M1342: CMS OASIS Q&As

When assessing a surgical incision that has been cemented rather than sutured, follow the same guidance found in Chapter 3 of the OASIS Guidance Manual, M1342 Status of most problematic surgical wound. 1. If the wound can be visualized, it is observable. Only surgical wounds that have a dressing that cannot be removed as directed by the physician/allowed practitioner and obscures visualization of the incision are considered non-observable. 2. For the purposes of determining the healing status, a surgical wound can be considered fully healed and not reportable as a current surgical wound approximately 30 days after complete epithelialization. The incision must be clean, dry and completely closed with no signs or symptoms of infection. 3. The Status of Most Problematic Surgical Wound that is Observable (M1342) is determined by assessment of the skilled clinician following the definitions outlined in Chapter 3 of the OASIS Guidance Manual, M1342 Status of most problematic surgical wound.

A surgical wound with staples in place would only be considered not healing if it meets the definition of not healing as outlined in the OASIS Guidance Manual.

For the purposes of scoring M1342 - Status of Most Problematic Surgical Wound that is Observable, openings in the skin, adjacent to the incision line, caused by the removal of a staple or suture, are not to be considered part of the surgical wound when determining the status of the surgical wound. The status of these sites would be included in the comprehensive assessment clinical documentation. When determining the healing status of the incision, follow the definitions outlined in the OASIS Guidance Manual, in addition to other relevant current CMS Q&As. The status of "Not healing" would only be selected if the wound, excluding the status of the staple/suture site(s), meets the healing status descriptors.

Surgical incisions healing by primary intention do not granulate. Because of this the only response that could be appropriate for a surgical wound healing by primary intention would be 0-Newly epithelialized or 3-Not healing. “Newly epithelialized” should be chosen if the surgical incision has epidermal resurfacing across the entire wound surface, and no signs/symptoms of infection exist.

When a needle is inserted and removed from an implanted venous access device, it is possible that the skin that was pierced by the needle could have a resulting wound that would heal by secondary intention. Usually, with good access technique and current needle technology there will be no perceptible wound. Occasionally, if there was an extremely large bore needle or traumatic entry or removal, there may be a resulting wound that heals by secondary intention. In this situation, the accessing clinician would rely on guidance outlined in the OASIS Guidance Manual to determine the healing status. Note that a scab is a crust of dried blood and serum and should not be equated to either avascular or necrotic tissue when applying the guidance. Therefore, while the presence of a scab does indicate that full epithelialization has not occurred in the scabbed area, the presence of a scab does not meet the criteria for reporting the wound status as "Not healing".

The assessing clinician must determine the healing status of a wound following guidance in Chapter 3 of the current OASIS Guidance Manual and related CMS OASIS Q&As. Some sites, because they are being held open by a line or needle, cannot fully granulate and may remain "non-healing" while the line or needle is in place.

Assuming the assessing clinician determines the peritoneal catheter site is the most problematic observable surgical wound, the clinician would determine the healing status of the wound following the definitions provided in the OASIS Guidance Manual, Chapter 3, M1342 Status of Most Problematic Surgical Wound that is Observable Coding Instructions. The peritoneal catheter exit site cannot fully granulate and/or epithelialize because of the presence of the catheter. In this scenario Response 3 - Not healing for M1342 would be appropriate.

M1342 - Status of Most Problematic Surgical Wound that is Observable is reporting healing status based on the clinician's assessment of the patient and visualization of the wound. Since the patient could be at the point in the course of the antibiotic regimen where the infection has resolved, ongoing treatment for an infection should not be the sole basis for selecting 3 Not healing, unless signs and symptoms of infection are currently present.