Coding for Pressure Ulcers on the OASIS-C2 Item SetPosted by admin | January 4, 2018 , (0) comments
Pressure ulcers are among the most common conditions that are addressed by home health care workers. Patients with limited mobility — especially those who are bedridden or who use wheelchairs — are often at high risk of developing pressure ulcers, so home healthcare workers are often involved in prevention, identification, management, and/or treatment. As a result, a significant portion of the OASIS-C2 Item Set is dedicated to pressure ulcers.
The Integumentary Status Section of the OASIS-C2 Item Set
The items addressing pressure ulcers are contained fall under the Integumentary Status heading of the OASIS-C2 Item Set. Although it is not necessary to fill out every question for every patient, some questions are relevant for all patients. For instance, the first question addresses whether and how the patient’s risk was addressed, and, if so, the second addresses whether or not the patient is at risk. From there, the OASIS-C2 form asks a series of in-depth questions about the patient’s integumentary status as it relates to pressure ulcers.
For multiple items within the Integumentary Status section, there are specific instructions to direct the person filling out the form to skip certain questions but include others, depending on the numerical code that was entered. This format is helpful because it ensures that coders don’t have to worry about irrelevant questions, but it can lead to problems if the coder accidentally overlooks a specific question. For this reason, an OASIS-C2 form audit can be extremely helfpul for home health care agencies.
Another problem that is commonly encountered when filling out the Integumentary Status section of the OASIS-C2 form is the challenge of determining the patient’s status over the course of the episode of care, beginning either at the start of care (SOC) or the resumption of care (ROC). To answer these questions accurately, it may be necessary to look back on previous OASIS-C2 forms. Given that pressure ulcers can last for weeks, months, or even years, it is essential to ensure that all OASIS-C2 forms are accurate, in order to guarantee the integrity of the patient’s long-term care record.
The 2017 Change to Pressure Ulcer Staging
Starting in January 2017, the numbering for pressure ulcer staging was changed from Roman to Arabic numerals on the OASIS-C2 Item Set. Although the change was small, it is important to be aware in order to avoid confusion. It is also important to note that the CMS verified that the January 2017 version of the OASIS-C2 is the current version going into 2018.
AnnexMed provides OASIS review and assessment services for home health care agencies. We can help you make sure there are no issues in the complex Integumentary Status section — or on any other part of the form! Contact us today to learn more!