OASIS Alert

Published on Thu Jan 24, 2008 PDF

You don't have to know exactly when a surgical wound healed.

If a post-surgery patient transfers to home health from a nursing home, you must be able to track her wounds' healing process, right? Wrong.

A surgical wound is considered healed and no longer reportable as a surgical wound for M0482 if four weeks have passed since it completely epithelialized. However, when patients move from one care setting to another, tracking their wounds' progress can be difficult.

Better: The Centers for Medicare & Medicaid Services wants clinicians to use their best judgment to determine when and if a wound has healed.

When "the clinician assess the wound to be completely epithelialized (including no sign of infection or separation), and the date of complete epithelialization is unknown, the clinician will have to make a determination regarding the wound status based on the history of the date of surgery, any reported wound healing progress/ complications and clinical assessment findings," the agency stated in an October 2008 clarification on the OASIS Certificate and Comp-etency Board (OCCB) Web site.

Do it this way: Based on the date of surgery, if the wound couldn't have been fully epithelialized for at least four weeks, the clinician should report "fully granulating." If four weeks could have passed since epithelialization, then the wound is considered healed and is no longer reportable.

You shouldn't have to search too far for information on when the surgery occured or what has passed, CMS noted. Even if the date of surgery isn't in the patient's record, you can simply ask the physician about the surgery during your initial consultation.