M1311: CMS OASIS Q&As

The presence of osteomyelitis is not a characteristic used to stage a pressure ulcer/injury and does not automatically result in a Stage 4 ulcer. The pressure ulcer/injury stage should correspond to the clinician’s visual assessment or ability to directly palpate on the day of assessment. The definitions for staging the pressure ulcer are available in Chapter 3 of the OASIS Guidance Manual.

Assuming the patient had no other pressure ulcers, on the SOC assessment, M1311A1, Number of Stage 2 pressure ulcers, would be coded “1”. M1311B1, Number of Stage 3 pressure ulcers, would be coded as “1”. In the scenario you describe, at discharge the surface areas of the pressure ulcers extended to the point that the assessing clinician could no longer differentiate one pressure ulcer from the other. In this case, the patient would be considered to have one pressure ulcer. If at discharge, the pressure ulcer was stageable and had not progressed in anatomic depth, the patient would have one Stage 3 pressure ulcer. On the discharge assessment, M1311B1, Number of Stage 3 pressure ulcers, would be coded “1”. M1311B2, Number of these Stage 3 pressure ulcers that were present at the most recent SOC/ROC would be coded “1”. If there had been an increase in numerical stage and the pressure ulcer was a Stage 4 at discharge, M1311C1, Number of Stage 4 pressure ulcers, would be coded “1”. M1311C2, Number of these Stage 4 pressure ulcers that were present at the most recent SOC/ROC would be coded “0”. If the pressure ulcer was unstageable due to slough or eschar at discharge, M1311E1, Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar, would be coded “1”. M1311E2, Number of these unstageable pressure ulcers that were present at the most recent SOC/ROC, would be coded “0”.

A pressure ulcer that was staged and now has a scab indicates it is healing therefore, staging does not change. In this scenario, it is a healing Stage 3. Scabs and eschar are different. A 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 (like pressure ulcers, lacerations, evulsions, etc.).

For each pressure ulcer/injury observed at discharge, consider current and historical levels of tissue involvement. We would like to clarify that discharge coding for the scenario described is dependent upon the clinical progression of the wound during the episode. If the patient is admitted with two unstageable Deep Tissue Injuries that do not evolve during the home health episode to be numerically staged and are unstageable due to eschar at the time of discharge, then on the discharge assessment M1311E1 - Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar = 2 and M1311E2, Number of these unstageable pressure ulcers that were present at most recent SOC/ROC = 2. M1311F1 - Number of unstageable pressure injuries presenting as deep tissue injuries = 0. However, any pressure ulcer/injury that is observed to be unstageable due to slough and/or eschar at the time of discharge but was previously numerically stageable during the home health quality episode, is considered new, and not coded as present at the most recent SOC/ROC.

If at discharge you have two stage 3 pressure ulcers, then M1311B1 - Number of Stage 3 pressure ulcers = 2. Assuming no other pressure ulcers/injuries are present M1311F1 Number of unstageable pressure injuries presenting as deep tissue injury = 0. If both stage 3 pressure ulcers present at discharge evolved from the DTI that was present at SOC/ROC, they would both be considered “present at the most recent SOC/ROC” and M1311B2 - Number of these Stage 3 pressure ulcers that were present at most recent SOC/ROC = 2. This is because they were both numerically staged as a stage 3 when first numerically stageable.

For M1311 – Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage, code based on the findings from the first skin assessment that is conducted on or after and as close to the actual time of the SOC/ROC as possible. Do not reverse stage. Consider current and historical levels of tissue involvement. If the pressure ulcer/injury was previously classified at a higher numerical stage than what is observed now, as long as it remains stageable, it should continue to be classified at the higher numerical stage until healed. If historical information is not available to inform the assessment of whether the ulcer/injury was previously classified at a higher numerical stage than what it is observed as now, code based on the current observation of the wound.