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MDS end-of-life wound coding changes leave providers with compliance, legal questions

The changes to end-of-life skin wound classification in the most recent Minimum Data Set update are ultimately a positive for long-term care, but regulatory ambiguity and potential legal concerns still surround the new coding procedures, experts explained Tuesday. 

“The regulatory changes that happened Oct. 1 are definitely going to impact our skilled nursing facilities and long-term care,” said Martha Kelso, CEO of Wound Care Plus. “If we’re not aware of the changes… we’re already behind the eight ball.”

A panel of experts in the field of wound care — hosted by the Post Acute Wound & Skin Integrity Council — offered advice on these complex issues to providers.

The new MDS changes overhauled much of the patient assessment process, including a key change to Section M, which covers skin conditions, they reminded. 

The Centers for Medicare & Medicaid Services now recognizes that some skin changes at the end of life may be inevitable, much like other forms of organ failure, and not the result of lapses in provider care quality. Such skin changes — often identified broadly as “skin changes at the end of life” (SCALE), or more narrowly as Kennedy Terminal Ulcers — can no longer be coded as pressure wounds or under Section M at all.

“This is a complete about-face,” Kelso said. “I applaud CMS for making those changes.” 

Identifying and reporting

Despite the change acknowledging the impossibility of avoiding some of these end-of-life wounds, the panel agreed that CMS left providers with unanswered questions about how such wounds should now be coded. 

“Quite frankly, I didn’t find a good spot,” Kelso said.

The panel acknowledged that improperly classifying skin changes could lead to lowered star ratings following audits or even to legal problems if there was evidence that end-of-life care was handled inappropriately.

Educating staff more about these types of wounds, and also more proactively talking with caregivers about end-of-life care can help, said Diane Krasner, a wound and skin care consultant. 

“Having reviewed dozens of these cases,” she said, “when there’s an end-of-life wound, we providers don’t do as good a job as we should in educating patients and families about what’s going on…. If you think you’re dealing with an end-of-life wound, there are very compelling reasons to talk to the families and explain to them what’s happening.”

More changes to come?

The lack of MDS clarity likely will require the creation of new codes in the future, Krasner believes. She acknowledged, however, that process is easier said than done — and it doesn’t address the current ambiguity.

Kelso suggested providers consider filing end-of-life wounds under alternate codes such as L98.9 or I8000. 

Part of the difficulty in properly coding these skin changes also arises from how difficult it can be to distinguish end-of-life skin changes from other wounds. Even after careful examination, it’s far from simple to definitively assess such wounds, explained Catherine Milne, a nurse and wound care expert at Connecticut Clinical Nursing Associates “We don’t have an actual test to say, ‘Yes, you have an end-of-life skin failure going on,’” Milne explained. “That is why it’s so hard sometimes to code [a skin change] and to explain to families.” 

The panel — hosted by PAWSIC President Jeanine Maguire — also included Vycki Nalls, director of learning and development at care provider CareBridge, and Karen Kennedy-Evans, a wound care consultant who was instrumental in the discovery of what are now called Kennedy Terminal Lesions and Ulcers.

They emphasized the importance of educating staff on how to identify and make note of skin conditions that are indicative of the end-of-life. This would include steps such as using patient self-reports and staff meetings, looking at both long- and short-term patient health signs and taking detailed notes about the characteristics of any skin abnormal conditions to provide detail as to how complex care decisions were made.

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