Download CATEGORY 4 A - OASIS DATA SET FORMS

[Q&A added 06/05]
Q99. M0445-M0464. If a wound heals and breaks down again should it be staged at its
prior level or should it be staged on the current level of breakdown?
A99. The type of wound is not identified here, but this response pertains to a healed
pressure ulcer. This is the only type of wound that clinicians can stage. The appropriate
response to this question for pressure ulcers will depend on the stage of the pressure ulcer
at its worst prior to healing. If the ulcer was a Stage 1 or 2 prior to healing, then the updated
guidance included in the response to Q97 (above) should be followed. The stage of this
(newly deteriorated) pressure ulcer must be determined based on the current visual
assessment by a clinician skilled in this clinical practice. If the ulcer was a Stage 3 or 4 at its
worst prior to healing, then the ulcer's stage will be reported according to what it was at its
worst. If the ulcer is worse now, the ulcer's stage at its worst (i.e., its current stage) also is
what will be reported.
[Q&A added 06/05]
Q100. M0468-M0476. Would an arterial ulcer be considered a stasis ulcer?
A100. No, because venous stasis ulcers and arterial ulcers are unique disease entities.
Refer to the WOCN web site (http://www.wocn.org/) for Clinical Fact Sheets regarding
the assessment of leg ulcers, information on arterial insufficiency, and information on
venous insufficiency (stasis).
Q101. M0468-M0476. How can I determine whether the patient's ulcer is a stasis
ulcer or not?
A101. The patient's physician is the best information source regarding the root cause of
the ulcer. Refer to the WOCN web site (http://www.wocn.org/) for Clinical Fact Sheets
regarding the assessment of leg ulcers, information on arterial insufficiency, and
information on venous insufficiency (stasis).
Q102. M0482-M0488. Is a gastrostomy that is being allowed to close on its own
considered a surgical wound?
A102. A gastrostomy that is being allowed to close would be excluded from
consideration as a wound or lesion (M0440), meaning that it could not be considered as
a surgical wound. However, the "take-down" of an ostomy done as a surgical procedure
would result in both a wound/lesion ("yes" to M0440) and a surgical wound ("yes" to
M0482).
Q103. M0482. If the patient had a port-a-cath, but the agency was not providing
any services related to the cath and not accessing it, would this be coded as a
skin lesion?
A103. For M0440 you would answer YES for a lesion. At M0482, response 1-Yes is
appropriate. The port-a-cath or mediport site is considered a surgical wound even if
healed over. The presence of a wound or lesion should be documented regardless of
whether the home care agency is providing services related to the wound or lesion.