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Documentation of Surgical Wounds for Medicare ReimbursementWith the advancements in post-operative care management, there is a significant rise in the number of hospital discharges to home healthcare for patients with infected wounds after surgery. Home care facilities provide cost-effective as well as efficient services to heal wounds and reduce complications. However, home health reimbursement is shifted to a prospective payment system as mandated by the Balanced Budget Act of Medicare, in which the payment is given on the basis of the patient’s clinical severity, functional status, and therapy requirements. Home Health Agencies (HHAs) have to submit a complete Outcome and Assessment Information Set (OASIS) form to participate in the Medicare program and receive proper reimbursement for their services provided to the patient at home. OASIS-C is a modification to the OASIS documentation and its implementation became effective from January 2010. Registered nurses are responsible for completing the OASIS-C assessment form for surgical wounds, which include sections to record the presence of surgical wound, healing status, diagnosis details, risk for hospitalizations, and the patient’s status and pain. Let’s take a look at each section in detail.

M1340: Does this patient have a surgical wound

  • Status 0: No
  • Status 1: Yes, patient has at least one (observable) surgical wound
  • Status 2: Surgical wound known, but not observable due to non-removable dressing

M1342: Healing Status of Most Problematic (Observable) Surgical Wound

  • Status 0: Newly epithelialized
  • Status 1: Fully granulating
  • Status 2: Early/partial granulation
  • Status 3: Not healing

Though this guidance is applied to both surgical wounds closed by primary intention (approximated incisions or edges brought together without any areas of separation) and secondary intention (open surgical wounds or wounds in which the edges are open requiring granulation tissue to form and fill the open space), healing status responses that apply to these two types of wounds are different. If clinicians must choose either ‘Newly epithelialized’ or ‘Not healing’ for wounds healing by primary intention, they can choose any of the four responses for wounds healing by secondary intention. If the surgical wounds are completely epithelialized for more than 30 days, then they are not considered in the OASIS data items.

M1020/1022/1024: Diagnosis, Symptom Control, and Payment Diagnosis

It is required to list out each diagnosis for which the patient is receiving care at home care facilities and assign the ICD-9-CM code at the level of highest specificity. This should be listed in an order that clearly reflects the severity of each condition and supports the disciplines and services provided.

M1034 – Overall Status

The overall status of the patient is reported with the following status codes so as to signify whether the wounds increase risks and complications.

  • Status 0: The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient’s age).
  • Status 1: The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of patient’s age).
  • Status 2: The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.
  • Status 3: The patient has serious progressive conditions that could lead to death within a year.

M1240/M1242: Pain

Though M1240 asks whether the patient is experiencing severe pain, home health agencies should consider all levels of pain including no pain, slight, mild, moderate, severe and worst pain for this section. M1242 refers to frequency of pain interfering with activity.

Importance of Completing the OASIS Form

It is estimated that 9 out of 10 home healthcare agencies are unaware of the fact that their registered nurses are not completing the OASIS patient assessment form in an appropriate manner and it is largely affecting their overall reimbursement. The major reason for this dilemma is that most registered nurses are not familiar with current wound care classifications and staging guidelines, and lack of in-depth wound care knowledge. Home health agencies should either provide appropriate training to their staffs or consider obtaining value-added support from professional, experienced medical billing companies.