates one or more new or worsened Stage 2-4 pressure
ulcers or unstageable pressure ulcers/injuries as compared to admission. So you have to have an admission, you have
to have a discharge, to compare the two. The denominator then, are patient stays with
both an Admission and a Discharge Assessment, planned or unplanned, except for those that
meet any of the exclusion criteria. And we’re going to go through the exclusion
criteria. Patients are excluded if the data on new or
worsened Stage 2, 3, or 4 or unstageable pressure ulcers/injuries, including deep tissue injuries
are missing on the Discharge Assessment. And that makes sense, right. Because I said you have the Admission and
you have to have Discharge Assessment. So if you have missing data we can’t calculate
it. Makes sense. Or the other exclusion is that the patient
died during the stay, so they’re excluded from this measure. So the measure will be calculated quarterly
using a rolling 12 months of data. So that’s important if this is part of your
job and what you’re responsible for. You need to understand it’s reported quarterly
and as a new quarter comes on the oldest quarter falls off. So it’s kind of a moving target. For public reporting, the QM score reported
for each quarter is calculated using that 12 months of data. All patient stays during the 12 months, except
for those that meet the exclusion criteria, are included in the denominator and are eligible
for inclusion in the numerator. For patients with multiple stays during the
12-month time window, each stay is eligible for inclusion in the measure. So if you’re into the measure’s piece of this
and trying to understand it, these slides I think clearly articulate who do we include,
who’s excluded, how the measure is rolling, so that we understand what we’re looking at. So the risk adjustment, Admission Assessment
items used to adjust this quality measure. So there’s a couple of areas that we look
at in the assessment that then say, someone is either at higher risk or lower risk for
a pressure ulcer. Functional mobility admission performance,
so the question GG0170C, Lying to Sitting on Side of Bed is a risk-adjuster for this
measure. Bowel Continence, H0400, Bowel Incontinence,
so whether they’re incontinent or not is an area that if they’re incontinent will put
you at high risk. Peripheral Vascular Disease, Peripheral Arterial
Disease or Diabetes. So I0900. PVD or PAD and or
I2900. Diabetes Mellitus. And then the other, or the last risk-adjuster
is Low Body Mass Index based on Height and Weight. So calculating that using 25A. Height
and 26A. Weight. So those together then give you your BMI. And we’re looking at the low end of the BMI,
not the high end of the BMI for these risk adjusters. So again, those are important when you’re
looking at the overall picture. So how many, if you’re looking at your patient
who develops a pressure, I would also, if I was doing this, go out to these other
questions and say, how did we answer these questions. So were they at higher risk for this? Not that that’s acceptable to still end up
with a pressure ulcer/injury, but it is something that we should look at. So let’s look at — Ah, excuse me. The first thing in the morning, I’ve already
had my coffee but I have to get my tongue going — coding guidance and practice coding
scenarios. I think the one way to really learn this material
is to apply it. So we’ll go through lots of opportunities
for coding. So CMS is aware in an array of terms used
to describe alterations of skin integrity due to pressure. They include things like pressure ulcer, pressure
injury, pressure sore, the old term of the decubitus ulcer and bed sores. And any number of these words may be used
to imply or indicate the same idea. It is acceptable to code pressure-related
skin conditions in Section M if different terminology is recorded in the clinical record. So if somebody happens to talk about a decubitus
ulcer, it equals a pressure ulcer or pressure injury if the primary cause of the skin alteration
is related to pressure. And you will hear that and hear that again. So it’s very important that it needs to be
related to pressure. When you’re considering a wound of mixed etiology,
such as moisture-associated skin damage, it is extremely important to identify the primary
cause. That’s when we start to get into the subtleties
of understanding how we’re coding this particular area. This is where we have to develop some level
of expertise in your staff to understand that they can understand what they are looking
at. And I think that’s the greatest opportunity
that you have in educating your front line staff. Per the requirements of Section M and the
IRF-PAI assessment, pressure should be the primary cause of the wound if you’re going
to code it here in this particular section. If the ulcer or injury arises from a combination
of factors and pressure is considered the primary cause, then the ulcer or injury would
be coded in Section M as a pressure ulcer/injury. Other types of skin injury or alterations
are not coded in Section M. So just because they have an open area doesn’t mean it absolutely
will meet the criteria for pressure. So again, an opportunity for education. So there’s a variety of different types of
pressure ulcers. CMS adheres to the following guidelines, so
a Stage 1 pressure injury and DTIs are termed pressure injuries because they are usually
a closed wound. A Stage 2, 3, or 4 pressure ulcer or unstageable
ulcer due to slough or eschar are termed “pressure ulcers.” So again, slightly different terminology here. So it’s important to understand when we’re
talking about an injury versus an ulcer. And these are termed an ulcer because they
are usually an open wound. So the epithelialization is gone from them. A unstageable ulcers/injuries due to non-removable
dressings/devices are termed pressure ulcer/injury because they may be open or closed wounds. For example, we’re going to go through some
of these examples if we have a non-removable device or dressing and we have a known ulcer
or injury related to pressure underneath it. “Known” that’s going to be another key piece
of that. Since we can’t look at it, it may be an ulcer,
it may be an injury. We don’t know because we can’t put our eyes
on it at that point in time. So let’s look at some of the coding components. So M0300A1-G1, it identifies the number of
unhealed pressure ulcers/injuries at each stage. And it establishes the patient’s baseline
assessment. So this says closest to admission I’ve done
a full skin assessment. This is what we have today upon admission. So it sets your admission or your baseline
criteria. M0300A1-G1 identifies the number of unhealed
pressure ulcers/injuries at each stage. And M0300B2-G2, these are done at the time
of discharge and it identifies if the unhealed pressure ulcers/injuries in M0300B1-G1 were present
on admission or if the pressure ulcers/injuries were acquired or worsened during the stay. And we are going to spend — we’re going to
do some scenarios around that where we’re going to understand. People seem to have a pretty easy time I think
understanding the admission side of it. It’s when we get into the discharge where
there’s this confusion like, what am I talking about. Hopefully I’ll give you some strategies as
we go through that to make this clear and and maybe a way to take this back and work
with your staff so that they understand how to interpret that discharge question. So when we’re going through and we’re doing
this assessment we want to use documentation from the previous setting to inform about
the original stage of a pressure ulcer/injury. And we want to review the history of each
pressure ulcer/injury in the patient’s medical record. Why is that important? Well we should take the opportunity to utilize
all of the information that’s being communicated to us both in writing or maybe you’re having
a warm hand-off, or you have someone who’s gone out and done a pre-assessment prior to
admitting someone. You want to take all of that information in,
especially related to a pressure ulcer. Because if someone had an extended stay, let’s
say you’re taking a patient from the acute care side, they may have developed a Stage
4 pressure ulcer, and through great care and whatnot it may be healing, okay. And so when they get admitted to your organization,
or your IRF, you look at it and you’re like, wow, it looks like its a Stage 3 or it may
be looking like a Stage 2. But in fact what is that ulcer? It’s a Stage 4. It’s a healing Stage 4. So it will stay a Stage 4 until it’s healed. So that’s a really important piece of information
to have. So you want to make sure that we have accurate
information there. Okay. If the pressure ulcer/injury that is unstageable
due to being covered by a non-removable dressing or device or due to being covered by slough
or eschar is observed on admission to the IRF, subsequently becomes numerically stageable,
compare the numeric stage to the numeric stage prior to becoming unstageable if the documentation
is available. So okay, they came to you and now that wound
is covered with slough and eschar. You’re unable to stage it, but they told you
it was a Stage 3 prior to coming in. The first time that you’re able to numerically
stage it, you should look at that and say it was previously classified at a higher numerical
stage or whatever, you can say it is now a Stage 3. And it should be continued to be classified
at the higher numeric stage. So again, let’s go back to that example. It was a Stage 4. It’s starting to heal, now it gets covered
with slough. They come to you, now once you’re able to
clean all that slough up you debride the wound, and now it’s a Stage 3. It appears to you to be a Stage 3. It will still be a Stage 4, right. Because you have clear documentation from
the previous setting. So you see how important that is. Determine the deepest anatomical stage, identify
unstageable pressure ulcers/injuries. And this is for Section M0300A-G. So think about in your facilities who is coding
this information. Who is doing the assessments? And make sure that you feel comfortable that
these staff members are competent to be able to do that. For the Discharge Assessment, determine the
number of pressure ulcers/injuries that were present upon admission. For detailed instructions refer to Section
M in the Inpatient Rehabilitation Facility-Patient Assessment Instrument Manual. So there’s lots of examples in there. We’re going to go through some ones here. So when we’re doing the Discharge Assessment,
one, you first identify the pressure ulcers/injuries present upon the Discharge Assessment. So think about it as like two stages. So the first thing is saying, okay, I’m getting
ready for discharge. I’m doing the Discharge Assessment. This is a point in time. What does my patient look like today? What do we have on discharge related to pressure
ulcers/injuries, and code them? Some might have completely healed. So what do I have on discharge? You want to code that. And then you want to determine the number
of those identified at that same stage that were present upon admission. So it’s a two-phase kind of question. So I find that when I teach this with staff
that they find that easier. So I say the first thing it’s a point in
time. What do I have on discharge? Then whatever I then say, go down my list
that I have, how many of those were present upon admission at the same stage? So that’s how you get through that question. That’s a good way of kind of breaking it out
for staff. So we have an example here. A patient is admitted to the IRF with a healed
pressure ulcer/injury and a pressure ulcer/injury occurs in the same
anatomical area and remains at discharge it would be coded as observed at discharge and
would not be coded as present upon admission on the Discharge Assessment. Therefore the pressure ulcer/injury would
be considered new or facility-acquired. So in this situation, if the injury, the pressure
ulcer — so it’s healed, right. It comes into you. You know that they had a healed, let’s say
Stage 4 on the trochanter, and then it occurs at the same area and remains at discharge,
it would be coded as observed at discharge and would not be coded, I’m sorry, as present
upon admission. But it is important to understand where someone
has had a pressure ulcer in the past. And why is that? Does anyone know? Because, right, the skin’s not as strong,
right. The tensile strength of the skin and the underlying
structures are not as strong. It’s about 80%. So someone’s at higher risk. So from a care planning and prevention you
want to make sure that we’re paying attention to those areas, special attention, because
they have a higher risk of breaking down. So here’s just a screenshot looking at, on
admission, the current number of unhealed pressure ulcers/injuries. And we’re going to go through each one
of these questions and through our examples. So M0300A1-G1 for the coding instructions
here. We’re going to complete this upon admission
and at discharge. We enter the number of pressure ulcers/injuries
that are currently present. We enter 0 if no pressure ulcers/injuries
are present at that stage. So we answer each one these questions and
we say, yes, they have it. If they have it, how many do they have at
that particular stage? Then we look at discharge. And again, this is the screenshot from discharge. You can look at that. We’re actually going to go through with some
examples and you are going to use your tool. But the first part of this question says,
how many of these pressure ulcers do we have? For example, the number of Stage 2 pressure
ulcers. I’m looking at that particular question. And if you had 0, and this is at discharge,
how many do I have today? Do I have 0? Do I have 1? Do I have 2? Whatever it is, you put that number. And it says, now, of that number, because
you just told me you had 1. Of that 1 that you have at discharge, how
many of these 1s, of these Stage 2 pressure ulcers were present upon admission. That’s that two-pronged question that we’re
asking. So that’s an important thing. So how many do I have today? So I have a Stage 2 pressure ulcer here, okay. So we’re saying I have a Stage 2 pressure
ulcer, that’s at discharge. Then the next question I’m asking, of those
Stage 2 pressure ulcers, how many of those were present upon admission? Well, I didn’t have any. There was 0 that were present upon admission. And that tells me that it wasn’t there on
admission. I had it during the stay and at discharge,
so it was acquired basically in the inpatient rehab facility. And then this continues again. These are the screenshots looking at unstageable
for slough and eschar, and then unstageable deep tissue injury. So when we get into M0300B2-G2 we want to
enter the number of these pressure ulcers/injuries that were present upon admission. And you can see instructions under steps for
completing M0300A-G. Step 3, determine present upon admission in the manual. And enter 0 if no pressure ulcers/injuries
were noted at the time of admission. And again, we’re going to go through lots
of examples on this. Present upon admission are coded at discharge
and address whether the pressure ulcers/injuries were observed at discharge. So 1, again, was it present upon admission,
or was it acquired or worsened during the stay? A pressure ulcer/injury reported at discharge
and coded as not present upon admission on the Discharge Assessment and would not be
interpreted as new or worsened. And I just gave you an example of, so if it
wasn’t there and now it’s there, it is considered new or worsened? A pressure ulcer/injury reported at discharge
and coded as present upon admission on the Discharge Assessment at the same stage would
not be considered new or worsened. So if I had a Stage 3 on my right hip and
I went through my stay and I still have that Stage 3 on my right hip, it’s not covered
in slough or eschar and I can code it. It’s considered that it was there on admission
and so it is not considered to be new or worsened. This whole idea of program interruption, which
is something you deal with in the IRF setting. If the patient is transferred from the inpatient
rehab facility (or the IRF) to an acute care hospital and returns within 3 days (including
the day of transfer), the transfer is considered a program interruption and is not considered
a new admission. I’m not telling you anything that you don’t
already know. But this is important related to coding for
pressure ulcers. Therefore any new pressure ulcer/injury formation
or increase in numerical staging that occurs during the program interruption should not
be coded as present upon admission. So if you send someone out, let’s talk about
the right hip. So you send someone out with a Stage 2 to
the acute care setting, they come back within the 3 days including that day of transfer,
and now they have a Stage 3 in that, that is not considered present upon admission. It’s considered worsened on discharge if they
still have the — it will be a Stage 3 if it hasn’t completely healed. You want to make sure that you’re not saying,
oh, just because I had that program interruption and it worsened while in the hospital, you
get to still own it. So that’s an important piece. So let’s look at some practice scenarios. Because again, I think that’s the best way
to apply the methodology that we’re looking at. So in this practice scenario, this will be
a Slido. So if you can get your phones out these will
be important. So a patient is admitted to the IRF with a
Stage 2 pressure ulcer on the — I’m sorry, on the left hip. The patient is transported to the acute care
hospital and returns to the IRF within 2 days. Upon return to the IRF setting, the left hip
pressure ulcer is a full thickness ulcer assessed to be a Stage 3. This is how well — I guess I didn’t realize
that this was exactly the scenario that we were going to be doing at this point — the
patient is discharged to home with a Stage 3 pressure ulcer. All right. So let’s look at the question here. So using Slido, how would you code M0300 on
the Admission Assessment? Would it be a Stage 2? A Stage 3? A Stage 4? Or unstageable deep tissue injury? Okay. We’re just getting a few more answers in here,
just give it a minute. Okay. We’ve got most people answering. So how would we code this? On admission it would be coded as a Stage
2, right. Because when they came into you, it was a
Stage 2. Next question is, how would you code M0300
on the Discharge Assessment? So again this is a Slido. I’ll give you a moment to start answering
this. The numbers are still coming in. It looks good. All right. It looks like we’re not having a lot of variability. Let’s look at the answer. How would you code M0300 on discharge? It would be a Stage 3, right. They had a Stage 2 on admission. They had an interrupted stay. It progressed to 3. They came back to you. It’s not considered on admission. At discharge they have a Stage 3. And then it would ask you, of those Stage
3, how many of those were present upon admission? And you would say, 0. I’ll give you the answer to this question. This is how bad I do these. Number of these Stage 3 pressure ulcers that
were present upon admission? Okay. Good, I gave that away. So let’s look at the answer. So we would say how many of these were present
upon admission? 0. That’s where people trip up. That’s the question/answer issue in this particular
coding area of this assessment. All right. So if you were looking at your assessment
tool we would say, the number of Stage 2 pressure ulcers upon admission? We had 1. And on discharge? So on admission we can — sometimes I find
it’s even easier when you start filling this out, you do it on admission. So this is your Discharge Assessment where
you have that column. What did I have on admission? Just go ahead, go down the line. Fill in all your admission information. Then on discharge we’re now saying, what
do we have today? For this particular patient we ask the Discharge
Assessment do they have any Stage 2s? No. The next question says of those Stage 2s,
how many were present upon admission? Because we don’t have any, if you put a zero
in there it’s automatically a skip for the next box. If this is in your computerized system they
usually put skip patterns in. It skips you out to the next question. The next question says, the number of Stage 3 pressure
ulcers, we didn’t have any upon admission. We have one on discharge. We then have to answer the question. Because we have at least 1 in that answer
on discharge, how many of those were present upon admission? And we say 0. So this goes through the rationale. We talked about that. They had that Stage 2 on the left hip. We coded it as a 1. Then the patient transferred, developed. A return in those two days. There was no new Admission Assessment
required and the change in the pressure ulcer status so it’s captured on the Discharge Assessment
assessment. And so that’s how we had our coding here. So it’s now — the Stage 3 was not present
upon admission. So let’s look at another scenario here. Sorry unstageable pressure ulcers. Let’s talk about unstageable pressure ulcers. So visual inspection of the wound bed is necessary
for accurate staging, right. If we can’t see the wound bed then it’s going
to be really hard for us to stage that. So pressure ulcers that have eschar or slough
tissue present such as the anatomical depth of soft tissue damage cannot be visualized
or inspected or palpated. The wound bed should be classified as unstageable. If you can’t clearly understand what you’re
looking at then it’s unstageable. If the wound bed is only partially covered
by eschar or slough and to the extent the soft tissue damage can be visualized and inspected
or palpated, the ulcer should be numerically staged and should not be coded as unstageable. So for example, if you have a Stage 4 that’s
a very common one. And you look and you see tendon or bone, even
if it’s partially covered, you know it’s a Stage 4. So you wouldn’t then cover that and say that’s
unstageable. You would say that that’s a Stage 4. Let’s look at another coding scenario. A patient is admitted to the IRF with a Stage
4 pressure ulcer on the left hip. When the pressure ulcer is reassessed at discharge
it is entirely covered with eschar and the wound bed cannot be assessed. The patient is discharged with an unstageable
pressure ulcer due to slough or eschar. So it’s a little bit of a different scenario
here. And these scenarios should be on your coding. So let’s go through. How would you code M0300 on the Admission
Assessment? Would it be a Stage 3 being a 1? A Stage 4 as a 1? Unstageable due to slough or eschar? Or unstageable due to a deep tissue injury? Okay. Let’s look at this now. So the answer is? How would you code M0300 on the Admission
Assessment? Let’s see the answer. It would be a Stage 4. And let’s look at the — and how would you
code the M0300 on the Discharge Assessment? Okay. All right. Great. Let’s look at the answer. And so how would we code it? Would it be a Stage 3? A Stage 4? Unstageable? Or unstageable DTI? We would be coding that as unstageable slough
or eschar. Everyone did very well on that. The next question is, was this unstageable
pressure ulcer due to slough or eschar present upon admission? Is it yes? No? Or skip? Okay. We got a little bit of dissent here. Some people think yes, some people think no. Let’s look at the answer. So the answer is no. And we’re going to go through. All right. Let’s look at the coding here. We’re actually coding this. So we would have no Stage 2 pressure ulcers
at admission or discharge. No Stage 3 at admission or discharge. We have one Stage 4 upon admission and none
at discharge. And then we have no unstageable due to non-removable
dressings. And we have number of unstageable pressure
ulcers due to coverage of the wound bed by slough or eschar. We didn’t have any of that at admission, but
we do have one at discharge. Number of these unstageable pressure ulcers
due to slough or eschar that were present upon admission? We only have 1 and it wasn’t there on admission
so we put a 0 in there. So what’s the rationale here? So at admission the patient had a Stage 4
pressure ulcer on the left lip. So M0300D1 is coded as a 1. Then the Stage 4 pressure ulcer on the left
hip developed eschar and is unable to be assessed and numerically staged on discharge. And the patient is discharged with an unstageable
pressure ulcer due to slough or eschar. So here we have M0300D1 is coded as 0. And M0300F1 is coded as 1. M0300F2, those were how many were present
upon admission, is coded as 0 on the Discharge Assessment. Now let’s talk about non-removable dressings
or devices. So a non-removable dressing/device refers
to a dressing or device that may not be removed from a patient per a physician’s order. So a non-removable dressing/device includes
for example, a primary surgical dressing that cannot be removed, or an orthopedic device
or a cast, something that you specifically have an order that says, no, you can’t remove
it. Another key caveat for here, and this again
is an area where people struggle a little bit. And we get lots of questions. We have to have a known pressure ulcer/injury
covered by that non-removable dressing/device should be coded as unstageable. So the pressure ulcers/injuries are considered
unstageable due to the inability to further assess and document the pressure ulcer/injury
that is covered by that non-removable dressing/device. But I can’t stress enough, you have to know
that it’s there. And you have to know that it’s pressure-related
for you to code this item. It is going to be critically important that
you get this information from a previous setting. Or if someone develops one in your organization,
that’s fine, and then they end up with some sort of a removal device or cast or something
over that, so now you know that it was there, until that device comes off you can’t assess
it, then you would code that. But you have to know that something’s under
there. That’s a key caveat that some people miss. Known refers to when there’s documentation
available indicating that a pressure ulcer/injury exists under the non-removable dressing. You want to review the medical record for
documentation of that pressure ulcer/injury covered by that dressing. Do not assume that there’s a pressure ulcer/injury
that is covered by a non-removable dressing/device without actually knowing there’s something
under there. So let’s look at another coding scenario. So a patient is admitted to your IRF with
documentation in the medical record of a sacral pressure ulcer/injury. The ulcer/injury is covered by a non-removable
dressing. Therefore the pressure ulcer/injury is unstageable. On day 4 of the IRF stay, the dressing is
removed by the physician and assessed to reveal a Stage 3 pressure ulcer. On day 9 of the IRF stay the pressure ulcer
is covered with eschar and is assessed as unstageable. The eschar covers the ulcer and is unchanged
at the time of discharge. So they come in to you, they have a sacral
ulcer. It’s covered with a device, either a dressing
or device. You can’t stage it but you know that it’s
there. Then at day 4 we know that we can remove it. We have a Stage 3. By day 9 and at discharge it’s covered with
eschar. All right. So using Slido, how would you code on Admission
Assessment? So would you code M0300C1 as Stage 3? Unstageable non-removable dressing? Unstageable due to slough or eschar? Or unstageable deep tissue injury? Getting most people weighing in here. Let’s look at the answer. And the answer is, B, which most people got. We are on admission, unstageable due to non-removable
dressing/device, because we know that there’s something underneath there and we can’t remove
it. How would you code M0300 on Discharge Assessment? So again this is discharge. Would it be a Stage 3? An unstageable due to a non-removable dressing? Unstageable due to slough or eschar? Or unstageable? And let’s look at the answer. Most people are clicking in. Here we would code this as unstageable due
to slough or eschar. So we knew it was a Stage 3 but now it’s covered
in slough or eschar. Was this unstageable pressure ulcer due to
slough or eschar present upon admission? Yes or no? Or skip? Let’s look at the answer. And the answer is no. And most people got that correct. Then if we were coding this, again you can
just see how we would do the 0s here and skip. And then we would say they had a unstageable
due to non-removable dressing. We would code that as a 1. On the discharge, M0300F1, we now have that
unstageable due to slough or eschar. We code the next, M300F2 as 0 because that
one was not present upon admission. So here’s the rationale. And we just talked about it. So we knew about it. They had a known ulcer. So we coded that as a 1 on the admission assessment
for non-removable dressing. This goes on to talk about the unstageable
due to slough or eschar. All right. We’ve got a lot to cover here, so we’re just
going to move on. So in this scenario a patient is admitted
to the IRF with a Stage 3 pressure ulcer on the coccyx. On day 5 of her IRF stay the ulcer is assessed
as a Stage 4. She is seen at the wound clinic and returns
to the IRF with a dressing and orders that the dressing is to remain intact until the
next clinic visit. The patient is discharged to a skilled nursing
facility prior to the follow-up to the wound clinic visit. At the time of discharge the ulcer is covered
with a non-removable dressing. So this is not an uncommon situation. So let’s look at this. How would you code M0300 on the Admission
Assessment? Would you code a Stage 3? A Stage 4? Unstageable non-removable dressing? Or slough and/or eschar? Again this is admission. We have most people answering in. So let’s look at the answer. And here we would code a Stage 3, right. They came in with a Stage 3 pressure ulcer. So how would you code M0300 on Discharge Assessment? Would it be a Stage 3? A Stage 4? Or unstageable non-removable dressing? Or unstageable slough or eschar? We have most people answering it. So let’s look at the answer. And so here we have the answer would be unstageable
due to a non-removable dressing. So we know that that was present when they
were discharged. Was this unstageable pressure ulcer/injury
due to a non-removable dressing present upon admission? And the answer is either yes, or no, or skip. And we’ll look at the answer. And the answer is no. Because it wasn’t present upon admission. So if we were going to code this we just want
to give you a scenario of what this would look like. So we have our coding here and then we get
into our areas with non-removable dressing. So they had a unstageable due to a non-removable
dressing, 0. But they had 1 at discharge. So you’ll see the coding here. And this gives us our rationale. So we have at admission the patient has a
Stage 3 pressure ulcer. We coded that as 1. Then it goes through on the Discharge Assessment. And we’ve talked about that. So let’s talk about healed pressure ulcers/injuries. So the terminology referring to healed versus
unhealed ulcers and injuries refers to whether the ulcer/injury is closed versus open. Because we know that wounds heal from the
inside out. So it’s hard to say whether it’s truly healed. But for our terms, it’s whether it’s closed
or not. So a Stage 1 pressure injury, deep tissue
injury and unstageable pressure ulcer, although covered with tissue, eschar, or slough, would
not be considered healed. So this is just a subtlety. So we want to make sure that people say oh,
well they have a Stage 1. You told me if the skin is in intact then
that’s healed. Well we know that a Stage 1 is that persistent
redness. So in that situation it wouldn’t be healed. Remember we never reverse stage. That’s probably one the hardest things for
people to know. It’s what they see and they want to code it
as that. That’s really important when someone comes
to you and you know that an ulcer was a Stage 4 and now it might be looking like a Stage
2 to you, it’s still a Stage 4, it’s just a healing Stage 4. So in this coding scenario, a patient is admitted
to the IRF with multiple fractures following a motor vehicle accident and the skin assessment
upon admission reveals no pressure ulcers or injuries. On day 7 of the IRF stay a Stage 2 pressure
ulcer is identified on the coccyx. Wound treatment is initiated and the pressure
ulcer successfully heals a week prior to discharge. At discharge the patient’s skin assessment
reveals a healed Stage 2 pressure ulcer on the coccyx. So how would you code M0210 on the Admission
Assessment. Does this patient have one or more unhealed
pressure ulcers/injuries? So let’s go to the answers? So let’s see what we said here. Do they have one or more unhealed pressure
ulcers? Our answer is no. So in this situation we’re done with the skin
section, right. We would skip right out to N2001 starting
the Drug Regimen Review because we’re saying the skin is intact. So we’re done with that. But how would you code M0210 on the Discharge
Assessment? Does the patient have one or more unhealed
pressure ulcers/injuries? A lot of people are answering in on this. We have a mixed kind of bag here. OK, let’s look at the answer. And the answer is no. We would again skip to N2005, Medication Intervention. Why? Because they came in, their skin was intact. They developed the Stage 2. You healed the Stage 2. And on discharge the skin is intact. So these are really snapshots in time, admission/discharge. Even though they had a wound in between, we
don’t capture that wound for this assessment. We certainly would capture it clinically. You would certainly treat it, obviously they
did here. But it wouldn’t be captured on the assessment. So basically what I said, they had the ulcer. They came in intact. They developed the ulcer, you healed the ulcer. So both would be coded as no. So let’s look at medical device-related injuries. When an ulcer/injury is caused due to the
use of a medical device, assess the area to determine if the pressure is the primary cause. Again, that’s going back to that same language. Is it the primary cause? These ulcers/injuries generally conform to
the pattern or shape of the device. And I think most of us, if you’ve been clinical,
you’ve seen one of these. If pressure is determined to be the primary
cause, use the staging system to stage the ulcer and code in Section M of the IRF-PAI. If the ulcer/injury is not due to pressure
do not code in Section M. So often you’ll see people kind of being detectives. They’re putting a splint back on or seating
them in a particular wheelchair trying to look. All right, here’s my area or injury, does
it line up with anything to determine whether pressure was involved? So here we have a scenario. A patient is admitted to the IRF with a right
ankle foot orthosis to compensate for weakness with a foot drop. On the initial skin assessment the clinician
notes a Stage 2 pressure ulcer on the right calf that conforms to the shape of the AFO. The orthotist, I can never say this word,
the orthotist is consulted and the AFO is adjusted. At discharge the ulcer has decreased in dimensions
and remains an open Stage 2 pressure ulcer. No other pressure ulcers/injuries are noted. So they identified it, they brought in someone
to work on it. So let’s look at the coding scenario here. So let’s just walk through this. Here we have the number of Stage 1 pressure injuries on admission? What would you say? 0. Right. How about on discharge? 0. Right. And so the next question we would — okay
the number of Stage 2 pressure ulcers/injuries? We had 1. On discharge? 1., right. We had 1. Number of these Stage 2 pressure ulcers that
were present upon admission? 1. Right. How about Stage 3s? 0. On admission? 0. On discharge? 0., right. And then we would skip. Then how about Stage 4s? 0. On discharge? 0. And then we would skip. Okay. How about number of unstageable pressure ulcers
due to non-removable dressings? 0. Discharge Assessments? 0. Okay. And then number of these unstageable pressure
ulcers/injuries due to non-removable dressings/devices? Right. I would skip it. Remember. How about number of pressure ulcers due to
slough or eschar? 0. Okay. How about at Discharge Assessment? 0., right. And the next one would be? Skip, right. And then how about number of unstageable pressure
ulcers/injuries with deep tissue? 0., right. Then Discharge Assessment? 0. And then the next one is a skip, right. Okay. So here’s the rationale. The area was identified on the calf due to
the AFO and was determined to be caused by pressure of the device against the skin. And then the medical device-related pressure
injuries resulted from the use of the device designed and applied for diagnostic and therapeutic
purposes. The result in pressure injury generally conforms
to the pattern or shape of the device and the injury should be staged using the staging
system. Just note that the National Pressure Ulcer
Advisory Panel-Resources-Educational and Clinical Resources is an area where you can go out and
get some additional information. And just know that our coding for CMS is adapted
from that area. So we have some more practice scenarios here. Why don’t you take out your Coding Sheets. I’m going to go to the next scenario here,
okay. So if you take out your Coding Sheets — does
everyone have that? So let’s find Practice Scenario 7? Then I think there’s Practice Scenario 8. I’ll just go through this here. Okay. Why don’t we just take a couple of minutes
for you that are online. Take out the coding scenarios. And why don’t you go through these two coding
scenarios. Code it on your paper. And then what we’re going to do is pull the
group back in just a couple of minutes and then we will go through the scenarios and
debrief on them. So it gives you an opportunity to now use
your own brains to work through these and think about the rationale that you would use
if you’re explaining this to your staff. Okay. It looks like most people are done, hopefully
those who are watching live streaming are done also. Lets just take the opportunity because we’re
going to go over the two scenarios, then I have some ending slides, then we’ll be closing
out the session. So let’s look at this practice coding Scenario
7. Take out your coding sheets. Upon admission to the IRF, the patient’s skin
assessment reveals two Stage 4 pressure ulcers. One is located on the coccyx and the other
is on the right hip, so two Stage 4s. At discharge the patient’s skin assessment
reveals a healed Stage 4 pressure ulcer on the right hip. Yay to the care that was provided! The pressure ulcer on the coccyx remains a
Stage 4 with granulation tissue visible in 50% of the wound bed and no slough or eschar
is noted. Taking this scenario, let’s look at our coding. So let’s imagine that you have your coding
sheets in front of you. So let’s just follow along then you can make
any corrections, then we’ll talk about the rationale. So the number of Stage 1 pressure ulcers on
admission? How many did we have? Do we have any? We had none. Okay. How about on the Discharge Assessment? Did we have any Stage 1 pressure ulcers? No. The next question is, number of Stage 2 pressure
ulcers? Did we have any on the Admission Assessment? No. Did we have any on the Discharge Assessment? No. And so, then that next question would automatically
be a skip because we had a 0, right. Because it always asks “of” the number that
was present at discharge, how many were present upon admission. Number of Stage 3 pressure ulcers upon admission? We didn’t have any. How about the number on discharge? No. We didn’t have any on discharge. And then again, the next one would be a skip. Number of Stage 4 pressure ulcers on admission? They had 2, right. And then the number of Stage 4 on the Discharge
Assessment? 1. Okay. Coded 1, right. And we code it 1, because one healed, right. And the number of these Stage 4 pressure ulcers
that were present upon admission, because we’re saying there’s one on discharge. How many of those were present upon admission? 1. So really again, this question is just referring
back. It’s saying of the ones I have at discharge,
I have one at discharge, right. You had one left. Of that one , because that’s the question its asking
you, how many of that one were present upon admission? It was 1. Even though they had 2, one of them, which
is what you still have, was present upon admission. That’s just telling the system that, yes,
they still have one but they had that on admission also. Okay. Then we look through and we said the number
of unstageable pressure ulcers/injuries due to non-removable dressings? Do we have any of those on admission? No. Did we have any on discharge? No. So then we skip. Then the same thing, the rest of these are
no. We didn’t have any ulcers due to slough or
eschar on admission or discharge and we didn’t have any unstageable pressure injuries or
deep tissue injuries. So this would be the rest of that coding. So the rationale, again, this is important. You’ll have all of these completed with the
answers to use in training materials and/or I would encourage you to take your own cases
in your facilities and go through a similar exercise. But upon admission the patient had two Stage
4 pressure ulcers, one on the coccyx and one on the right hip. So M0300D1 was coded as 2 on the Admission
Assessment. Then at discharge the Stage 4 pressure ulcer
on the right hip was healed and would not be captured in M0300 because it’s not there
on discharge. The coccyx pressure ulcer remains as a Stage
4, therefore on Discharge Assessment we would code M0300D1 as a 1. Then when we ask how many of those were present
on admission, we would say in M0300D2 that we had 1 of those were present upon admission. So that’s the rationale that we would use. We then had another scenario that you worked
on which is Practice Scenario 8. On admission to the IRF the patient’s skin
assessment reveals three small distinct Stage 2 pressure ulcers in the sacral area. Upon the Discharge Assessment two of the sacral
pressure ulcers have merged and remain a Stage 2. The third sacral pressure ulcer has increased
to a Stage 3. So let’s go through this practice scenario. Let’s see how people did. Number of Stage 1 pressure injuries on admission? 0. Good. How many at discharge? 0. How many Stage 2 pressure ulcers on admission? We had 3, right, three distinct pressure ulcers. How many on the Discharge Assessment? Want to guess? 1. Right. We have 1. How many of these Stage 2 pressure ulcers
that were present upon admission? 2? 1? I’m hearing a couple of different numbers. Remember it’s 1 because we’re talking about
what we have left at discharge. It’s only referring back to that discharge. You have one ulcer left. You can’t say 2 of the 1 ulcers. Do you see what I mean? How many were present upon admission is referring
back to that — it ties back to that, I have one present. Even though I had two on admission, it’s saying
how many do I have at discharge. Of those that are present on discharge, that’s
how the verbiage is, of those that are present upon discharge, how many of that 1, 2, 6,
whatever the number is, were present upon admission? So you only have 1, the max number you can
do there is 1. How many number of Stage 3 pressure ulcers? 0. On admission, sorry I didn’t finish the verbiage
here. On admission how many Stage 3s? 0. How many on discharge? 1, right. How many of that one Stage 3 pressure ulcers
were present upon admission? 0, right. Because they were all Stage 2s when they came
in. How many Stage 4 pressure ulcers on admission? 0. How about at discharge? 0. And so the next one would be skip, right. And then number of unstageable pressure ulcers
or injuries due to non-removable dressing? Okay. We would have 0, 0. The rest of these are all 0s. Because we didn’t have slough, eschar, or
any of the non-removable dressings. So it’s important. Let’s go through the rationale for this particular
coding scenario. So upon admission the patient had three Stage
2 pressure ulcers in the sacral area. So you are correct, M0300B1 is coded as 3
on the Admission Assessment. At discharge, two of the sacral pressure ulcers
have merged and remain a Stage 2. The third sacral pressure ulcer has increased
to a Stage 3. So on the Discharge Assessment, when the two
pressure ulcers — they must have been like right near each other, the two Stage 2 pressure
ulcers, and sometimes they have this little bit of a skin bridge. And when that bridge goes away they just become
one ulcer, okay, at the same stage there. So M0300B1 is coded as a 1. M0300B1 is coded as a 1. M0300C1 is coded as a 1. And M0300C2 is coded as a 0. All right. This is basically what I just said. If two or more pressure ulcers/injuries were
observed at the same time of admission and merge into a single pressure ulcer or injury
by discharge, the resulting pressure ulcer/injury is reported as one single pressure ulcer/injury
at the appropriate stage on the IRF-PAI. And now I’m competing with vibrations in the
ceiling here. (Laugher) Hopefully you can hear me if you’re
listening remotely. So that’s again an important concept. If you’re having your general staff nurses
who are assessing and then coding, that they understand about that skin bridge and when
that skin bridge goes away and they merge. And that’s not an uncommon thing that can
happen in that sacral area, that that goes away. They’re very small. And that bridge goes away and it stays as
a Stage 2 in this particular situation but they become one. Let’s look at finishing up and talk about
some other unique ulcers. Hopefully, first off, by going through these
scenarios that’s the best way to educate and teach and for staff to learn about these are
these various scenarios. I love the fact that we have a lot of scenarios
in here and in the manual. But taking your own situation, taking your
own patients and writing up scenarios around them and the rationale can give you an opportunity
to train and educate your staff. Mucosal ulcers, so mucosal pressure ulcers
are not staged using the skin pressure ulcer injury staging system because the anatomical
tissue comparisons cannot be made. So this is an important concept again to make
sure that your staff understand. Therefore mucosal ulcers, for example those
related to NG tubes, oxygen tubing, endotracheal tubes, urinary catheter, mucosal ulcers in
the oral cavity should not be coded on the IRF-PAI. So again, this is, — I looked at many assessments
and this can be a common issue where staff want to treat all ulcers, they want to stage
them. Actually in fact they want to stage every
wound, whether it’s pressure-related or not. So we have to educate them. It has to have pressure as a primary source
then we have to have them understand that there are openings that are caused by other
things than, ulcers like stasis ulcers and whatnot. Then the third thing is they need to understand
around the mucosal ulcers. So you have to make sure that if you’re going
back into your own organization would you be confident that if you went up to any staff
who were responsible for this, would they understand these subtleties? If not, an opportunity for education. Just a really great thing. So I will put that down in your Action Plan
as just going back, let me do some gut checking. If I’m unsure, let me just validate. Take some of your best, what you consider
your “best” high performers ask them some of these questions. Then take kind of your general staff who maybe
haven’t had as much passion in doing this, and really are invested, that they may have
an opportunity to make sure that they understand these subtleties. So we want to have accurate assessment. Of course you want to have the same thing. We want to then code the IRF-PAI with accurate
information so that these again are impacting public reporting quality measures. So let’s talk about this idea of a Kennedy
ulcer. So it’s a skin ulcer that occurs at the end
of life and are known as Kennedy or terminal ulcers. Most of us, if you’ve been around your career
in any length of time you’ve seen these. And a Kennedy or terminal skin ulcers are
not captured in Section M. The evolution and appearance differ from a typical pressure
ulcer or injury and its related to tissue perfusion issues due to organ and skin failures. As we know, our skin is one of our largest
organs. So it’s a totally different process. That does not mean you ignore them clinically. That’s not what we’re saying here. We still want you to go ahead, treat them. Do all the things you need to do. We just don’t want you to code them into the
IRF-PAI. So again, another opportunity to educate your
staff. So for the etiology, if you don’t know a lot
about these ulcers, certainly that’s maybe an opportunity to do an education with your
staff. The evolution and appearance differs from
the typical pressure ulcer/injury. They generally appear from six weeks to two
to three days before death. And they present as a pear-shaped purple area
with irregular borders, usually on that coccyx type of area. But there’s lots of great materials out there
if you Google some of this, there’s some great pictures that you can use for education and
training. Or if you actually have a patient who has
an ulcer like this and a newer nurse has not seen it, it is an opportunity to educate. Bring them in and let them take a look as
long as it’s okay with the patient. It’s a great thing to be able to see it yourself. You’ll usually never forget what you’ve seen. So our summary, Changes in Skin Integrity
Post-Acute Care: Pressure Ulcer/Injury is a cross-setting quality measure. So we are looking at this in all of the PAC
settings. They’re being asked to do the same thing that
you’re being asked to do. Data collection for this measure began on
October 1, 2018. So this is something you’ve been doing for
awhile, yet we are getting lots of questions continually about this. And I think some of this is getting back,
all those key points that I talked about, which are education points, the subtleties
using data elements that already exist in the IRF-PAI. And this measure replaces the Percent of Residents
or Patients with Pressure Ulcers that are New or Worsened, because we added and changed
some of the assessment items. So for this measure, an ulcer/injury is considered
new or worsened at discharge if the Discharge Assessment shows a Stage 2-4 or unstageable
pressure ulcer/injury that was not present on admission at that stage. I’m sure you are sick of me saying that. But that is the key point behind this. Please submit your questions and we will try
to answer them and give clarity. Take out your Action Plans. I think this is an opportunity for you to
say, oh, let me just go back and do this. Now I always think I’m going to remember all
this when I leave a conference. I don’t. So just take the notes and then you can flesh
out those ideas once you get back to your organizations. And I am done. And I will hand this back over to Brigitte. (Applause)

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