OASIS Alert

A significant portion of home health claim denials are related to coding and definition of wounds on the OASIS assessment and to wound care documentation, regional home health intermediary Cahaba GBA reports in its November Medicare A Newsline.

"Accurate and complete documentation is crucial for the medical review process," Cahaba reminds providers. To prevent denials, clinicians should use a standardized tool for both the initial assessment and weekly follow-up on each wound, the RHHI recommends.

Your wound care record should include the wound type and location, shape and measurements, description of the wound bed and surrounding tissue, and any drainage noted, Cahaba says.

Make a New Year's resolution to prevent downcoding and cash flow problems by addressing these trouble spots:

1. Inaccurate wound definition. M0440 through M0480 address integument status, and different answers add different numbers of points to the patient's clinical severity score that determines reimbursement (see chart in Eli's OASIS Alert Vol. 4, No.11, p. 103). Pressure ulcers and stasis ulcers can look the same, but both the cause and the treat-ment differ, explains consultant Pam Warmack with Ruston, LA-based Clinic Connections. And the home health resource group case mix points differ significantly between pressure and stasis ulcers, she adds.

A wound can't be defined as more than one type. For example, a diabetic ulcer can't also be a pressure ulcer, Cahaba instructs providers. Consult the physician to clarify the type of wound involved, the RHHI suggests. And document that discussion in the record, experts advise.

If a wound is coded as a trauma wound, be sure to document the type of injury that caused the wound and the location of the wound, Cahaba warns. When a wound is a diabetic ulcer, coding guidelines require you to code the diabetes before the manifestation, Cahaba notes, and failure to do that may mean you lose the extra case mix points.

2. Inconsistent documentation. The OASIS assessment, plan of care and visit notes should be consistent, Cahaba instructs. And focus on providing good descriptive documentation. Don't ignore wounds that aren't addressed on the OASIS and don't affect reimbursement. They still should be documented, the RHHI adds.

In its wound care quality improvement project, St. Elizabeth's Home Health in Belleville, IL improved outcomes by mandating documentation and observation of the wound at every visit, although measuring the wound once a week was usually enough, reports Grace Grider, who leads quality improvement efforts at the agency. (For an example of how St. Elizabeth's integrated the wound assessment with the visit note, see Eli's OASIS Alert, Vol. 4, No. 9, p. 86).

3. Inappropriate skilled care. "A service is not necessarily 'skilled' merely because a nurse performs it," Cahaba reminds providers. Ask if a non-medical person without special training can safely and effectively perform the service, the RHHI suggests. If so, it's not skilled just because no one else is available to do it, the intermediary argues.

Skilled nursing can be required to observe and assess the wound and to teach the family to care for the wound, the Centers for Medicare & Medicaid Services instructs in CMS Medicare Benefit Policy. Be sure to document the medical necessity for observation and assessment in the record to avoid downcoding, Cahaba warns.

TIP: Not all wounds or ulcers require skilled nursing care. For more detailed guidelines and examples, go to CMS Medicare Benefit Policy at www.cms.hhs.gov/manuals/102_policy/bp102c07.pdf and scroll down to page 50.