Objectives. Major Changes to Section M. MDS 3.0 Section M Pressure Ulcers. Risk assessment Introduction of NPUAP guidelines

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1 MDS 3.0 Section M Pressure Ulcers Moderator: Barbara Baylis Sr. VP of Clinical and Residential Services, Kindred Healthcare Presenter: Glenda Mack, Sr. Director of Clinical Operations, Peoplefirst Rehabilitation Dedicated to Hope, Healing and Recovery Dedicated to Hope, Healing and Recovery 1 Objectives Learner will review NPUAP Pressure Ulcer staging guidelines with a focus on key differentiators between stages. Learner will be able to define present on admission as it relates to MDS 3.0 requirements. Learner will be able to state key healing assessment and treatment considerations for different PU stages. Learner will possess key knowledge to support current and ongoing process improvement related to accuracy of MDS 3. Dedicated to Hope, Healing and Recovery 2 Major Changes to Section M Risk assessment Introduction of NPUAP guidelines No more reverse staging Deepest pressure ulcer Worsening pressure ulcer(s) Unstageable and suspected Deep Tissue Injury (sdti) Dedicated to Hope, Healing and Recovery 3 1

2 Major Changes to Section M Present on Admission/Re-entry status Date of oldest Stage 2 pressure ulcer Dimensions in centimeters as actually measured Type of tissue in the wound bed Dedicated to Hope, Healing and Recovery 4 Present on Admission - Defined Review the medical record for the history of the ulcer. Review for location and stage at the time of admission or reentry. If the pressure ulcer was present on admission and subsequently worsened to a higher stage during the resident s stay, the pressure ulcer is coded at that higher stage, and that higher stage should not be considered as present on admission. If the pressure ulcer was unstageable on admission, but becomes stageable later, it should be considered as present on admission at the stage at which it first becomes stageable. If it subsequently worsens to a higher stage, that higher stage should not be considered present on admission. If a resident who has a pressure ulcer is hospitalized and returns with that pressure ulcer at the same stage, the pressure ulcer should not be coded as present on admission because it was present at the facility prior to the hospitalization. If a current pressure ulcer worsens to a higher stage during a hospitalization, it is coded at the higher stage upon reentry and should be coded as present on admission. Dedicated to Hope, Healing and Recovery 5 Organizational Assessment Look at your systems Clinical and administrative oversight Who does the data collection and how does it flow? Timeliness of documentation? Clinical expertise? How is documentation done? Who is responsible? Review your current: Pressure ulcer policies and guidelines Process for pressure ulcer risk Process for developing and implementing a care plan for at risk residents Dedicated to Hope, Healing and Recovery 6 2

3 Clinician Skills Needed Etiology Etiology Etiology Etiology Etiology Etiology Etiology Dedicated to Hope, Healing and Recovery 7 NPUAP Pressure Ulcer Definition CMS has adapted the NPUAP 2007 definition of a pressure ulcer as well as categories/ staging. A pressure ulcer is a localized injury to the skin and/ or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear and/ or friction. Dedicated to Hope, Healing and Recovery 8 Items M0100 & M0150 Determination of Pressure Ulcer Risk Dedicated to Hope, Healing and Recovery 9 3

4 Pressure Ulcer Risk Factors Immobility and decreased functional ability Co-morbid conditions (ESRD, thyroid, diabetes) Drugs such as steroids Impaired diffuse or localized blood flow Resident refusal of care and treatment Dedicated to Hope, Healing and Recovery 10 Pressure Ulcer Risk Factors 2 Cognitive impairment Exposure of skin to urinary and fecal incontinence Undernutrition, malnutrition, and hydration deficits Healed pressure ulcer that has closed Higher risk of opening up due to damage, injury, or pressure Due to loss of tensile strength of the overlying tissue Tensile strength of skin overlaying a closed pressure ulcer only 80% of normal skin Dedicated to Hope, Healing and Recovery 11 Healed PU = Risk of PU Ulcer healed in 3 months Presented with Stage 4 ulcer Dedicated to Hope, Healing and Recovery 12 4

5 M0100 Determination of Pressure Ulcer Risk Reflects multiple approaches for determining a resident s risk for developing a pressure ulcer. Presence or indicators of pressure ulcers Assessment using a formal tool Physical examination of skin and/ or medical record Dedicated to Hope, Healing and Recovery 13 M0100A Risk Factors Existing Pressure Ulcer Non - Removable Dressing Non - Removable Device Healed (Closed) Pressure Ulcer Dedicated to Hope, Healing and Recovery 14 M0100C Clinical Assessment Observe the resident s skin. Review the medical record. Imperative to determine etiology of all wounds and lesions. Dedicated to Hope, Healing and Recovery 15 5

6 M0150 Risk of Pressure Ulcers Determine if resident is at risk for pressure ulcers. Recognize/ evaluate each resident s risk factors. Identify/ evaluate all areas at risk of constant pressure. Determine if resident is at risk. Dedicated to Hope, Healing and Recovery 16 Item M0210 Unhealed Pressure Ulcer(s) Dedicated to Hope, Healing and Recovery 17 M0210 Unhealed Pressure Ulcers Coding Instructions Dedicated to Hope, Healing and Recovery 18 6

7 Item M0300 Current Number of Unhealed Pressure Ulcer(s) at Each Stage Dedicated to Hope, Healing and Recovery 19 M0300 Guidelines 1 1. Determine deepest anatomical stage of each pressure ulcer. 2. Identify unstageable pressure ulcers. 3. Determine present on admission. Dedicated to Hope, Healing and Recovery 20 M0300 Guidelines 2 Do not reverse stage. Consider current and historical levels of tissue involvement. Do not code lesions not primarily related to pressure. Initial numerical staging and the initial numerical staging of ulcers after debridement or sdti that declares itself should be coded in terms of what is assessed (seen and palpated) during the lookback period. Dedicated to Hope, Healing and Recovery 21 7

8 Item M0300A Number of Stage 1 Pressure Ulcers Dedicated to Hope, Healing and Recovery 22 M0300A Number of Stage 1 Pressure Ulcers Document number of Stage 1 pressure ulcers. Stage 1 pressure ulcers may deteriorate without adequate intervention. They are an important risk factor for further tissue damage. Dedicated to Hope, Healing and Recovery 23 M0300A Assessment Guidelines Assessment to determine staging should be holistic. Stage 1 may be difficult to detect in individuals with dark skin tones. Determine whether an ulcer is a Stage 1 pressure ulcer or suspected deep tissue injury. Do not rely on only one descriptor as the descriptors for these two types of ulcers are similar. Code pressure ulcers with intact skin that are suspected deep tissue injury in M0300G not here Dedicated to Hope, Healing and Recovery 24 8

9 Stage 1 Pressure Ulcer Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching. Color/temperature may differ from the surrounding area. Dedicated to Hope, Healing and Recovery 25 Treatment Strategies Health-related Quality of Care Stage 1 pressure ulcers may deteriorate to more severe pressure ulcers without adequate intervention; as such, they are an important risk factor for further tissue damage. Planning for Care Development of a Stage 1 pressure ulcer should be one of multiple factors that initiate pressure ulcer prevention interventions. Patient specific interventions are necessary to prevent further breakdown. Dedicated to Hope, Healing and Recovery 26 Item M0300B Stage 2 Pressure Ulcers Dedicated to Hope, Healing and Recovery 27 9

10 Stage 2 Pressure Ulcer Partial thickness loss of dermis presenting as: Shallow open ulcer Red or pink wound bed Without slough Dedicated to Hope, Healing and Recovery 28 Stage 2 Pressure Ulcer May also present as an intact or open/ ruptured blister. Dedicated to Hope, Healing and Recovery 29 Stage 2 Pressure Ulcer Do NOT code as a Stage 2 when a deep tissue injury is determined. Code in M0300G Unstageable Pressure Ulcers Related to Suspected Deep Tissue Injury. Clearly document assessment findings in the resident s medical record. Facilities may adapt NPUAP guidelines in their clinical practice and nursing documentation. Dedicated to Hope, Healing and Recovery 30 10

11 M0300B Assessment Guidelines Stage 2 ulcers will generally lack the surrounding characteristics found with a deep tissue injury. Blood-filled blisters related primarily to pressure are more likely to be associated with sdti than serous filled blisters. Ensure, again, a complete, and comprehensive, assessment of the resident and the site of injury. Do not code skin tears, tape burns, perineal dermatitis, maceration, excoriation, vascular wounds diabetic foot ulcers or suspected deep tissue injury in M0300B. Dedicated to Hope, Healing and Recovery 31 M0300B Stage 2 Pressure Ulcers Coding Instructions 1. Number of Stage 2 pressure ulcers 2. Number of Stage 2 pressure ulcers present upon admission/ reentry Number of pressure ulcers first noted at time of admission Number of pressure ulcers acquired during a hospital stay if being readmitted 3. Date of oldest Stage 2 pressure ulcer Code suspected deep tissue injury at M0300G. Dedicated to Hope, Healing and Recovery 32 Pressure Ulcer Blister Dedicated to Hope, Healing and Recovery 33 11

12 Blood - Filled Blister Dedicated to Hope, Healing and Recovery 34 Treatment Considerations Planning for Care Most Stage 2 pressure ulcers should heal in a reasonable time frame (e.g., 60 days). Stage 2 pressure ulcers are often related to friction and/or shearing force, and the care plan should incorporate efforts to limit these forces on the skin and tissues. Stage 2 pressure ulcers may be more likely to heal with treatment than higher stage pressure ulcers. The care plan should include individualized interventions and evidence that the interventions have been monitored and modified as appropriate. Maintaining moisture balance is a key strategy to encourage healing. Dedicated to Hope, Healing and Recovery 35 Items M0300C & M0300D Stage 3 Pressure Ulcers/ Stage 4 Pressure Ulcers Dedicated to Hope, Healing and Recovery 36 12

13 Stage 3 Pressure Ulcer Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed or immediately palpable. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Dedicated to Hope, Healing and Recovery 37 M0300C Stage 3 Pressure Ulcers Coding Instructions 1. Number of Stage 3 pressure ulcers Identify all Stage 3 pressure ulcers currently present. 2. Number of Stage 3 pressure ulcers present upon admission/ reentry Code the number of pressure ulcers first noted at time of admission. Code number of pressure ulcers acquired during a hospital stay if being readmitted. Dedicated to Hope, Healing and Recovery 38 Treatment Considerations Planning for Care Pressure ulcers at more advanced stages typically require more aggressive interventions, including more frequent repositioning, attention to nutritional status, and care that may be more time or staff intensive. An existing pressure ulcer may put residents at risk for further complications or skin injury. If a pressure ulcer fails to show some evidence toward healing within 14 days, the pressure ulcer (including potential complications) and the resident s overall clinical condition should be reassessed. Care must be taken to maintain moisture balance and prevent infection Dedicated to Hope, Healing and Recovery 39 13

14 Stage 4 Pressure Ulcer Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Depth varies by anatomical location (bridge of nose, ear, occiput, and malleous ulcers can be shallow). Dedicated to Hope, Healing and Recovery 40 M0300D Stage 4 Pressure Ulcers Coding Instructions 1. Number of Stage 4 pressure ulcers 2. Number of Stage 4 pressure ulcers present upon admission/ reentry Dedicated to Hope, Healing and Recovery 41 Treatment Considerations Planning for Care Pressure ulcers at more advanced stages typically require more aggressive interventions, including more frequent repositioning, attention to nutritional status, more frequent dressing changes, and treatment that is more time-consuming than with routine preventive care. An existing pressure ulcer may put residents at risk for further complications or skin injury. If a pressure ulcer fails to show some evidence toward healing within 14 days, the pressure ulcer (including potential complications) and the resident s overall clinical condition should be reassessed. Care must be taken to maintain appropriate moisture balance and prevent infection Appropriate debridement methods must be employed to expedite healing Dedicated to Hope, Healing and Recovery 42 14

15 Item M0300E/ M0300F/ M0300G Unstageable Pressure Ulcers Dedicated to Hope, Healing and Recovery 43 Unstageable Pressure Ulcers Three types to differentiate Number of these unstageable pressure ulcers present upon admission/ reentry Dedicated to Hope, Healing and Recovery 44 M0300E Unstageable Non-Removable Device Ulcer covered with eschar under plaster cast Known but not stageable because of the nonremovable device Dedicated to Hope, Healing and Recovery 45 15

16 M0300E Unstageable Non-Removable Dressing Known but not stageable because of the non-removable dressing Dedicated to Hope, Healing and Recovery 46 M0300F Unstageable Slough and/ or Eschar Known but not stageable related to coverage of wound bed by slough and/ or eschar Full thickness tissue loss Base of ulcer covered by slough (yellow, tan, gray, green or brown) and/ or eschar (tan, brown or black) in the wound bed Dedicated to Hope, Healing and Recovery 47 Treatment Considerations Planning for Care Visualization of the wound bed is necessary for accurate staging. The presence of pressure ulcers and other skin changes should be accounted for in the interdisciplinary care plan. Pressure ulcers that present as unstageable require care planning that includes, in the absence of ischemia, debridement of necrotic and dead tissue and restaging once the necrotic tissue is removed. Wounds with necrotic tissue are at increased risk for infection, interventions should be in place to limit risk Dedicated to Hope, Healing and Recovery 48 16

17 M0300G Unstageable Suspected Deep Tissue Injury 1 Localized area of discolored (darker than surrounding tissue) intact skin. Related to damage of underlying soft tissue from pressure and/ or shear. Area of discoloration may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Dedicated to Hope, Healing and Recovery 49 Treatment Considerations Health-related Quality of Life Deep tissue injury may precede the development of a Stage 3 or 4 pressure ulcer even with optimal treatment. Quality health care begins with prevention and risk assessment, and care planning begins with prevention. Appropriate care planning is essential in optimizing a resident s ability to avoid, as well as recover from, pressure (as well as all) wounds. Deep tissue injuries may sometimes indicate severe damage. Identification and management of Suspected Deep Tissue Injury (sdti) is imperative. Planning for Care Suspected deep tissue injury requires vigilant monitoring because of the potential for rapid deterioration. Such monitoring should be reflected in the care plan and should be individualized to the patient/resident need. Dedicated to Hope, Healing and Recovery 50 M0300E, M0300F, M0300G Coding Instructions Code number of each type of pressure ulcer. Code number of each type of ulcer present upon admission/ reentry. Do not code M0300G when a lesion related to pressure presents with an intact blister and the surrounding or adjacent soft tissue does not have the characteristics of Deep Tissue Injury. Code under M0300B Unhealed Pressure Ulcers -- Stage 2. Dedicated to Hope, Healing and Recovery 51 17

18 Item M0610 Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Unstageable Pressure Ulcer Due to Slough or Eschar Dedicated to Hope, Healing and Recovery 52 Dimensions of a Pressure Ulcer What to Measure Identify pressure ulcer with the largest surface area from the following: Unhealed (nonepithelialized) Stage 3 or 4 Unstageable pressure ulcer related to slough or eschar Measure every Stage 3, Stage 4, and unstageable related to slough or eschar pressure ulcer to determine the largest. Dedicated to Hope, Healing and Recovery 53 M0610A Length Measure the longest length from head to toe using a disposable device. Head Toe Dedicated to Hope, Healing and Recovery 54 18

19 M0610B Width Measure widest width of the pressure ulcer side to side perpendicular (90 angle) to length. The depth of this pressure ulcer is 3.7 cm. Head Toe Dedicated to Hope, Healing and Recovery 55 M0610 Coding Instructions Enter pressure ulcer dimensions in centimeters. If depth is unknown, enter a dash in each space. Dedicated to Hope, Healing and Recovery 56 M0610C Depth Moisten a cotton-tipped applicator with 0.9% sodium chloride (NaCl) solution or sterile water. Place applicator tip in deepest aspect of the wound and measure distance to the skin level. Dedicated to Hope, Healing and Recovery 57 19

20 Item M0700 Most Severe Tissue Type for Any Pressure Ulcer Dedicated to Hope, Healing and Recovery 58 M0700 Most Severe Tissue Type for Any Pressure Ulcer Determine type(s) of tissue in the wound bed. Code for most severe type of tissue present in pressure ulcer wound bed. Code for most severe type if wound bed is covered with a mix of different types of tissue. Dedicated to Hope, Healing and Recovery 59 MO700 Epithelial Tissue Dedicated to Hope, Healing and Recovery 60 20

21 MO700 Granulation Tissue Dedicated to Hope, Healing and Recovery 61 MO700 Slough Dedicated to Hope, Healing and Recovery 62 MO700 Necrotic Tissue (Eschar) Dedicated to Hope, Healing and Recovery 63 21

22 Item M0800 Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA, PPS, or Discharge) Dedicated to Hope, Healing and Recovery 64 M0800 Assessment Guidelines Complete only if this is not the first assessment since the most recent admission (A0310E = 0). Look-back period is back to the ARD of the prior assessment. Dedicated to Hope, Healing and Recovery 65 M0800 Coding Instructions Enter the number of pressure ulcers that: Were not present. OR Were at a lesser stage on prior assessment. Code 0 if: No pressure ulcers have worsened. OR There are no new pressure ulcers. Dedicated to Hope, Healing and Recovery 66 22

23 Item M0900 Healed Pressure Ulcers Dedicated to Hope, Healing and Recovery 67 M0900 Healed Pressure Ulcers Complete only if this is not the first assessment since the most recent admission (A0310E=0). Dedicated to Hope, Healing and Recovery 68 M1200 Skin and Ulcer Treatments 2 Pressure-relieving devices do not include: Egg crate cushions of any type Doughnut or ring devices in chairs Turning/ repositioning program Patient specific approaches for changing resident s position and realigning the body Program should specify intervention and frequency Nutrition and hydration High calorie diets with added supplements to prevent skin breakdown High protein supplements for wound healing Dedicated to Hope, Healing and Recovery 69 23

24 M1200 Skin and Ulcer Treatments 1 Dedicated to Hope, Healing and Recovery 70 M1200E Ulcer Care Dedicated to Hope, Healing and Recovery 71 Acknowledgements CMS Training Materials Inits/45_NHQIMDS30TrainingMaterials.a sp Kindred Healthcare training resources Dedicated to Hope, Healing and Recovery 72 24

25 Clarifications? Dedicated to Hope, Healing and Recovery 73 25