Reporting Closed Stage III and Stage IV Pressure Ulcers on OASIS-C
Posted on February 05, 2010 in Coding Education
by Ann Giles, RN, BSN, HCS-D, COS-C
With the implementation of OASIS-C, reporting of pressures ulcers has changed. Today, I want to focus on the reporting of closed stage III and stage IV pressure ulcers. These two stages of ulcers are considered "full thickness" ulcers, which according to the WOCN guidelines, means there is total loss of epidermis and dermis and damage extends into the subcutaneous tissue and possibly into the muscle or bone. An important point to remember is that stage III and stage IV pressure ulcers can be considered closed when they are fully granulated, but never "fully healed." M1308 asks the clinician to report the current number of unhealed (non epithialized) pressure ulcers at each stage. Because stage III and stage IV pressure ulcers never fully heal as discussed above, it is still appropriate to report closed stage III and stage IV pressure ulcers in M1308. Also remember that reverse staging of stage III and stage IV pressure ulcers is not an appropriate clinical practice according to the National Pressure Ulcer Advisory Panel (NPUAP). Stage III and stage IV pressure ulcers should continue to be reported at its worst stage, even if re-epithelialized. The next items on the OASIS ask the clinician to report the measurements of stage III or stage IV pressure ulcer with the largest surface dimensions. Guidance in the OASIS manual tells the clinician to report 00.0 for all of these items for closed stage III and stage IV pressure ulcers. The final question asked relating to these pressure ulcers addresses the status of the ulcer. Again, the OASIS manual should be referenced for guidance. It tells assessing clinicians that response 0 (newly epithelialized) is the appropriate response for pressure ulcers that have re-epithelialized. As always, the key to ensuring OASIS accuracy is being familiar with the guidance in the OASIS manual and other OASIS resources.
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My understanding, from the guidance, is that if a stage III or IV has been newly epithelialized for more than 30 days, it is not to be used in that item. “For the purpose of this OASIS item, when complete epithelialization has been present for more than 30 days, the pressure ulcer is no longer described as a pressure ulcer and should not be included in this item.” (Chapter 3, F-11)
That statement, along with earlier guidance for the same item referring to “non-epithelialized stage III or IV pressure ulcers” led me to interpret the item as NOT measuring a stage III or IV if it has been epithelialized > 30 days.
In all other items, I continue to count closed stage III’s and IV’s.
What are your thoughts on this?
Sue Hull, RN, MSN, CWOCN
By Sue on Feb 10, 2010 at 10:49 am
Sue, you are correct in that chapter 3 of the original OASIS manual did have this guidance. Since the release of the manual, however, additional guidance has been released. In the October 2009 Q&A’s, question #17 offers this additional guidance: “Immediately after a stage III or IV pressure ulcer achieves complete epithelialization (closes), assuming it is the pressure ulcer with the largest surface dimension, its length, width, and depth would be each reported as 00.0 forever, unless the ulcer deteriorates, or is replaced by an advancement or muscle flap.” Secondly, in the OASIS-C Guidance Manual Errata (page 4) released December 4, 2009, it states that the first bullet on the top of page 11 in chapter 3 should be deleted. Remember that the most updated guidance is what should be followed when answering these OASIS items.
By Ann Giles on Feb 10, 2010 at 01:21 pm
Thank you so much for that clarification! I was just re-reading the Oct. Q&As; and the Errata when your comment came in, and there it was!
I knew I had seen that somewhere
Sue
By Sue on Feb 10, 2010 at 02:20 pm