Carol Siem, MSN, RN, BC, GNP, RAC-CT
QIPMO Team Leader, Clinical Educator/Consultant

There has been a growing discussion between MDS coordinators, administrators, DONs, and wound care companies about the coding of the MDS. Let’s talk about the issues that are a source of many of the problems.

“Nurses cannot diagnose pressure ulcers.” In isolation that is true, but they can identify a wound as a pressure ulcer. This is supported by the National Pressure Ulcer Advisory Panel (NPUAP) and the American Nurses Association. (ANA).

Differentiating pressure ulcers from other wound etiologies is within the domain of registered nurses. As per the Scope and Standards of Nursing Practice detailed in the statement from ANA president, Rebecca M. Patton, MSN, RN, CNOR, RNs are expected to assess the patient’s skin, stage the wound and implement an individualized plan of care based on the patient needs. Due to licensed practical/vocational nurse state practice act restrictions, wounds that have the appearance of a pressure ulcer should be inspected and described by these nurses. Nurses, in particular, examine the skin and are most likely to be the first professional to examine any skin lesion. In the absence of licensed independent practitioners/wound care specialist, the registered nurse needs to identify and stage the pressure ulcer so that early and appropriate care can be rendered. This care involves independently initiated nursing care, such as turning and repositioning.

As noted above, RNs can identify and implement a plan of care. Our residents cannot wait for a physician or wound care company to be available for every admission as soon as the resident arrives.

On the MDS in Section I, the manual instructions dictate that diagnoses placed in this section must be obtained from a physician, nurse practitioner, clinical nurse specialist or physician assistant. So as with any other diagnosis, an attending physician or extender would have to write the diagnoses in the chart to complete the MDS for this section. So bottom line to complete Section I, the diagnoses must come from a physician or physician extender.

Section M is where many of the issues/concerns are arising. CMS discusses the issue of pressure ulcers from the very beginning in the Intent of Section M.

CMS is aware of the array of terms used to describe alterations in skin integrity due to pressure. Some of these terms include: pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bed sore. Acknowledging that clinicians may use and documentation may reflect any of these terms, it is acceptable to code.

CMS further discusses the fact that they adapted the NPUAP recommendations for Pressure ulcers/injuries that were presented in 2016. So what is the difference between adapted and adopted? “Adapted is defined as to make suitable to requirements or conditions; adjust or modify fittingly: They adapted themselves to the change quickly”. So CMS took the NPAUP recommendations and made it suitable to the requirements for the MDS. If CMS had adopted the NPUAP recommendations it would have embraced the NPUAP definitions with no changes or corrections. This is not unlike when we had MDS 2.0. For those who remember when we coded the pressure ulcer stages we would “backstage” as the wound would begin healing. So prior to 2010 we would show on the MDS a healing stage 4 would magically turn into a stage 3, then 2 then 1 and be healed. We all understood that this was technically impossible but according to the instructions that is what we did.

We are caught in a similar position today. So when the documentation given by your own staff or a Wound Care Company may not match the MDS documentation, it does not mean you made an error in your coding according to the RAI Manual. So if questioned by an outside entity (Wound Company or a State Surveyor) refer them to the RAI Manual on page M-4:

Nursing homes may adopt the NPUAP guidelines in their clinical practice and nursing documentation. However, since CMS has adapted the NPUAP guidelines for MDS purposes, the definitions do not perfectly correlate with each stage as described by NPUAP. Therefore, you must code the MDS according to the instructions in this manual.

Along this same line on page M-5 under coding tips:

If an ulcer/injury arises from a combination of factors that are primarily caused by pressure, then the area should be included in this section as a pressure ulcer/injury.

Continuing on page M-6:

Residents with diabetes mellitus (DM) can have a pressure, venous, arterial, or diabetic neuropathic ulcer. The primary etiology should be considered when coding whether a resident with DM has an ulcer/injury that is caused by pressure or other factors.
If a resident with DM has a heel ulcer/injury from pressure and the ulcer/injury is present in the 7-day look-back period, code 1 and proceed to code items in M0300 as appropriate for the pressure ulcer/injury.

There has also been discussion that we need “diagnostic” testing to complete section M. The word “diagnostic” is not found in Section M. We are instructed to code section M based on the appearance of the skin as described by CMS. Diagnostic testing is discussed in Section I but again the sections are to be coded based on the RAI Manual information. Section I and Section M have two different roles and instructions and the two may not produce the same answer.

Diagnostics have a role in the care of our elders but it will not change how Section M is coded. As previously noted if the primary cause of the skin alteration is pressure, then that is how it is to be coded. Testing may show venous or arterial insufficiency that will impact the healing of the wound but the initial cause of the wound is pressure that is what goes on the MDS. A question to ask ourselves is: are the diagnostics going to help in the treatment plan or are we doing it to change the wound type. If it is the latter we are causing the resident additional discomfort, the costs of the testing and it will not change the reason for coding the wound as a pressure ulcer per the RAI Manual. Diagnostic testing may help with why a wound is not healing BUT it will not change the coding if the initial cause of the wound is pressure then it is a pressure ulcer. We are not looking for “why” it is not healing for the MDS coding but what started the problem.

Another workaround that has been seen is homes are coding all wounds under M 1040 D “other” until they have “diagnostic testing” to prove it something else. According to the RAI Manual other is described as: Most typically skin lesions that develop as a result of diseases and conditions such as syphilis and cancer. MDS Frequency reports by CMS show nationwide the frequency of this type of wound is very small is 1.23% and Missouri as of third quarter 2018 is 1.34%. So unless it is felt that the skin lesion is from syphilis or cancer, it should not go under M 1040 D.

So what do we do moving forward? As an industry we must realize that we have to follow the RAI Manual for coding on the MDS and that the physician or wound care company documentation may not be the same as what is on the MDS in Section M. CMS has made it very clear we must follow their definitions for coding the MDS as noted in the RAI Manual.

References
http://www.npuap.org/wp-content/uploads/2012/01/NPUAP-Position-Statement-on-Staging-Jan-2017.pdf

http://www.npuap.org/wp-content/uploads/2012/01/NPUAP_position_on_staging-final-Jan-2012.pdf

https://downloads.cms.gov/files/1-MDS-30-RAI-Manual-v1-16-October-1-2018.pdf