1. Section M Skin Conditions Presented for the DOH by Catharine B. Petko RN BSN Myers and Stauffer LC July 18, 2013

2. Updates RAI Manual www.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIManual.ht mlwww.cms.gov/Medicare/Quality-Initiatives- Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIManual.ht ml New ISCs for 10/1/13 www.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/NHQIMDS30Technical Information.htmlwww.cms.gov/Medicare/Quality- Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/NHQIMDS30Technical Information.html –New items included K0710, O0400*3A, O0420 SOM F309 Dementia and F329 Unnecessary Drugs www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey- and-Cert-Letter-13-35.pdf www.cms.gov/Medicare/Provider-Enrollment-and- Certification/SurveyCertificationGenInfo/Downloads/Survey- and-Cert-Letter-13-35.pdf Discharges and Dashes video - http://youtu.be/Qkn22jv2HSYttp://youtu.be/Qkn22jv2HSY

3. Quality Assurance and Performance Improvement (QAPI) www.cms.gov/Medicare/Provider- Enrollment-and- Certification/QAPI/NHQAPI.htmlwww.cms.gov/Medicare/Provider- Enrollment-and- Certification/QAPI/NHQAPI.html Five Elements –Design and Scope –Governance and Leadership –Feedback, Data Systems and Monitoring –Performance Improvement Projects (PIPs) –Systematic Analysis and Systemic Actions Regulation coming

4. M0100 Determination of Pressure Ulcer Risk A. Resident has a stage 1 or greater, a scar over bony prominence, or a non-removable dressing/device B. Formal assessment instrument/ tool (e.g., Braden, Norton or other) C. Clinical assessment – Head to toe examination – Observation – Medical record review of pressure ulcer risk factors. Z. None of the above

5. M0150 Risk of Pressure Ulcers Is this resident at risk of developing pressure ulcers? –0. No –1. Yes

6. M0210 Unhealed Pressure Ulcer(s) Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? –0 No Skip to M0900 Healed Pressure Ulcers –1 Yes Continue to M0300 Current number of Unhealed Pressure ulcers at each stage Code based on the presence of any pressure ulcer (regardless of stage) in the past 7 days

7. M0210 Coding Tips Unhealed Pressure Ulcer(s) If an ulcer arises from a combination of factors which are primarily caused by pressure, then the ulcer should be included in this section as a pressure ulcer. If a pressure ulcer is surgically closed with a flap or graft, it should be coded as a surgical wound and not as a pressure ulcer. If the flap or graft fails, continue to code it as a surgical wound until healed. If a resident had a pressure ulcer on the last assessment and it is now healed, complete Healed Pressure Ulcers item (M0900). If a pressure ulcer healed during the look-back period, and was not present on prior assessment, code 0.

8. M0210 Coding Tips 5/13 Oral Mucosal ulcers caused by pressure should not be coded in Section M. These ulcers are captures in item L0200C Abnormal mouth tissue. Mucosal ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made (p. M-5)

9. M0300 Current Number of Unhealed Pressure Ulcers at Each Stage “Unhealed” or “non-epithelialized” –The epithelium is the layer of cells forming the epidermis of the skin and the surface layer of mucous and serous membranes “Closed” versus “open” –Closed does not mean healed –Stage 1, sDTI, and unstageable pressure ulcers may be closed but would not be considered healed

10. M0300 Current Number of Unhealed Pressure Ulcers at Each Stage - 1 Step 1: For each pressure ulcer, determine the deepest anatomical stage. Do not reverse or back stage. Consider current and historical levels of tissue involvement. –Observe and palpate the base of any identified pressure ulcers to determine the anatomic depth of soft tissue damage involved –Staging should be based on the ulcer’s deepest anatomic soft tissue damage that is visible or palpable –If the PU has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage

11. M0300 Current Number of Unhealed Pressure Ulcers at Each Stage - 2 Step 2: Identify Unstageable Pressure Ulcers –If the wound is totally covered with eschar or slough, it is unstageable. If partially covered but you can measure depth of tissue loss, do not code as unstageable –Known pressure ulcers covered by non- removable dressing/device should be coded as unstageable –A pressure ulcer with suspected deep tissue injury should be coded as Unstageable Suspected deep tissue injury in evolution (M0300G) not as Stage 1

12. M0300 Current Number of Unhealed Pressure Ulcers at Each Stage - 3 Step 3: Determine “Present on Admission” –For each pressure ulcer, determine if the pressure ulcer was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement. (p. M-7) Current numerical stage also affects the decision about “Present on Admission”

13. Present on Admission Examples PU present on admission but has increased in numerical stage: not considered “present on admission” Unstageable on admission but numerically stageable later: consider as present on admission at that stage. If it later increases in numerical stage, not considered “present on admission” Resident hospitalized but PU at same numerical stage when he returns: not considered “present on admission” Resident hospitalized but PU at higher numerical stage when he returns: considered “present on admission”

14. M0300 Current Number of Unhealed Pressure Ulcers If a pressure ulcer fails to show some evidence toward healing within 14 days, the pressure ulcer (including potential complications) and the patient’s overall clinical condition should be reassessed (p. M-9, M-11)

15. M0300A Number of Stage 1 Pressure Ulcers An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness), tissue consistency (firm or boggy), sensation (pain, itching) and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hue.

16. Suspected Deep Tissue Injury Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. (p. M-19) Adapted from the National Pressure Ulcer Advisory Panel definitions www.npuap.orgwww.npuap.org –Blood-filled blister without surrounding tissue involvement is classified as Stage 2 on MDS

17. M0300A Number of Stage 1 Pressure Ulcers May deteriorate if adequate interventions not implemented Suspected deep tissue injury should not be coded as Stage I Usually over a bony prominence Non-blanchable: Reddened areas of tissue that do not turn white or pale when pressed firmly with a finger or device Code –0 if no Stage I pressure ulcers are present OR –Enter the number of Stage I pressure ulcers that are currently present.

18. Stage 1 or Perineal Dermatitis? Stage 1: usually presents as a localized area of erythema or skin discoloration Perineal dermatitis –More diffuse are of erythema or discoloration where the urine or stool has contacted skin –Occur in area where incontinence brief or underpad has been used –Presents as intense erythema, scaling, itching, papules, weeping and eruptions –Probably code at M1040H MASD

19. M0300B Number of Stage 2 Pressure Ulcers Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed without slough –May also present as an intact or open/ruptured blister –Also presents as a shiny or dry shallow ulcer without slough or bruising 1. Code –0 if no Stage 2 pressure ulcers are present OR –Enter the number of Stage 2 pressure ulcers that are currently present. 2. Enter the number of Stage 2 Pressure Ulcers present at the time of admission/entry or reentry –Enter 0 if no Stage 2 pressure ulcers were first noted at the time of admission. (p. M-10)

20. Eschar or Scab? Eschar is a collection of dead tissue within the wound that is flush with the surface of the wound –May be hard or soft –Usually black, brown or tan –Usually firmly adherent to base and or sides of wound Scab is made up of dried blood cells and serum, sits on the top of the skin, and forms over exposed wounds such as wounds with granulating surfaces –Is evidence of wound healing

21. M0300B Number of Stage 2 Pressure Ulcers (cont’d) 3. Enter the Date of oldest Stage 2 pressure ulcer –Date it was first noted as Stage 2 –Use dashes if the date is unknown, e.g., resident admitted with Stage 2 ulcer Most Stage 2 pressure ulcers should heal in a reasonable time frame, e.g., 60 days

22. M0300C Number of Stage 3 Pressure Ulcers Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling If a pressure ulcer fails to show some evidence of healing within 14 days, the resident’s overall clinical condition should be reassessed (5/13) 1. Number of Stage 3 Pressure Ulcers (0 – 9) 2. Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry

23. M0300D Number of Stage 4 Pressure Ulcers Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes –Undermining - The destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface AND –Tunneling – A passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound 1. Number of Stage 4 Pressure Ulcers (0 – 9) 2. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry

24. M0300D Number of Stage 4 Pressure Ulcers Cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that have exposed cartilage should be classified as Stage 4 (p. M-15)

25. M0300E Number of Unstageable Ulcers – Non-removable Dsg. Ulcer known but not stageable due to non- removable dressing/device –Includes, e.g., primary surgical dressing that cannot be removed, an orthopedic device or a cast –Review hospital records of skin condition –Monitor surrounding area for redness, swelling, drainage, tenderness, pain 1. Number of unstageable Pressure Ulcers due to non-removable dressing/device (0 – 9) 2. Number of these unstageable Pressure Ulcers due to non-removable dressing/device that were present upon admission/entry or reentry

26. M0300F Number of Unstageable Ulcers – Slough and/or eschar Slough tissue: Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. Eschar tissue: Dead or devitalized tissue that is hard or soft in texture, usually black, brown or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound –Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heels serves as “the body’s natural (biological) cover” and should only be removed after careful clinical consideration (p. M – 17)

27. M0300G Number of Unstageable Ulcers – Deep tissue injury “Suspected deep tissue injury in evolution” Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue Difficult to detect in individuals with dark skin Potential for rapid deterioration

28. M0610 Dimensions of Unhealed Stage 3 or 4 Ulcers or Eschar Complete only if M0300C1 # of Stage 3 Ulcers, M0300D1 # of Stage 4 Ulcers, or M0300F1 # of Unstageable Pressure Ulcers Due to Slough and/or Eschar >0 Identify the pressure ulcer with the largest surface area (length x width) and record in centimeters

29. M0610 Measurements Length = head to toe length Width = side to side. Should be a 90 degree angle Measure the distance between healthy skin tissue at each margin –Tunneling and undermining are not reported on the MDS but should be monitored Measure all stage 3, 4, eschar covered ulcers. Select the largest by comparing the surface area of each Determine the greatest depth of the largest ulcer

30. M0610 Measurements (2) M0610A Enter the current longest length of the largest ulcer in centimeters to one decimal point, e.g., 2.3 cm. M0610B Enter the widest width of the same pressure ulcer, side-to-side perpendicular (90 degree angle) to length in centimeters to one decimal point M0610C Enter the depth of the same pressure ulcer in centimeters to one decimal point –If unable to measure depth, e.g., covered with eschar, enter dashes.

31. M0610 Measurements (3) From the data specifications: This item should be rounded to the nearest tenth decimal place. –If the value in the hundredth decimal place is equal to 0 through 4, round the value down to the nearest tenth (i.e., discard the fractional portion of the number after the tenth decimal place). 3.34 would be recorded as 3.3. –If the value in the hundredth decimal place is equal to 5 through 9, round the value up to the next largest tenth decimal value. 3.35 would be recorded as 3.4.

32. M0700 Most Severe Tissue Type Identify the most severe type of tissue present in any pressure ulcer bed 1. Epithelial Tissue: New skin that is light pink and shiny (even in persons with darkly pigmented skin). –Stage 2: All coded as 1. Seen in the center and edges of the ulcer. –Stage 3 and 4: advances from the edges of the wound. 2. Granulation tissue: Red tissue with “cobblestone” or bumpy appearance, bleeds easily when injured.

33. M0700 Most Severe Tissue Type Granulation tissue, slough, or eschar are not present in Stage 2 pressure ulcers. Therefore, Stage 2 pressure ulcers should not be coded as having granulation, slough or eschar tissue and should be coded as 1 [Epithelial tissue] for this item (p. M-24)

34. M0700 Most Severe Tissue Type (2) 3. Slough tissue: Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. May be adherent to the base of the wound or present in clumps throughout the wound bed 4. Necrotic tissue (eschar): Dead or devitalized tissue that is hard or soft in texture, usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound (p. M-23)

35. M0800 Worsening in Pressure Ulcer Status Since Prior Assessment Pressure ulcer “worsening” is defined as a pressure ulcer that has progressed to a deeper level of tissue damage and is therefore staged at a higher number using a numerical scale of 1-4 (p. M-25) Lookback period is to ARD of the prior assessment (OBRA or Scheduled PPS) If there is no prior assessment (A0310E = 1), skip this section Enter the number of pressure ulcers that were not present OR were at a lesser numerical stage on prior assessment. Code only for Stages 2, 3 and 4 –Code 0 if no pressure ulcers have worsened OR there are no new pressure ulcers

36. M0800 Worsening Pressure Ulcers If a numerically staged pressure ulcer increases in numerical staging, it is considered worsened If it was unstageable on admission/entry or reentry, do not consider it worsened on the first assessment that is able to be numerically staged If a numerically staged ulcer becomes unstageable due to slough/eschar, do not consider it as worsened If a numerically staged ulcer becomes unstageable and then is debrided sufficiently to be numerically staged, it is considered worsened if the numerical stage has increased (p. M-26)

37. M0800 Worsening Pressure Ulcers M0800 Worsening Pressure Ulcers: “If two pressure ulcers merge, do not code as worsened. Although two merged pressure ulcers might increase the overall surface area of the ulcer, there would need to be an increase in numerical stage in order for it to be considered as worsened” (p. M-26)

38. M0800 Worsening Pressure Ulcers The interdisciplinary care plan should be reevaluated to ensure that appropriate preventative measures and pressure ulcer management principles are being adhered to when new pressure ulcers develop or when pressure ulcers worsen (p. M-25)

39. M0900 Healed Pressure Ulcers A. Were pressure ulcers present on the prior assessment (OBRA or Scheduled PPS)? 0 No 1 Yes Indicate the number of pressure ulcers that were noted on the prior assessment (OBRA or Scheduled PPS) that have completely closed (resurfaced with epithelium) by the ARD –Healed Pressure Ulcer: Completely closed, fully epithelialized, covered completely with epithelial tissue, or resurfaced with new skin, even if the area continues to have some surface discoloration –Do not downstage Code 0 for Stages 2, 3 and 4 (M0900B, C, D) if no healed pressure ulcer at the given stage since the prior assessment.

40. M1030 Number of Venous and Arterial Ulcers Look-back period is the last 7 days Do not code pressure ulcers in this item These wounds are typically not found over bony prominences and pressure forces play virtually no role in the development of the ulcers Enter the total number of venous and arterial ulcers present

41. Definition Of Venous Ulcers Caused by peripheral venous disease Commonly occur proximal to medial or lateral malleolus, above the inner or outer ankle, or on the lower calf area of leg Wound may start due to minor trauma Characterized by: –Irregular wound edgesPossible pain –Hemosiderin stainingRed granular wound bed –Leg edemaYellow fibrinous material –Exudate

42. Definition Of Arterial Ulcers Caused by peripheral arterial disease (Ischemia) Wound may start due to minor trauma Usual location: –Toes –Top of foot –Distal to medial malleolus

43. Definition Of Arterial Ulcers (2) Characterized by: –Necrotic tissue or pale pink wound bed –Lower extremity and foot pulses diminished or absent –Muscle atrophy –Often painful –Minimal exudate –Minimal bleeding –Trophic skin changes: Dry skin Loss of hair Brittle nails

44. M1040 Other Ulcers, Wounds, and Skin Problems Check all that apply in last 7 days: –Foot Problems A = Infection of the foot B = Diabetic foot ulcer(s) C = Other open lesion(s) on the foot –Other Problems D = Open lesion(s) other than ulcers, rashes, cuts E = Surgical wound(s) F = Burn(s) G = Skin tear(s) H = Moisture Associated Skin Damage (MASD) –None of the Above Z = None of the above were present

45. M1040H Moisture Associated Skin Damage (MASD) Moisture Associated Skin Damage (MASD) is a result of skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate and perspiration. It is characterized by inflammation of the skin, and occurs with or without skin erosion and/or infection. MASD is also referred to as incontinence-associated dermatitis and can cause other conditions such as intertriginous dermatitis, periwound moisture-associated dermatitis, and peristomal moisture associated dermatitis. Provision of optimal skin care and early identification and treatment of minor cases of MASD can help avoid progression and skin breakdown (p. M-35)

46. M1200 Skin and Ulcer Treatments Document any specific or general skin treatment that the resident received in the past 7 days Check all that apply: –A Pressure reducing device for chair –B Pressure reducing device for bed –C Turning/repositioning program –D Nutrition or hydration intervention –E Pressure ulcer care

47. M1200 Skin and Ulcer Treatments –F Surgical wound care –G Application of non-surgical dressings (with or without topical medications) other than to feet –H Application of ointments/medications other than to feet –I Application of dressings to feet (with or without topical medications) Includes interventions to treat any foot wound or ulcer other than a pressure ulcer –Z None of the above were provided

48. Care Area Triggers: # 16 Pressure Ulcer G0110A1 Bed mobility self-performance coded 1 – 4, 7, 8 H0300 Urinary continence or H0400 Bowel continence coded 2 or 3 K0300 Weight loss coded 2 (not physician prescribed) M0150 Resident at risk of developing pressure ulcers = 1 M0300A through M0300G1 Number of pressure ulcers at any stage is >0 and <=9 M0800A-C Number of pressure ulcers that have worsened is >0 and <=9 P0100B or E Trunk Restraint used in bed or chair: coded 1 or 2

49. Appendix C – CAA Resources Existing pressure ulcers Extrinsic risk factors Intrinsic risk factors Medications Diagnoses and conditions Treatments and other factors

50. F314 – Pressure Ulcers May be considered “unavoidable” if facility: –Evaluated resident’s clinical condition and pressure ulcer risk factors. –Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice –Monitored and evaluated the impact of the interventions –Revised the approaches as appropriate

51. Questions? qa-mds@pa.gova-mds@pa.gov Next teleconference: October 17, 2013