Section M Dr. Jeff Levine And today we’re going to talk to you about Section M Skin Conditions. I just want to give you something a little bit about my own background. I’m an internist geriatrician and wound care specialist, and I first became interested in pressure sores during my geriatric fellowship in 1985. And at that time I decided to do a fellowship in geriatrics in New York City at one of the best and, at that time, one of the only places there was to do a geriatric training. And at that time, I was rotating through a nursing home which was supposed to be one of the best nursing homes in the country. And I noticed — and this was 1985 — I noticed, I looked around, and some of my patients had bedsores. There was no standardized nomenclature. We called them bedsores or decubitus ulcers at the time; we still do. I said, “Wow, this is interesting.” I never saw, you know, these things. And so I looked in the textbooks, and this was 1985. There was nothing in the texts, in the geriatric textbooks, at the time. So I did a little review in the medical literature, and there was very little in the medical — the medical literature. There’s some stuff in the nursing literature. So I went to one of my chiefs who was one of the founders of the field of geriatrics, and I said tell me. I said, “Tell me about pressure sores.” So he said, “Okay, Jeff, I’ll tell you all about pressure sores.” He said, “Come up to my office at 3:00.” So I was there at 3:00, and he wasn’t. [Laughter] And I was still there at 3:30, and he didn’t show up. And 4:00, I was sitting there, and he still didn’t show up. So I went back to the ward, and I decided to ask the nurses about pressure sores. And again this is 1985. And I spoke to one of the nurses who’s been around a really long time. And, you know, some nurses, you know, they’ve just been around the block. I said tell me, tell me about bedsores. And she says, “Well, the best way to treat these things that I know is you take some chicken liver — that’s fresh — and you mash it up, and you put a little cottage cheese in there and then you mash that up, and then you fill the wound with it and you cover it up and you change that twice a day.” So I said, “Wow.” So from that time in 1985, I decided to spend a great deal of my time and efforts learning about pressure sores, photographing them, and teaching about them and doing research about them. And I was thrilled when the opportunity to teach Section M, the upgraded version of Section M, MDS 3.0 Skin Conditions came up. So, today we’re going to talk about pressure sores, Section M. And just some housekeeping. We have two hours to do this. I need to point out that MDS 3.0 Section M is at least twice the size, if not more, than Section M 2.0. In 2.0, there were six sections, and I think it was less than half a page. In 3.0, it’s three pages long, and there’s 11 sections. So it’s big, and it’s long, and it’s complicated. And wound care itself is very complicated. And then to add on MDS 3.0 is going to be even more complicated. Now, I just want to see hands, how many doctors do we have here in this audience? Any? Do we have one doctor? That’s hard to believe there’s not one doctor in the room. [Audience: You.] Where? Me? No. Who? Oh, one doctor. Okay, great. Thank you, thank you for coming. Everybody give a hand. We have one doctor here. [Applause] All right. We’re going to talk about physicians later. [Laughter] All right. So, it’s going to be two hours, and unfortunately, part of the show is going to be some photographs that need be a little distasteful to look at. And I just want to just give you a head’s up in advance. So also who here — which one of the attendees is mainly wound care in their institutions? Do we have wound care nurses? We have one, two — I want to see high, please, high hands. So we only have a small handful of wound care nurses and wound care clinicians. Hi, how are you doing? Well, I just want to congratulate all of you wound care people because when you go back to your facilities as of October 1st, your job is going to be a lot more important, and it’s going to be a lot more complicated. And I hope that you’re able to work out with your administration how your time is going to be spent because I have to tell you that the time that we’re going to be spending on MDS 3.0 Section M is going to be significantly more than it used to be. As well as the education — who here does education? We have a lot of educators. I’m sure we have a lot of educators here. Okay. All right. Well get ready, we’re going to start getting into it. In general, okay, we’re going to review key components of pressure ulcer risk assessment, okay, which is new — the way they’ve structured pressure ulcer risk assessment. We’re going to discuss the upgraded and newly adapted pressure ulcer staging schema. We’re going to describe how to measure pressure ulcers. And we’re going to discuss the importance of interdisciplinary collaboration for wound differentiation. Interdisciplinary collaboration is really important, and I’m sorry there’s only one doctor here. Let me ask another — see another hands thing. How many people have worked with doctors that have never examined their patient’s wounds? Wow. Wow. Well, I want you to repeat after me — get with the program. [Audience: Get with the program.] Get with the program. Please everybody. Get with the program. [Audience: Get with the program.] And that’s exactly what I want you to tell your doctors when you go back. And you can say Dr. Levine told me to say that. I don’t care. Tell them — give them my name. And the reason is that you need your doctors to collaborate with you. You need your doctors to learn from you. And you need your doctors to go to their own trainings to get on the same page as you. The days of physicians not examining wounds and managing wounds by telephone orders is over. Okay, and if they continue to do that, they’re getting in your way; they’re getting in our way. It’s not quality care. It’s not endorsed by CMS because it’s not quality care. And it’s a risk management issue. So we all make ourselves liable by working with people who don’t take proper care of wounds. So, please, inform your physicians when they get back to get with the program, not just in examining the wounds but helping you to diagnose your wounds. And one of the things we’re going to be talking about later is differential diagnosis of other types of wounds. And we’re going to learn how to code CMS Section M accurately and correctly. Okay. Major changes to Section M, including rearrangement of the risk assessment section. There are major changes in staging. Reverse staging is over. The days of reverse staging are over. Once it achieves a higher stage, it is never down-staged or back-staged. And the reason for that, does everybody understand reverse staging? Should I just explain it a little bit? Did I hear a yes from anybody? [Audience: Yes.] Okay. The original ulcer staging system was from 1 to 4, and that was adapted back in the 1980s. And so if a wound is Stage 2, it’s a superficial skin break. Stage 3 is a full thickness skin break. Stage 4 goes down to muscle and bone. And clinicians were grasping at a way to describe wounds when they got better. So they said, “Okay, if it’s a Stage 4, now it’s getting better, there’s some skin creeping across it, let’s call it a Stage 3, and then a Stage 2, and then it’s healed. So that’s, that is reverse staging. Experts in the field said, “You know, that’s really inaccurate because a Stage 4 never really gets back to Stage 2 because the anatomical tissue is never really replaced. So once it’s a Stage 4, it’s always a Stage 4. And it’s been a very heated discussion amongst experts and policymakers as to how to handle this. Especially in recent years as more and more attention has been paid to pressure sores, and we need uniformity in describing it. So NPUAP, the National Pressure Advisory – the National Pressure Ulcer Advisory Panel, has been recommending for years that we get rid of reverse staging. Now, those of you who have worked with MDS 2.0 since it came out in, I think in the 1990s, in MDS 2.0 Section M, they recommended reverse staging. So in other words, if it looks like it’s a 2, it’s a 2, even though it used to be a 4. Well, MDS 3.0, there’s no more reverse staging. Once it’s a 4, it’s a 4. If a 4 gets better, it’s a healing Stage 4. If a 3 gets better, it’s a healing Stage 3. MDS 3.0 Section M has sections for deepest pressure ulcer or largest pressure ulcer. It has separate sections for worsening pressure ulcers. And it has separate sections for unstageable suspected deep tissue injury. And actually divides unstageable into three parts. We’re going to go through all this step-by-step. All right. Other changes to Section M include notations for whether or not the pressure ulcer was present on admission. So if the patient came in from the community now, it’s documented in our record that this pressure ulcer was present on admission. But there’s a twist. And the twist is if that ulcer worsens in your nursing home or in your facility, guess what, it’s no longer present on admission. So in other words — and we’re going to talk about this more in detail — if a patient comes in with a Stage 2 on admission, it’s present on admission, and a month later it’s a Stage 4, it’s no longer present on admission, and it’s coded differently. So we date Stage 2 ulcers. And Stage 2 is the only ulcer that we date presumably — I was asking why they decided this. And I think the reason is that Stage 2 is expected to heal in a very short period of time. So we like to — so for the purposes of MDS Section M, revised Section M, dates the oldest Stage 2 pressure sore. We ask you to put the dimensions — length, width and depth — in MDS Section M but only for the largest sore. And what that means is that – and it doesn’t mean that oh you only have to measure the largest one and the rest you can ignore. That’s not what I said, and please don’t interpret it that way. You have to measure all ulcers, but the largest ulcer and only if it’s Stage 3, 4 or unstageable secondary to eschar gets entered. And the dimensions are in centimeters. No more nickels, dimes, quarters, half dollars, oranges, if you’re in Florida, there’s an orange-sized pressure sore. It’s in centimeters to the nearest one-tenth. And then there’s an entry level for, an entry point for type of tissue. So what we’re seeing here is an upgrading of clinical skills, and your clinician who is deciding these things is going to have to be both good at this, facile at staging things and determining tissue type and comfortable with it. And it’s raising the bar for clinical skills. The other thing that MDS 3.0 Section M does is it raises the bar for your system requirements, and this slide emphasizes the clinical/ administrative interface. What I mean by that is that when you go back to your facilities to equip your facilities for Section M, you’re really going to have to go over every aspect of your wound care program. If you already have a very sophisticated wound care program that has really great bookkeeping and flow sheets, your job is going to be a lot easier than a facility that has haphazard policies regarding coding, staging, and measuring your wounds. And everybody, whether, no matter what your quality, the quality of your system right now, I’m recommending that you go back and review all of your policies, procedures and guidelines to make sure that they’re current. You need to look at your systems, at your clinical/ administrative intersection, and figure out and clearly demarcate who does the data collection, how does it flow, where is it kept. I worked in a facility where it was always an issue. Where do we find the wound care sheets if they weren’t in a chart. It was a special book. The book was often missing. Other facilities may have a stack in the nursing station, a stack in the basement, who knows, but you’re going to have to figure out where this documentation is kept and who keeps it, how it’s done, and who is responsible. You’re going to have to review — I’m recommending that you review your policies and guidelines, your processes, and your techniques for pressure ulcer risk and your process for developing and implementing your care plan for patients who are at risk. I’m also recommending that you identify your resource library. What are you using? Are you using NPUAP? Are you using AMDA (AMDA clinical practice guidelines)? So I’m recommending that you develop your own clinical resource library. The skills that you’re going to need are risk assessment, staging, ulcer measurement, and wound identification. And I’m recommending, once again, please involve your physician. Please get your medical director involved. The Ftag for medical director clearly mandates that the medical director coordinate the quality of care throughout your facility and pressure ulcers are a known quality indicator. Your medical director should be on top of everything and involved with everything that goes on with your wound care and your wound care system. Okay. CMS has adapted and based their staging system on NPUAP 2007, and I’m recommending that you go to the NPUAP website for their definitions. And just so we can be on the same page, let’s define what a pressure ulcer is. 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. And that is a pressure ulcer. Now, we have in bold here and underlined that CMS has adapted the NPUAP guidelines. In other words, they’re not identical to the NPUAP guidelines. So I’m recommending that if in doubt, please look at the CMS resident assessment– RAI Manual, Resident Assessment Instrument Manual and go by that when there’s a doubt, not the NPUAP. One of the biggest differences — anybody know what the biggest difference is between CMS guidelines and NPUAP? What is that? [Audience: Blister.] Blisters we’re going to talk about, but the other thing is Roman numerals. Okay? NPUAP has Roman numerals, and CMS, all of CMS guidelines use Arabic numerals. And that’s what I’m recommending that you use in your documentation is Arabic numerals because that’s what CMS has recommended. All right. We’re going to start with pressure ulcer risk. And one of the things that I’m going to recommend for those of you who are going to be intimately involved with MDS Section 3, Section M is MDS 3.0 Section M, is to memorize these numbers, please. And I’ve got a cheat sheet here. It’s very confusing. There’s a lot of numbers. And it’s going to make your job a lot easier if you can just know which number to go to. So Section M0100 and M0150 both have to do with pressure ulcer risk. Pressure ulcer risk factors include immobility and decreased functional status. Co-morbid conditions, such as renal disease, thyroid disease, diabetes, congestive heart failure and here again is where your doctor is going to help you out. Medications such as steroids thin the skin and make the skin more susceptible to damage. Impaired or impaired diffuse or localized blood flow. If somebody has severe congestive heart failure and their ejection fraction is like 20 or 30%, normal ejection fraction is 60%, that heart is not pumping tissue – is not pumping blood normally. Okay? And skin to live needs blood and nutrients. So severe congestive heart failure could be a pressure ulcer risk. Anemia with a severe — severely low hemoglobin hematocrit is another pressure ulcer risk. Severe lung disease with hypoxia — another severe pressure ulcer risk. So all that impairs on tissue perfusion or impaired blood flow. The other thing I like about MDS 3.0 Section M is that they recognize that refusals of care are a risk factor for pressure sores. And it’s explicitly written out. Does that mean that if a patient refuses care that you can just say, okay, document refused care and walk away? No. Because what you need to do is you need to care plan it. Make sure the patient is — and their caregivers — are educated. Maybe get a psych consult if you question their competency. But pay attention to it, and just don’t let it go. Other pressure ulcer risk factors include cognitive impairment, exposure of skin to urinary and fecal incontinence. We know fecal incontinence is worse than urinary incontinence. And it’s becoming a huge problem with our patients that come from hospitals with CDIF, which is all over the place, and these patients have terrible, very, very damaging fecal incontinence. Undernutrition, malnutrition, hydration long recognized as pressure ulcer risk factors. And healed risk factors — if you have a healed pressure sore, you’re automatically at risk according to MDS 3.0 Section M0100A. So why is that? Because if you have a pressure ulcer that healed, I discussed it earlier in my back-staging discussion, the tissue that heals — tissue that heals over a pressure sore is not normal. And it’s always going to be weaker than normal tissue. So we’ve got a couple of slides. This slide shows a healed pressure sore. Is this evidence of a risk factor? The answer is yes. And this shows before and after the wound that’s opened is to your – to my right. And then healed to produce this scarred hyperemic wound to the left. And this is a healed pressure sore. Anytime you have a healed pressure sore, you’re automatically at risk. So what I like about M0100, it’s actually one of my favorite, if there is one, favorite sections, because it promotes a more sophisticated view of pressure ulcer risk. And I think that many of us in healthcare have gotten into the habit of using the risk assessment scales, whether it’s the Braden scale or the Norton scale, and just using that only. But these scales can be misused, and they can be underused. I worked in a hospital which every Wednesday was Braden day. So what if a patient came in on a Thursday? You know, they don’t get their Braden until the following week. It didn’t make sense. The other thing about risk factor sliding — risk factor scales is they don’t include a lot of the medical things that I mentioned. For example, I talked about congestive heart failure, anemia, hypotension — if somebody’s blood pressure systolic is 90 or 100, that’s certainly a situation that leads to hypo-perfusion. So what M0100 does is it broadens the scope of who is at risk. And let’s take a look at some of these. We have M0100A is if the resident has a Stage 1 or greater or a scar over bony prominence or a non-removable dressing or device. They’re at risk. M0100B is your formal assessment tool, such as your Braden or your Norton. And M0100C is your clinical assessment. And if it’s not A, B, or C, it’s Z. So your risk factors are summarized in this slide with your non-removable device, your existing pressure sore, your closed pressure sore, and your non-removable dressing. All these are considered to be things that place you at risk. Now, one of the things I remember someone once showed me a risk assessment scale that showed that the patient wasn’t at risk. But the patient had two pressure sores. I said, “Please, don’t even show me that. I don’t even want to see it.” If the patient has a pressure sore, they’re at risk; I don’t care what the risk assessment scale shows. And this section will adjust for that. Your formal assessment tools include your Braden scale and your Norton scale. How many people still use the Norton scale? That’s the grandma of risk assessment scales. If you want to use another scale, make sure it’s validated. CMS does not require one of these. As long as you have a validated scale that’s got some data behind it, it will be accepted. By the way, devices account for 10% of all pressure sores. Does anybody know what the most common device-related site is? Sorry? Ears. Yeah, that’s right. Ears are the number one device-related site. Usually from oxygen tubing, because we put in the hospital frequently in nursing homes, too, they put the tubing behind your ear, and nobody checks. And patient comes to your facility, and they can have awful pressure sores behind their ear. So clinical assessment. You want to determine the etiology of all wounds and lesions. I’m going to suggest a mnemonic which Elizabeth Ayello is responsible for in a minute. And think about your clinical assessment for who is at risk. For example, has anybody here ever worked with bariatric patients? Okay. I’m sure by now a lot of people, if not most of us, have worked with bariatric patients. I mean, somebody who is 400 pounds and can’t turn, I don’t care what their risk assessment scale shows, this patient is at risk for Section M0100C. Okay. Somebody who is severely anemic with severe congestive heart failure is Section M0100C. Someone who is actively dying, there’s a movement to put people who are actively dying on a list of people who are severely at risk for pressure sores. And these people might be stage — might be determined as M0100C, clinical assessment. I’m going to go over this mnemonic. It belongs to Elizabeth Ayello she wrote this. And it’s called HALT. The reason she named it this is we want to halt pressure ulcers and their progression. H stands for History of pressure ulcer or history of pressure sores or patient events, goes through immobility, decreased functional status and nutrition. A is Associated Diagnoses, co-morbidities, including advancing age, medications, some of the other things that we mentioned, hypotension. L and T stand for Look at the skin and Touch the skin. It’s something that we need to always remember to do with a gloved hand. We want to put your hand on areas that look suspicious, and you want to always give the patient a head-to-toe assessment whenever there is a new pressure sore or a worsening of a pressure sore and that includes looking and touching. And when you feel the area over the bony prominence, you want to feel, see if the patient is tender, has pain. Is it warm? Is it cool? Is it boggy? Is it mushy? All these things you need to check when examining for skin integrity. There’s L and T. All right. M0150, you take the information that you gathered in M0100, and it’s basically a yes or no. Yes is 1. No is 0. And the question is: Is this resident at risk for developing pressure sores? And this is gleaned from the information that you’ve gotten in M0100. Section M0210 is unhealed pressure sores. Again, it’s a quick yes or no entry. Does this resident have one or more pressure ulcers that are Stage 1 or higher? This is an easy question. In your patient to the right, does this patient have a pressure sore? [Audience: Yes.] Okay, very good. How about the patient to the left? Yes. Very good. Both these patients have pressure sores. So we put in yes. We code 1 as Yes, and then we continue to M0300. If it’s no, we skip to M0900, and we’ll be coming to later. Now we’re going to start getting into breaking down your ulcers by stage. And breaking down each staged ulcer into whether it’s present on admission or not present on admission. And I just want to go over some basics of skin assessment. Okay. M0300 is where we are. Okay. Skin assessment is always part of your health status. Skin assessment includes differentiating pressure sores from other wounds, and don’t forget if a wound is not from pressure, if a wound is not primarily from pressure, it does not get coded in Section M. There’s areas for other wounds, but what they want for your coding is only wounds that are associated with pressure. Okay. And Elizabeth makes the point of saying that diagnosis of stage and determination of stage is within the nursing scope of practice. There was some discussion about this a couple of years ago, when the rules were changed for hospitals, but I think it’s pretty certain that determination of pressure ulcer staging is within the nursing scope of practice. If in doubt, please contact your or look up your local practice laws. We’re going to go over staging definitions. And once again reiterate that CMS has adapted the NPUAP guidelines, and when in doubt please go to your Resident Assessment Manual for the CMS guidelines. You want to determine the deepest anatomical stage of each pressure sore. To stage a wound, you need to see the base of the wound or at least part of it. And you want to identify unstageable pressure sores. And we’re going to talk about that because unstageable pressure sores are divided into three separate sections. And determine whether or not they’re present on admission. Once again, reverse staging is prohibited. You want to consider your current and historical levels of tissue involvement. You do not want to code lesions that are not primarily related to pressure. And this is a long bullet. And I’m going to try to translate it for you. But basically what it says is after you have an unstageable wound, the stage that you use is the first stage that you see after that wound is debrided. Okay, M0300A is Stage 1. You want to document your number of Stage 1 pressure sores. So under every stage, there’s number of pressure sores of that stage and whether or not they’re present on admission. And Stage 1 pressure sores can deteriorate without adequate intervention, and they’re an important risk factor for further tissue damage. Whenever there’s a Stage 1 or any other ulcer, you want to perform the head-to-toe full-body assessment, focusing on bony prominences such as sacrum, heels, ankles, etc. Conduct the assessment: check any reddened areas for ability to blanch. So in other words, the strict definition of a Stage 1 is non-blanchable. So you have to put your finger there, press it, and then pick your finger up, and if it stays red, it’s definitely a Stage 1. And you want to search for other areas of skin that differ from their surrounding tissue. And this gets into the area of skin color because it’s known that if you have dark skin, Stage 1 and suspected deep tissue injury, there are certain stages that are harder to determine the diagnosis of in dark-skinned people. So we have to get beyond color. Put your glove on. Feel the area that’s at risk. Look closely, take a flashlight, look for discoloration. Feel for bogginess, warmth, or tenderness. Your assessment is recommended to be holistic. And what I interpret this word to be you have to examine the whole patient and consider the whole individual. Elizabeth likes to say look at the whole patient, not the hole in the patient. [Laughter] And that’s from Elizabeth Ayello. All right. So Stage 1 again can be difficult to determine in people with dark skin. Please look carefully at your Stage 1’s. Make sure it’s not a deep tissue injury. Deep tissue injury, the area under the skin is more maroonish or purplish, looks more like a bruise, still with the skin intact. And code your pressure ulcers. If it is a deep tissue injury, that goes to M0300G. And we’re going to come to that. Okay, Stage 1. Stage 1 has intact skin with non-blanchable redness of a localized area usually over a bony prominence. Again, watch out and be a little bit more alert with darkly pigmented skin and the color may differ from the surrounding area. So these two slides in front of you, the one to your left is simple redness over the bony prominence. Looks like certainly a Stage 1. And to the right is a Stage 1 in someone with dark skin. And you can’t really see the redness. If you look really carefully, someone drew a little line, if you have that in front of you. There’s a little line around the area that feels boggy and warm. Okay, so take a look at this. What are we looking at here? We’re looking at someone’s buttocks and is this a pressure sore? [Audience: No.] What is it? It’s incontinence dermatitis, which is now relabeled moisture-associated skin damage. Do not code this as a pressure ulcer, please. One thing I’m always concerned about is when you look at wounds like this, always look at the periphery. And if you see little satellites — it’s not really shown that well on this one, but we’re going to see other ones with these little satellites, these little red spots that pop off the edge. Always think about yeast. In my view, yeast is something that’s terribly underdiagnosed. And if you suspect yeast infection in a patient like this, your off-the-shelf anti-fungals, they’re not going to touch this thing because the patient is so impaired. So if you suspect yeast, please get a doctor’s order for something that’s going to hit it and knock it out. So, what we’re looking at is not a pressure sore. It’s moisture-associated skin damage from incontinence, and please don’t document this in M0300A. Now, the thing about skin is, wound care is, wounds can evolve in different types, and if you don’t care for this wound, what are you going to get? You’re going to get a skin break, and then next thing you know, it’s going to be a Stage 2. So please make sure you catch this redness early. We’re moving ahead to M0300B, Stage 2 pressure sores. Stage 2 pressure sores are partial thickness skin loss that presents as a shallow open ulcer that’s red or pink wound bed. And this is very important criteria: it is without slough. So you are permitted to clean the wound before you examine it. It may have some residual drainage. It may have some residual hydrocolloid. If you put the hydrocolloid, it turns into a yellow mush. It can be mistaken for slough. So please clean the wound off and take a look at it. If you see slough, it’s probably not a Stage 2 and shouldn’t be coded here. Stage 2 pressure sores can also present as an intact or open blister. Now, blisters can be really confusing. There’s no topic that I’ve seen at the bedside that causes more discussion or more argument or more yelling and screaming than blisters. And CMS has tried to deal with this and give you guidelines how to deal with it. But blisters are very commonly seen on the heels. And it has to do with the unique architecture and environment and anatomy of the heel. The heel is a big bone, the calcaneus. It’s the biggest bone in the foot. And the skin is very thick because it’s skin on the foot. And the blood supply comes in from all different angles and not from underneath because of the bone. But when you have pressure damage, it pops up as a blister. If you have a clear blister that doesn’t have signs of duskiness and you want to look at the periphery of the wound — and you want to examine the whole foot — if you do not see evidence of any deep tissue injury and it’s just a blister, it’s coded in M0300B. Do not code a Stage 2 if you see what looks like deep tissue injury, which is when the blister is dusky or when the blister is filled with blood or you have other areas around the periphery of the wound that can clue you into the fact that there might be deep tissue injury, then it would go to M0300G. Excuse me. Yeah, M0300G. Okay. Clearly document your assessment findings in the resident’s medical record. Now, this is something that I just need to emphasize that MDS Section M; this is a minimum data set. And just checking the box for a stage doesn’t really give you enough documentation about the wound. So I always encourage, if you have a question or if the wound is a complex wound, has different types of areas in it, please write a narrative note somewhere else in your wound documentation and justify why you made this determination. I see this. I see that. And give me a reasoning. So I’ll see on one end, I’ll pick up the MDS, I’ll see your check box. And then I can turn to your clinical documentation, and I can see what you were thinking in evaluating that wound. And facilities can adapt the NPUAP guidelines in their clinical practice. NPUAP has some books for sale on their website that go over their recommended practice guidelines. Anytime you have a new ulcer, again, perform a head-to-toe full-body assessment, focusing on bony prominences and pressure areas. Examine the area adjacent to the wound. It’s a very important principle of wound care that you don’t just look at the wound, and you don’t just look at that awful stuff inside the wound. You want to look at the environment of the wound — the whole leg, the whole buttocks — particularly – it’s particularly important in the leg when we get to different types of wounds. But it’s not just the wound itself; it’s the environment of the wound and what’s around it that’s also important. You want to make sure that this lesion is primarily related to pressure. If it doesn’t — if it’s not, it doesn’t belong in section M0300. You want to rule out other conditions. And again, don’t code it if pressure is not the primary cause. Assessment should be holistic. In other words, you want to look at the whole patient. Determine if tissue adjacent to or surrounding the blister demonstrates signs of tissue damage. I’m going to go over these things again: color change, tenderness, bogginess, and warmth or coolness. And the only way you can do this is if you look and feel. Okay. Stage 2 will generally lack the surrounding characteristics found with deep tissue injury. We’re kind of being repetitive here, but we want to make sure that you don’t confuse and make sure that you differentiate Stage 2 with deep tissue injury. Blood-filled blisters related primarily to pressure are more – sorry, blood-filled pressures related primarily pressure are more likely than serous-filled blisters to be associated with a deep tissue injury. In other words, if the material is dark or dusky or blood-filled, it’s more likely to be coded — it’s more likely to have deep tissue injury and coded in M0300G. This is not a place to code skin tears, tape burns, perineal dermatitis, maceration, or any of the other types of skin breaks. This M0300B is only for Stage 2 pressure sores. You want to note the number of Stage 2s, and you want to know the number of Stage 2s present on admission. And that affects the number of ulcers that were first noted at the time of admission and the number of pressure ulcers that were acquired during a hospital stay or if the patient was just readmitted. And then you want to note the oldest Stage 2. And this is the only stage that you need to know how old it is, for this Stage 2. And, again, deep tissue injury is not coded here, but it’s coded in M0300G. When you’re getting into issues of age and size, if your facility has really good pressure ulcer tracking that stages and sizes your ulcers on a regular, hopefully at least minimally, a weekly basis, you’re going to have a much easier time with adapting to MDS 3.0 Section M. Okay, here’s a blister. So, according to our assessment — our skin assessment – requirements, what steps do you need to take to assess this? The answer is that I would examine the patient from head to toe, looking at bony prominences all over the place. If it’s a new pressure ulcer, this patient needs to be seen by a doctor and the pressure ulcer looked at. Why does this patient have a new pressure sore? And this would be coded under M0300B. If it happened in your facility, it’s M0300B, not present on admission. Here’s your blood-filled blister. Same steps for assessment. You want to look closely at the blister. Look closely at surrounding tissue. Give the patient a full head-to-toe assessment. Have a doctor come take a look. And code this — this is deep tissue injury, and this should be coded in M0300G. Okay, remember that not all blisters are from pressure. There’s a really common disease in old people, blistering disease. Bullous pemphiguoid if anybody’s heard of that. There’s other types of diseases that give rise to blisters. And this slide shows blister from burns. This unfortunate person put their hand down on a very hot surface and ended up with these blisters on their hand. And we have a book for anybody who can tell me right now the first person who says where this is to be coded in MDS 3.0 Section M? Under what number and letter? M01040 what? Who said F? This lady gets a book. Okay. M01040 F is where burns get coded. We’re going to come to that. Now, we’re going to go into M0300C and M0300D. M0300C is Stage 3, and M0300D is Stage 4. Remember again, we’re using Arabic numerals. NPAUP uses Roman numerals, and we’re using the Arabic. Okay. Once again, any new pressure ulcer or worsening pressure ulcer. Please perform your head-to-toe full body assessment, focusing on bony prominences and pressure bearing areas. Determine if the lesion is being assessed, if the lesion being assessed is primarily related to pressure. And if it’s not related to pressure as a primary cause, it shouldn’t be here under section M0300. Okay. Section 3, I’m sorry, Stage 3 pressure sore. Full thickness tissue loss is a Stage 3. You can see subcutaneous fat, but bone, tendon, or muscle is not exposed. You can have slough in Stage 3. But if it completely obscures the wound base, you can’t see the wound base, it’s no longer a Stage 3. It’s unstageable, which we’re going to come to very shortly. And it may include undermining and tunneling. But if there’s undermining and tunneling, I sometimes suspect Stage 4s. And you want to support, if in doubt, you want to support your clinical judgment in your narrative note elsewhere in the chart. M0300C Stage 3 coding instructions. You want to code the number of Stage 3s and identify all Stage 3 pressure ulcers that are currently present. You want to code the number of Stage 3s that were present on admission or readmission or reentry. And we’re going to come to some scenarios where we are going to go over some basics of coding. Stage 4 is full thickness skin loss, and to have a Stage 4, you need to see the wound base and that wound base needs to — you need to see deeper tissue such as bone, tendon, or muscle. You can have slough or eschar in some parts but as long as it doesn’t obliterate the wound bed, you can still call this a Stage 4. And it often includes undermining and tunneling. If you have severe tunneling, I have like a little rule — I call it Dr. Levine’s rule — if you have severe tunneling, or undermining rather, where the wound margins form a shelf and you have undermining all the way around, guaranteed that patient has severe malnutrition and probably has a serum albumin that’s less than 2.2. And the depth varies by anatomic location. For example, you can have a Stage 4 of the ear that goes down to cartilage that’s got a depth of maybe 0.2 centimeters. But if you have a Stage 4 on a buttock of somebody that you could have a much greater depth. So depth varies by anatomic location. In M0300D, your coding instructions, you put in the number of Stage 4s and the number of Stage 4s present on admission or reentry. And that corresponds to M0300D-1 and M0300D-2. So we’re going to go over a couple of scenarios that are going to help you to understand how these things are coded. In slide 53, we have scenario one, a pressure ulcer is described as a Stage 2 and noted and documented in the medical record at the time of admission. On a later assessment, the wound is noted to be full thickness. So it’s now a Stage 3. M0300C-1 number of Stage 3 pressure ulcers is then you put in a 1 because there’s one Stage 3. And M0300C-2 is not present on admission, is 0 [zero]. It’s not present on admission because it developed into a Stage 3 in your facility, so it’s not present on admission. The designation of present on admission requires that the pressure ulcer be at the same location and not have worsened to a deeper anatomic stage. Okay, here’s your second scenario. On admission, the resident has three small Stage 2 pressure ulcers on the coccyx. Two weeks later, the coccyx is assessed, and two of the Stage 2 pressure sores have merged. So it used to be two Stage 2s and now there’s now it’s one bigger Stage 2, and the third one has worsened to a Stage 3. So the two merged pressure ulcers are now one Stage 2. And so M0300B1, there’s one Stage 2, and M0300B2, there’s one ulcer. This same ulcer is present on admission. So two of the pressure ulcers have merged, and they both remained at the same stage that they were at the time of admission. And for the Stage 3, the number of Stage 3 pressure ulcers is one, but it was not present on admission, because it got worse from a Stage 2 to a Stage 3. Therefore, it is not coded as present on admission. Okay, we have another scenario. This is our third scenario. A resident develops a Stage 2 pressure ulcer while in the nursing facility. The resident is then hospitalized due to pneumonia for eight days and comes back with that ulcer worsening to a Stage 3. So under M0300C1, under M0300C1, the number of Stage 3 ulcers is one and that also is present on admission. So even though the resident had a pressure ulcer, the same anatomic location prior to the transfer, because it worsened to a Stage 3 during hospitalization, it should be coded as a Stage 3 or present on admission. We’re now going to move on to unstageable pressure ulcers. Unstageable pressure ulcers are divided into three types. If you’re not confused enough, unstageable pressure ulcers are now divided into three types, which, actually, if you think about it, it makes a lot of sense because unstageable could be because it’s under a device, and you can’t see it. You know it’s there, but you can’t see it. That’s M0300E, M0300E is unstageable under a nonremovable dressing or device. M0300F is unstageable because it has slough and eschar covering the base, and M0300G is deep tissue injury. And we’re going to see examples of each one of these. M0300E is unstageable because it’s underneath a nonremovable device. And this one in this example is under a cast. We know it’s there, but we don’t know what stage it is. So it’s coded as M0300C — M0300E unstageable because it’s under a nonremovable device. These two photos represent negative pressure therapy. If we don’t know the stage underneath, we know it’s there, but we don’t know the stage, it’s a M0300E unstageable due to nonremovable dressing. M0300F is unstageable due to slough or eschar. It’s probable full thickness tissue loss, and the base of the ulcer is completely covered by slough that’s either gray, yellow, brown, green, tan in the wound bed. You don’t know how deep it goes, so this ulcer is unstageable due to slough or eschar, M0300F. And incidentally, it’s the only one of the three that we measure. And we’re going to get to measurements in a couple of minutes. M0300G is unstageable due to suspected deep tissue injury. It’s known but — it’s localized area of discolored area of intact skin. So in other words to have deep tissue injury, you need to have intact skin and you need to see a purplish discoloration underneath. And this discoloration, when you touch it, can be firm, mushy, boggy, warm, or cooler and can be difficult to determine in patients with dark skin tones, as we have discussed. With regard to suspected deep tissue injury and pressure ulcers in general, quality healthcare begins with prevention and risk assessment, and care planning begins with prevention. So we want to care plan your prevention and care plan all your treatments. Appropriate care planning is essential in optimizing the resident’s ability to avoid and recover from wounds. For deep tissue injury, we want to clearly document your assessment findings in the medical record. Please add it to your narrative. If you’re confused or if you just want to just give more details, please liberally add your descriptions to the medical record. You want to track and document your care planning and management. And remember that if you have deep tissue injury, you don’t know where it’s going to go. That’s the mystery of deep tissue injury. When you see it, it can just disappear in a couple of days, but it also could emerge into an angry eschar or even a hole that can just open up into a crater. So you want to keep an eye on it. And that’s why it’s called deep tissue injury, unstageable. And identifying this is very important. So now we’re going to do some scenarios with coding instructions. Okay. You want to code your number of each pressure ulcer. You want to code the number of each ulcer that’s present on admission, and make sure that M0300G, if you’re talking about blisters, there’s evidence of deep tissue injury. And any unhealed pressure sores that are — I’m sorry, any blisters that don’t show evidence of deep tissue injury get coded under M0300B. Scenario one, a pressure ulcer on the sacrum was present on admission and 100% covered with black eschar. On the admission assessment, it was coded as unstageable and present on admission. The pressure ulcer was later debrided using conservative methods, and after four weeks, you had some base showing but still covered with some eschar. So you can see the damage that extends down to the bone. So this was unstageable and unstageable present on admission. So, you want to reclassify this as a Stage 4, and on subsequent MDS, it’s coded as M0300D1, the number of Stage 4 pressure sores is 1. And M0300D2, it is present on admission because you had an unstageable on admission and then it was debrided. You found out it was a Stage 4 so this is still the same stage. It’s not considered to be deteriorated, and it was there, present on admission. I’m just going to read here. After debridement, the pressure ulcer was no longer unstageable because you could see the base. So it’s Stage 4, and it goes under the dimensions of this now go under M0610 if it has the largest surface area of all Stage 3 or 4 ulcers. Scenario two. Patient was admitted with one small Stage 2, and despite treatment, it’s not improving. In fact, it appears worse, and the wound bed is now covered with slough. So if it’s covered with slough and you can’t see the base, it’s now, what, it’s unstageable, M0300G. M0300F, excuse me. M0300F is the number of unstageable pressure ulcers related to coverage of wound bed by slough and eschar. M0300F is 0 not present on admission because it became that way while in the nursing home. And the pressure is coded as unstageable because it’s covered with slough, and it’s not coded as present on admission because it can no longer be coded as Stage 2. So, we’re going to go over a staging quiz, and then we’re going to take a stretch. And I’m told you don’t have copies of these slides; is that right? So, when you look at a wound, what are you looking at? I can tell you we’re looking at someone’s buttocks. And the head is off to your left and the legs are off to your right. And it’s a crater. It doesn’t look that deep, but it’s certainly full thickness. And it’s got some slough in there, but we can still see the wound bed. So, by definition, this is going to be a what? Stage 3, right. If you think that there– this could be subject to a little bit of argument, if you think there’s too much slough and you can’t see the wound bed, you might want to think this is unstageable. But I think this is a Stage 3. Okay, second wound. We’re looking at an ulcer behind the right ear. This is a patient that had oxygen tubing at one time, and now you can see there’s a big hole in the patient’s skin behind the ear. And on examination, I could put my gloved finger there and feel some deep tissue, possibly even some bone in there. So by definition, what is this? This is going to be a Stage 4, very good, M0300D. All right, next is, okay, we’re looking at someone’s buttocks. This is a left buttock, and it’s covered with a hard, leathery eschar. Okay. And by definition, if you can’t see the base, this has to be unstageable. Right? Due to slough and eschar. Okay, this is a deep tissue injury — excuse me, this is a deep pressure sore. All right. You can see the buttocks go off to your right. The head goes off to your left, and we can see this definitely goes down to deeper tissue. If you look deep in here, there’s some slough, alittle bit of necrosis, but not enough to cover up the wound base. And we’re going to call this, without a doubt, this is a — Stage 4 pressure sore. Very good, okay. All right. We’ve got this patient from the hospital, St. Elsewhere’s hospital, down the block. This unfortunate patient was in the ICU, was intubated, had sepsis or some other problem that caused extended period of immobility in the intensive care unit. And there’s this angry-looking pressure sore on both buttocks. It’s covered with dark eschar, so we’re going to have to call this what? Unstageable. Very good. Now, this is where you look at the periphery, and you can see these satellites coming off. It makes me very worried that this is infected. It definitely looks like it’s got cellulitis and possibly fungus. So, I’d be a little worried that this patient needs to be I would say there’s a good chance this patient needs to be treated with antibiotics along with debridement. Elizabeth has the phrase “eschargo.” If it has eschar, it’s got to go. All right. Okay, this is another very deep ulcer. It’s clean; itdefinitely goes down to deeper tissue. I think we’re all in agreement. This is a Stage 4. Very good. All right. These are two heels, okay. The left heel is at the bottom, and the right heel is at the top. And each one of these heels has a different stage of wound. So let’s look at the one on top, which looks like it’s a blister with some blood in there with — it looks like a fluid level. And it’s got this dusky, dark periphery. If you trace your finger around the edge of this ulcer, you can see directly north, there’s some dark areas. At around 9:00 there’s another dark area in that rim. But we don’t know how deep it goes, and the skin on top is intact. So I’m going to call this a what? Deep tissue injury. Deep tissue injury. Okay. Skin is intact. It’s a blister. It looks like there’s something deep. I’m going to call this a deep tissue injury. Remember, the key to deep tissue injury — deep tissue injury is always a cause for confusion. Deep tissue injury, you have to have intact skin. So, you know, if the skin is intact and looks like there’s something underneath, it’s a deep tissue injury. Okay, whereas down below in the left heel, it looks like you’ve got a plug of necrotic tissue. So by definition, this has to be unstageable. Very good, okay. This patient had been laying down on the floor because they passed out and they were brought into the emergency room. We don’t know how long they were down. But when the patient got undressed, we did a complete skin check, and we found out that the patient has intact skin over the sacrum and buttocks with these purplish areas underneath. So this is we don’t know how deep it goes. We feel that it’s a little bit hard. Okay. A little bit warm. So we’re going to call this a what? DTI. And which section under M9300 does it go? M0300G. Very good, okay. Last one in the series. We’re looking at a pressure sore of the mid-back. And the head goes off to your right. The feet go off to your left. We’re at the lower end of the thoracic spine, and it was cleaned off. There’s maybe a tad bit of slough in the base but not really that much. I’m going to call this no slough. And it’s superficial. So I’m going to call this what stage is this? Stage 2. Very good. No slough. If there’s slough tomorrow, it’s no longer Stage 2, it is a Stage 3. Very good, okay. All right, that’s the end of our quiz, and we’re going to go on to section M0610. Okay, that’s actually a good question. I just had a great question. Okay, let me see if I can rephrase this question. Okay, this uh, I’m sorry, what state are you from? [Audience member: Florida] Florida. A Florida skilled nursing facility has an outside physician, presumably contracted to do wound care. A wound care physician who comes into your facility and says you have a stage whatever, do we let that go as being what he said. Is that right? [Audience: I’m talking about our skin risk assessment. (indiscernible)] It has to be a valid – first of all, it has to be a validated risk assessment. And anybody that comes in from the outside, okay, like your contract physician, has to be on board with the staging because if they’re staging something different than what it should be, they’re doing it wrong. Okay, and it’s a big problem for people that have outside contractors, and it’s a big problem that we don’t have more physicians in this room. Okay, because if you say one thing and the doctor says something else and the documentation says two different things, that is a big problem. And I want you to repeat after me: Get with the program. [Audience: Get with the program.] Get with the program. You’ve got to teach the doctors how to stage wounds in accordance with CMS requirements, and that’s really the bottom line. Okay, thank you. All right, we’re going to go to section M0310. I’m sorry, M0610, all right. Dimensions of unhealed Stages 3 or 4, pressure ulcers or eschar. There’s only one wound that you need to have entered into MDS 3.0 Section M, and that’s the biggest one. And it has to be Stage 3 or a 4 or unstageable related to slough or eschar. All right, either 3 or 4, again 3 or 4 or unstageable due to slough or eschar. And that doesn’t mean you shouldn’t measure all of your wounds because all of your wounds should be measured. You need to keep records of all of your wounds. As a matter of fact, I can tell you, I was once a wound care doctor at a 700-bed facility up in the Bronx. And, boy, if you want a rough job, work in wound care in a 700-bed facility up in the Bronx. But we had a great nurse. And this nurse did such a super job; I learned so much wound care from her. And why was she such a great wound care nurse? Because nursing was actually her second career. And can anybody guess what her first career was? It was accounting. [Laughter] It was accounting and bookkeeping. So she became an RN, and then she became a wound care nurse in this humongous facility with all these very sick people, and she did a great job. But, that’s a skill that you need in your own facility in keeping track of all these wounds. Every wound needs to be measured. You pick the biggest one that’s either a 3 or 4 or unstageable due to eschar, and you enter it into M0610. And M0610A is length, and this is length from head to toe. And it’s sometimes this is sometimes a real art to measure wounds. First of all, you have to turn the patient. Secondly, you might need a flashlight because those areas are dark, and you can’t see them. Thirdly, the patient may be in pain. The patient may be deformed, have spinal deformities, have contractures. There may be redundant skin that’s hanging off. And you know so, measurement is often an art. But in general, you want to take the longest length from head to toe. Head is off to your right. Feet are off to your left. And you want to measure from the outer edge of the wound, the longest length. And that gets entered in M0610A. In M0610B, you want the width. So perpendicular to the length, 90 degrees, you want to get width. And enter that to the nearest 0.1 centimeter. One decimal point in M0610B is width. So here you have M0610. This is what it looks like. M0610A is pressure ulcer length. This one is 8.0, pressure ulcer width is 6.2, and on this one, the depth is 3.7. Now to get your depth, people have different techniques to get depth. The handiest way is to simply take a swab and moisten it and gently enter it into the wound to the deepest point and put your thumb there. And just measure with a measuring tape. And you need to have a measuring tape because, you know, if you just guess, that’s not the way to measure wounds. So you want to measure from where your thumb is, from the deepest point in the wound to where your thumb is. Some people take a pen and just mark it; I think the easiest way to do it is use your gloved hand and just measure it from there. So that’s length width and depth, and that’s in general how you measure wounds and how you would code M0610B. Okay. M0700 is most severe tissue type. This is an easy one, relatively easy. But once again, it shows you how your wound assessment skills need to be upgraded. And this incorporates terminology from the PUSH tool. Does anybody use the PUSH tool? It’s really not that common. We have a couple people who use the PUSH tool. Well, this one’s going to be easy for you because M0700 uses terminology directly from the PUSH tool. First thing you do is you examine the wound. You determine the types of tissue that’s in the wound bed. You code for the most severe type of tissue in the wound bed, and if there’s a mixture of different types, you code for the most severe tissue type. So you have a choice of four things. The first one is epithelial tissue. So epithelial tissue, usually you see in very superficial wounds. It’s a thin, nice pink stuff. The nice little microscopic cells that migrate across a healing wound is epithelial tissue. And this is a nice example. And then you have granulation tissue, which looks a little bit more rich and bubbly and wet and still superficial, but it’s granulation tissue. And this is a nice example of granulation tissue. Everybody see that? Okay. And then there’s slough. Okay. And slough is defined as yellow or white tissue that’s adherent to the ulcer bed. I had a question at the break where someone asked me about slough, and what I would do is what I try to do is just take a piece of gauze and wet that and wipe off what’s ever there. You might have residual dressing material that looks like slough. You want to get rid of that. But slough is generally adherent in thick clumps. And this is slough. And here’s necrotic tissue or eschar. So, you want to take a look at your wound. Code for the most severe type of tissue, which is one of these four. And we’re going to look at scenarios. Scenario 1, a resident has a Stage 2 pressure ulcer on the right ischial tuberosity that is healing. The resident has a Stage 3 pressure sore on the sacrum that’s also healing with granulation tissue that’s filled most of the ulcer and epithelial tissue also in that wound. And you want to code this most severe tissue type as what granulation tissue, right? Because you’re comparing granulation tissue to epithelial tissue, and we’re defining granulation tissue as being the most severe tissue type. Coding for M0700 is based on the sacral ulcer because that’s the pressure ulcer with the most severe tissue type. So if you have three ulcers and — you code for whatever is the worst tissue type in any of the ulcers. And we — here we chose granulation because it’s the most severe tissue type. Scenario 2. A resident has a pressure ulcer of the left trochanter that has black necrotic tissue, and granulation tissue and a little bit of epithelialization. So we have a choice of three. Which one do we choose? We choose the necrotic tissue to put in M0700, we choose that as number four, because the necrotic tissue is the most severe tissue type. It doesn’t need to be the majority, okay, but it’s the worst. So we want to code M0700 as 4. All right, we’re coming down the wire here, and we’re now talking about Section M0800. Section M0800 is for ulcers that have gotten worse since your last assessment. So if it’s our first assessment, you’re not going to enter anything here, because the look-back period is to the assessment reference date of the previous assessment. So we have a choice of Stages 2, 3, and 4, and we’re going to be coding ulcers that have gotten worse. We want to enter the number of pressure ulcers that were not present at the last assessment reference date or were at a lesser stage in the last assessment reference date. Coding 0, if there’s no pressure ulcers that have worsened or 0 if there’s no new pressure sores. And we’re going to illustrate that with a scenario. Resident’s admitted with an unstageable pressure sore of the sacrum. The ulcer is debrided and reclassified as a Stage 4 three weeks later. And your initial MDS assessment lists this pressure ulcer as unstageable. So M0800A, Stage 2, how many? There’s 0. Stage M0800B, Stage 3 is 0, because it’s not worsened. Stage M0800C, Stage 4 is 0. The unstageable pressure sore was present on the initial MDS assessment. After debridement, it was a Stage 4. This is because first staging since — this is the first staging since debridement and should not be counted as worsening on the MDS assessment. Scenario two. A resident has a previous medical record and has MDS documentation of a Stage 2 pressure ulcer on the sacrum and a Stage 3 pressure ulcer of the right heel. Your current, which is the newer, skin flow sheets show that there’s a Stage 3 on the sacrum, a Stage 4 on the right heel, and a Stage 2 on the left trochanter that wasn’t there in the previous assessment. So we’re coding this patient. M0800A, Stage 2, there’s 1 there because it’s a new Stage 2 pressure sore on the left trochanter. M0800B Stage 3 there’s 1 there because the ulcer had gotten worse, and M0800C Stage 4 is now — there’s 1 there because we now have a Stage 4 on the right heel that wasn’t there previously. So there’s your scenario number two. Okay. This is my favorite MDS item. MDS M0900 healed pressure sores. I want everybody to go out on the break and play these numbers on the roulette wheel. Okay, and if you win, I get half. [Laughter] So, healed pressure sores. Okay. Here’s just some photos. On the left is a open wound and to the right it’s healed for both of these sets. We have an open and a healed wound. And remember, that if a wound is healed, the patient is always at risk in M0100A and M0150 because they’ve got a healed pressure sore so they’re always at risk. You want to complete this if — you don’t want to complete this section if it’s not – if it’s the first assessment. You do want to complete it if it’s not the first assessment. And this goes back to A0310E, if that equals 0. All right. Now we’re going to go into another one of my favorite sections is arterial and venous ulcers. Now, I’m going to go through some guidelines as to how to diagnose arterial and venous ulcers, but you really need to have your physicians be involved in this diagnosis because, you know, there are different types of wounds and the wounds need some pretty specific types of treatments. And your treatments are always guided by your diagnosis. So we’re going to start with our assessment, and we’re going to review the medical record and we’re going to review the skincare flow sheets and other skin tracking forms. We’re going to speak to the direct care staff and confirm the conclusions from the medical record and talk to the physician and examine the resident. And we’re going to go through the different types of wounds. There’s venous ulcers, okay, and the wounds can start from minor trauma. The usual location is in lower areas or the medial malleolus or the lateral malleolus. Has anybody ever heard the term, sometimes if you read the older textbooks, they call it the gator area? Anybody ever hear that? Anybody ever hear about the gator area? I never quite understood what that was, and then when I went to Florida, I saw the Everglades. And I said, “Wow, if I walk into that, when the gator bites me, he’s gonna make a wound that looks like a venous ulcer.” I was thinking about that. Anyway. It’s usually located in the lower leg area, sometimes called the gator area, characterized by irregular wound edges and this this deep blueish, which is hemosiderin or iron-staining deposits. Now the thing about wound care that I think is so interesting and when I’m talking to you about these wounds is — I’m giving you these descriptions. And the reality is that old people don’t read textbooks before they get sick. So I’m giving you these descriptions, and people might not fit into each description. For example, they say that venous ulcers are not painful whereas arterial ulcers are painful. Well, anybody who has taken care of a patient with venous ulcers knows that those ulcers are painful. So, it’s another reason why you need to get your doctor involved, and sometimes you need to do some testing. I’m going to talk about some of the testing that you need to do, specifically with arterial ulcers. Okay. When you have arterial ulcers, the usual location is the distal part of the foot. The toes, the top of the foot, or the malleolus. When you look at the limb that’s affected by arterial disease, it’s pale. You have very poor capillary refill. You can put your, you can — if you have a patient that has severe arterial disease, you can actually squeeze the foot and then take your hand away and you can look and you can see the impression of your hand staying there for sometimes a minute. It’s amazing. But arterial ulcers are characterized by necrotic tissue or a pale wound bed, diminished or absent pulses. How many people – okay, let me put it this way. You send five people into a room to measure a pulse, how many different descriptions are you going to get? Five. Okay. So when you have an arterial ulcer, and you suspect that the patient might be having poor pulses, I’m going to recommend a test. It’s an easy test. It’s inexpensive. It’s called noninvasive vascular studies. They include the Ankle Brachial Index, abbreviated ABI, or pulse volume recordings. Those are the two most common. ABI and PVR, pulse volume recordings. And this settles any argument as to what the pulses are. You know, you review the chart of somebody with an arterial ulcer. In one note that says oh, good pulses. Another note says trace pulses, and another one says absent pulses. So what is it? Okay? And you get the doctor to order — your facility can develop a relationship with a local vascular lab. You’re probably going to have to get your vascular consultant involved. Please go through your medical director. Say we need to set up a system for getting noninvasive vascular studies. And it’s important because we’re talking about arterial ulcers, and we’re talking about venous ulcers. What is the mainstay of treatment for venous ulcers? Elevation and compression, right? Because with a venous ulcer, the reason you get your venous ulcers is that the blood is having difficulty coming back to the heart. So you want to wrap the leg with an ace wrap, wrap the leg with an uni boot, maybe put ted hose stockings on. But, the thing is, that if you put compression on a patient with underlying arterial disease, what’s going to happen? Big problem. Because then the next thing you know, the toes are blue, the heels now getting now bluish, so you don’t want to compress a patient with arterial disease. So before you treat, let’s get noninvasive vascular studies. It’s a standard of care in any wound care center. I work in a wound care center in Manhattan. We do it on anybody with a lower extremity wound. Highly recommended; it ends it ends the argument of pulse issues and helps you to guide your treatment. ABI, Ankle Brachial Index, when the vascular physician will compare the systolic pressure of the arm to the systolic of the ankle. And it comes up with a ratio, and it’s very simple interpretation. If it’s 0.9 or greater, hey, that’s fine. If it’s less than .9, then you’ve got some vascular problems. That’s not always the case because people with advanced vascular disease get falsely elevated ABIs, and that’s why you have to go to your PVR. So you usually want to get both ABI and PVR. Okay. Coding instructions. All you need to do is — it’s very simple for M01030. Add up the total number and put it in the box. How many arterial and venous ulcers do you have. And this is a big improvement over the previous MDS 2.0. I’m sure you all know there was only one type of ulcer recommended by MDS 2.0, and what was that? Stasis, very good. So a stasis ulcer is the antiquated terminology for a venous ulcer. So, out with that. We no longer use the term stasis ulcer. Some people still use it, but it’s a venous ulcer, and now we at least recognize in MDS 3.0 Section M that we do have arterial ulcers as well. That resulted in more diagnostic confusion, I can tell you. I’m sure you know just as well as I. So now we’re getting into the last two sections of M1040 and M1200 where other ulcers, wounds, and skin problems. Okay. M1040 and M1200, again, you want to conduct the assessment. Review your medical record, review your flow sheets. Review your treatment records for the look-back period. Speak with your direct care staff. Confirm your conclusions from the medical record, and examine the resident. Please examine the resident. And this is where you’re going to put your diabetic foot ulcers in M1040B. Okay, diabetic foot ulcers usually occur on the plantar aspect of a foot of a patient with long-standing diabetes. And those ulcers are usually not painful because the ulcers occur in a setting of diabetic neuropathy, where the patient has a stocking and glove distribution of anesthesia in the lower extremity. So the patient may not even know it’s there. So whenever you examine a patient, and this is — you can also call this Dr. Levine’s Rule. Whenever you examine a patient with a diabetic foot ulcer or any ulcer of the foot, please examine the other foot, you know. I mean, so many patients come into the office or you see a patient in bed, and they have their shoe and the sock on the non-affected foot, and they’re showing you their other foot. And I always say, well, please take off your other shoe and your other sock, and you’d be surprised what’s there. Okay, so, please, if it’s one foot, examine the other foot. It’s a great clinical bedside tool. So diabetic foot ulcers are here in M1040B. Usually on the plantar aspect and the head of the metatarsals. Not always but that’s the most common area of repetitive pressure where patients get this. And that’s coded under M1040B. Okay, M1040D, D as in dog. Open lesions, cuts other than ulcers, rashes or cuts get coded here. And what we’re seeing here is an unfortunate case of what looks to me like metastatic disease under the skin that’s breaking through. And these are open lesions that need to be coded under M1040D. Skin tears are not coded in M1040. Skin tears related to falls are coded elsewhere in the MDS under J1900B. So skin tears have no place in M1040. M1040E is where you put your surgical wounds. Okay. Remember, that if an ulcer goes for debridement, it is not a surgical wound. If an ulcer goes for debridement, it’s still an ulcer. If an ulcer goes for a flap surgery, that’s a different story. The patient comes back; it’s now coded as a surgical wound. That’s the only time when an ulcer is transformed into a surgical wound — after flap surgery. Okay, M1040F is burns. And I understand from the background of this clinical slide is that this patient had a heating pad that unfortunately burned their lower extremity. So this is coded in M1040F. And that covers the salient basics of M1040. So now that we’ve discussed wound all this classification, we’re going to discuss a little bit of treatment. This section of M1200 is very similar and almost identical to MDS 2.0. There is a book here for the first person that can tell me what’s different in MDS 3.0. We have a hand here. [Audience: Nutrition intervention.] No. No. No, it’s not G. [Audience: I.] Who was the first person that said I, dressings to the feet? We have a lady all the way back there. Okay. The last book. Great. That’s the only difference is the addition of I. Applications of dressings to the feet. So, I’m going to start by talking about A through D. All right. Now, remember, when wheelchairs — wheelchairs were not designed to have people in there all day. Wheelchairs were designed for transportation. Unfortunately, they’ve been adapted in our hospitals and unfortunately in our nursing homes, people sit in them for a really long period of time. They need to be properly cushioned. And if you have a wheelchair cushion, it needs to be coded in M1200A. The CMS position is that egg crate mattresses, egg crate cushions that used to be used commonly in pressure sore prevention should not be included as a pressure relief device. That egg crate cushions are more for comfort than they are for pressure sore – pressure reduction. By the way, those of you who read this really carefully will pick up on the fact that CMS uses the term “pressure reduction,” and NPUAP has adapted the term “pressure redistribution”. So if you look at the NPUAP website, you’ll see the words, the terms “pressure redistribution”. We’re using them here synonymously. So, we’re using pressure reduction as the same as pressure redistribution. Donuts are not acceptable pressure relieving devices because they cut off blood flow. Okay. For M1200B, pressure reducing device to the bed, it is not sufficient in my book to just check this off. There are so many different types of pressure relief devices to the bed that I strongly recommend that somewhere in your record you tell me what type of device it was. Was it a static air mattress overlay? Was it a dynamic air mattress overlay such as alternating pressure air mattress? Was it a low air loss mattress? So, please, tell me somewhere other than here what type of device you’re applying to the bed because there’s lots of different types. And it becomes a risk management issue. I can’t tell you how many times I’ve looked at a record. I just can’t figure out what they’re using as a pressure relief device, yet MDS is checked. So, please, tell me again what type of pressure relieving device you’re using. Turning and positioning. There needs to be both an assessment and an individualized care plan to tell me why this patient needs turning and positioning, and that’s the position of CMS. Okay. Just turning and positioning for the sake of turning and positioning; I know some facilities may have a policy. And I know that there’s some places in the New York metropolitan area that actually have a little bell that goes off every two hours that everybody needs to be turned. That’s not good enough to code here. You need to have a individualized assessment and an individualized care plan that tells me that this patient’s on pressure relief, that they’re coded as at risk in M0100 and M0150 and why and the fact that we need this turning and positioning schedule and how frequently. Nutrition and hydration should be part of any program for pressure ulcer prevention or pressure ulcer treatment. Please have your nutritionist be intimately involved, and this goes back to collaboration. Sorry, this is the first time I’m mentioning nutrition. In my regular lectures on pressure sores, I spend a lot of time on nutrition. It’s really an amazing thing. I worked with a nutritionist once who was very hohum about writing nutritional recommendations. The nutritionist would just sit there yawning, and, you know, just writing down, you know, yeah give supplements. And then one day we said, “Come on, come with me. I want to show you – let me take you on rounds.” We took this nutritionist on rounds to show some of these ulcers, and she had never seen ulcers. And her eyes just went like this. They became the size of dinner plates. And then she ran back to the nursing station, and she started scribbling, you know, about all these nutritional assessments. So please involve your nutritionist actively with wound care. Have them come on rounds with you. Have them look at the wounds. Especially tube-fed patients. Have your nutritionist be intimately involved with knowing who has wounds, who has the tubes, and making sure that your patients get adequate feedings. Okay. Ulcer care. Ulcer care, any type of ulcer care gets coded under M1200E. So M1200E should be checked for anybody that has any sort of pressure ulcer care. Other important parts of this are ointments or medicines other than to the feet. H — M1200H is where you treat your moisture-associated skin damage or incontinence dermatitis. Ulcers that are not coded here. Let’s say you’ve got a skin tear, and your skin tear is being treated, is coded somewhere else, I think it was J, I mentioned — J1900B. Well, you’re still treating that skin tear. Okay, and that skin tear, that treatment gets coded under M1200G, non-surgical dressings, that’s where you’re coding your skin tear treatments. And your diabetic foot wounds get coded under M1200I. So let’s look at some clinical material. All right. This is a patient with a pressure sore. Got admitted to your hospital from, admitted to your nursing home from a hospital down the block. And what we’re looking at here is — by the way, what location is this? Sorry. What location is this? The head is going off to your left, and actually we’re looking at the buttocks and the knees are going straight up. So we’re looking at a — the general area that we’re looking at is what? The thigh. So some person says thigh. Ischium. We have some person who says ischium. I’m saying it’s buttocks. Okay, so, thigh, ischium, and buttocks. We’re all right, aren’t we? We agree that in this patient could be described as thigh, ischium, and buttocks, right? Okay, so now, we’re looking at our documentation. And Dr. Levine says it’s buttocks, and Nurse Jones says it’s thigh, and the wound care nurse says it’s an ischium. All right. What does our documentation look like? Looks like a mess. Okay. And a surveyor comes in and, you know, starts saying, “These people — they don’t know what they’re talking about. Everybody’s calling it a different location.” And then down the line we get sued for this, and it goes to an attorney, and he’s going to use this as evidence that we didn’t know what we were doing. But, of course, we know what we’re doing. We’re all right. Thigh, ischium, and buttocks. What I’m getting at — the point I’m getting to is I believe that the wound care nurse needs to be empowered in a situation like this for the last word in locations. And you need to have an effort made in your facility to make your documentation uniform, as hard as it is with these ulcers with — they can be described differently by different people. So, please, you know, empower your wound care nurse to make decisions. If there’s a dispute or a discrepancy, please never alter your record, but have some correction written into the record that this is about the location or any other aspect of your wound for that matter. So this wound goes for debridement. I’m sorry, what stage was this? This is unstageable, right? Unstageable. Can’t be a 4 because we don’t see the base, so this is an unstageable due to eschar. So it’s M0300F. M0300F is unstageable due to eschar. And this is the one if this is the largest ulcer, it’s going to have to be measured and put into what section? M0610. Very good. M0610. Somebody said M0610. So we debride it, and now we can see the base. So it’s now a stage what? Stage 4. And it’s M0300D. All right, is it present on admission? Yes. Because I told you in the last slide that this patient came in from the hospital with this present on admission. This is the first time you’re looking at the base. It’s a Stage 4, and it is present on admission. Next quarterly, guess what, this wound has filled up with slough. And we can no longer see the base. So your next quarterly, we have to restage this as a unstageable, which is M0300F. Very good, all right. Now we go on, the wound heals. All right. And we’re restaging this as a healed Stage 4. And we’re going to code it in M what? M0900. But this patient is always at risk. So we always have to keep M0100 and M0150 that this patient has a scar over bony prominence, and this patient is always at risk for developing pressure sores. So let’s go over some scenarios. How are we doing on time? Oh, we have one more book. Oh boy. All right. The resident with diabetes mellitus presents with an ulcer on the heel that is due to pressure. This ulcer is not checked as M1040B. So what we’re doing, we’re actually narrowing the scope of our definition of what’s a pressure sore. So it used to be, I remember, when I was doing wound care up in the Bronx, we used to argue, is it PVD, is it pressure, is it diabetic, any way that we cannot code this as a pressure sore, we did. But according to CMS now, we’ve tightened up our definitions. You can’t do that anymore. If it’s over a bony prominence, this is not a diabetic ulcer according to CMS, this is a pressure sore. So we have to code this in the — appropriately code it as a pressure sore. Okay. Next scenario. The resident is readmitted from the hospital after flap surgery to repair a sacral pressure sore. Okay. So this comes back as a surgical wound. M1040E, surgical flap. It is now a surgical wound. Okay, this one’s a little bit more complicated. Resident has a venous ulcer, and during the last seven days, the resident has had a compression bandage. And, remember, you do not put a compression bandage on anybody who is suspected as having arterial disease because you will cause complications. So get your noninvasive vascular studies. The orders are to apply the compression bandage every five days. And the resident also has a wheelchair cushion. So in M1200, we’re going to check off M1200A, yes, because patient has pressure reducing device to the chair; pressure ulcer section M1200B, pressure reducing device to the bed; and M1200G, non-surgical dressings. T All right, this is the last of our scenarios, which I had a great deal of discussion yesterday with the folks from CMS about. The patient has a diagnosis of advanced Alzheimer’s and is totally dependent on staff for all care. And the care plan says that he’s to be turned and repositions per facility policy every two hours. Well, guess what, this does not qualify for coding in M1200C because, as for this example, it’s not part of the individualized assessment in care planning. And that’s the point of this scenario, that every turning and positioning plan must be individualized according to that patient’s known risk factors that are coded in M0100 and M0150. And I think that’s the end of my talk.