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ne of the more interesting things about the Outcome and Assessment Information Set (OASIS) is how it is linked to other regulations and guidelines from the Centers for Medicare and Medicaid Services (CMS). Sometimes a change in another area can impact OASIS and affect reimbursement as well. A good example is the recent revision announced by CMS to the ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes. While these coding changes impact all care providers, they are relevant to OASIS because ICD-9-CM codes are used to answer two important OASIS questions: M0230 (Primary Diagnosis) and M0240 (Other Diagnoses).
       CMS announces revisions to the ICD-9-CM codes each year in October, which have historically taken effect in January of the following year. This allows a 90-day grace period for organizations to review their guidelines for diagnostic coding and educate their associates before implementation.
       This year, however, the ICD-9-CM changes took effect on October 1, and several of them impact OASIS assessments and home care. For service periods beginning on October 1, home care agencies must bill using the new ICD-9-CM codes, because CMS’s Financial Intermediaries will no longer accept bills using the discontinued codes.

Pressure Ulcer Coding Changes

       Coding for pressure ulcers, known as decubitus ulcers in ICD-9-CM jargon, has been changed to include ulcer location. This has been accomplished by adding a fifth digit to the code, 707.0.
       Although the change is beneficial because it describes patient condition more effectively, it also means that the old four-digit code, 707.0, has been discontinued and is no longer used.
       Additionally, if a patient has more than one pressure ulcer, each ulcer should be coded individually. Here are the new decubitus ulcer codes and descriptions:
• 707.00: Decubitus ulcer, unspecified site
• 707.01: Decubitus ulcer, elbow
• 707.02: Decubitus ulcer, upper back
• 707.03: Decubitus ulcer, lower back
• 707.04: Decubitus ulcer, hip
• 707.05: Decubitus ulcer, buttocks
• 707.06: Decubitus ulcer, ankle
• 707.07: Decubitus ulcer, heel
• 707.09: Decubitus ulcer, other site.

Diabetes Coding Changes

       Coding of diabetes has also changed by removing the definitions of diabetes as NIDDM (noninsulin-dependent diabetes mellitus) and IDDM (insulin-dependent diabetes mellitus) and replacing them with type I for juvenile onset and type II for adult onset to reflect advances in our understanding of the condition. This is not a change in the codes themselves but in the descriptions associated with each code.
       Here are examples of how diabetes mellitus code descriptions changed (the phrases that appear in brackets have been removed):
• 250.00: Diabetes mellitus without mention of complication, type II [noninsulin-dependent type] [NIDDM type] [adult onset type], or unspecified type, not stated as uncontrolled
• 250.01: Diabetes mellitus without mention of complication, type I [insulin-dependent type] [IDDM] [juvenile type], or unspecified type, not stated as uncontrolled.

Other Coding Changes

       There are other changes to ICD-9-CM codes included in this year’s update. A complete list of the changes can be found in any of the 2005 ICD-9-CM coding manuals and at http://www.cms.hhs.gov/medlearn/icd9code.asp
       As previously noted, the changes to the ICD-9-CM coding of pressure ulcers has the most significant effect on OASIS datasets, because the previous four-digit code for pressure ulcers can no longer be used.

Frequently Asked Questions

       Question: In the last issue of ECPN, you discussed the new CMS policy on OASIS pressure ulcer assessment. My interpretation of the policy change described on the CMS OASIS site (http://www.cms.hhs.gov/oasis/npuap.pdf) is a little different than the one in your article on healed stage 2 pressure ulcers. Based on the CMS site, I understood that a healed stage 1 or 2 pressure ulcer would not be designated as a pressure ulcer even if there is scar tissue.
       The response to M0440 (Does this patient have a Skin Lesion or an Open Wound?) would be either “no” if there is no scar tissue or “yes” if there is scar tissue, but the response to M0445 (Does this patient have a Pressure Ulcer?) would always be “no.” Your last column, however, suggested that the response to M0445 might be “yes” for a stage 2 pressure ulcer if scar tissue was noted. Isn’t your article’s interpretation inconsistent with CMS’s guidance?
       Answer: Yes, our article was inconsistent with the CMS guideline on this point. Thank you for the opportunity to correct the mistake. According to the CMS guideline, M0445 is answered “no” for healed stage 2 pressure ulcers regardless of whether scar tissue is noted.
       Question: At our last home care OASIS update, we were instructed to mark M0440 “yes” on clients with freckles, moles, bruises, or scars. I think this would mean almost everyone we see. Is this correct?
       Answer: Yes, current OASIS guidelines direct home care clinicians to consider all freckles, moles, bruises, scars, etc. lesions and to therefore answer “yes” to M0440 in these cases. Remember, however, to exclude patients with ostomies and peripheral intravenous sites unless other lesions are noted.
       Question: When answering M0420 (Frequency of Pain interfering with patient’s activity or movement), how should clinicians determine the correct answer in a nonverbal patient?
       Answer: Clinicians can answer M0420 in a nonverbal patient by observing the patient for changes in vital signs and facial expressions, as well as irritability. Some nonverbal patients may be able to answer using a visual analog pain scale.
       Question: Should a pacemaker be considered a skin lesion when answering M0440?
       Answer: Yes, the scar present after healing would be considered a lesion. If the pacemaker was just inserted, the site would meet the criteria of a surgical wound as well (M0482).
       Question: Can clinicians tell whether a pressure ulcer has improved by comparing two OASIS assessments completed over time?
       Answer: No. OASIS items are used for outcome measurement and risk factor adjustment. There are no outcome measures computed for pressure ulcer improvement. Other documentation in the patient’s clinical record should be used to determine progress or decline.
       Question: When should foot ulcers in patients with diabetes be classified as pressure ulcers?
       Answer: The clinician would have to speak with the physician who must determine whether a specific lesion is a diabetic ulcer or a pressure ulcer. In responding to the OASIS items, an ulcer diagnosed by the physician as a diabetic ulcer would be considered a lesion (respond “yes” to M0440) but not a pressure ulcer.
       If you have a question that you would like addressed in a future edition of “OASIS: More Than Just an Assessment,” e-mail it to Renee Olszewski, Managing Editor, at rolszewski@hmpcommunications.com.