On a discharge OASIS, consider a pressure ulcer documented at the start of care and then documented at discharge at the same stage as “present at the most recent SOC/ROC” when completing the M1311 (Current number of unhealed pressure ulcers/injuries at each stage).
This guidance is true even if the original pressure ulcer healed and reopened during the episode, answer No. 1 of the January 2021 CMS OASIS Q&A states.
“In addition to coding the pressure ulcer as ‘present at the most recent SOC/ROC,’ a previously closed pressure ulcer that opens again should be reported at its worst stage,” CMS adds.
This was a helpful clarification on how to answer M1311. Otherwise, it is potentially confusing when patients have a wound that heals and then reopens again during care.
This was just one of 10 answers provided by CMS in their January quarterly Q&As published to the CMS website.
In addition to providing clarity on discharge following a telehealth encounter, CMS also provided further guidance on M1810 (Ability to dress upper body) and M1820 (Ability to dress lower body, as well as responding to several GG items.
View the CMS Q&As: https://qtso.cms.gov/system/files/qtso/CMS_OAI_4th%20Qtr_2020_QAs_January%202021_Final_508.pdf