# Presentation: 056175

## MEDICARE

- Stages and ICD-9 Coding
**Joanne Lynn, MD**
**Quality Measurement & Health Assessment Group**
**Office of Clinical Standards and Quality**
**Centers for Medicare & Medicaid Services**September 28, 2007
- Joanne.Lynn@cms.hhs.gov

- FOR OFFICIAL USE ONLY

## Definitions

- Pressure ulcers are localized injuries to skin and underlying tissues associated with pressure and also with friction, immobility, poor nutrition, hard surfaces, and existing scars.
- The stages:
- I – persistent erythema (no actual ulcer)
- II – shallow ulcer or abrasion – skin remains
- III – Through the skin into subcutaneous tissues
- IV – To bone, tendon, or muscle

- FOR OFFICIAL USE ONLY

## STAGE I 

- FOR OFFICIAL USE ONLY

**Notes:**
What does it mean for an area of skin to be non-blanchable?

## Stage II

- FOR OFFICIAL USE ONLY

## Stage III

**Stage III**

- FOR OFFICIAL USE ONLY

## Stage IV

- FOR OFFICIAL USE ONLY

## Why (Temporarily) “Unstageable?”

- Some lesions are known but not able to be examined at a particular time – e.g., under a dressing or not debrided
- Some lesions are covered by an eschar or blister and best practice is to let healing take place until the skin breaks down
- Some lesions are injuries in evolution, for which the eventual extent of injury is unclear until the dead tissue demarcates

- FOR OFFICIAL USE ONLY

## Why Stage?

- Stage III and IV cause most of the suffering, care burden, and complications
- Stage III and IV appear to respond well to improved practices
- Stage I and II are (mercifully) much more common
- Stage I is not very reliably detected
- Combining all stages makes improvement hard to track

- FOR OFFICIAL USE ONLY

## For example – the National Nursing Home Improvement Collaborative

- Three dozen nursing homes
- Reporting data over more than a year
- While improving care practices

- FOR OFFICIAL USE ONLY

## No Change in Combined Stages I-IV

- FOR OFFICIAL USE ONLY

## BUT – Major Reduction in Stage III/ IV

- FOR OFFICIAL USE ONLY

## NNHIC results

- FOR OFFICIAL USE ONLY

## Measurable Components of Quality

-  Assessment of risk
-  Mitigation of risk – prevention
-  Rapid detection, characterization
-  Low incidence, low prevalence
-  Rapid healing of Stage 2
-  Aggressive healing of Stage 3 and 4

- FOR OFFICIAL USE ONLY

## About Measuring Quality Care

- Stage I has poor reliability (e.g., dark skin)
- Stage II incidence may respond only weakly to improved practices
- Stage III/IV incidence responds to improved practices
- Most Stage II can heal within a month
- Most Stage III/IV can heal, but slowly.

- FOR OFFICIAL USE ONLY

## Multiple functions for CMS measurement

- Quality measures
- Quality monitoring and improvement
- Payment
- Pay for performance
- Evidence of effectiveness
- Practicality, burden

- FOR OFFICIAL USE ONLY

## Proposed Minimum Data

- PU – Yes or No
- Risk Evaluation timely – Yes or No
- N at stage II, III/IV, and unstageable
- N by stage, incident with this provider
- N Stage II healed within a month
- Length, width of largest Stage III/IV
- Follow up on unstageable

- FOR OFFICIAL USE ONLY

## Reasons to change the Coding

- To enable tracking incidence and prevalence of Stage III/IV pressure ulcers (which cause suffering and nursing costs)
- Separately from Stage II (which are indicators of risk but much less harmful)
- To treat Stage I as a risk factor
- And thereby to enable cross-setting improvement activities

- FOR OFFICIAL USE ONLY

## The proposed changes

- 707 Chronic ulcer of skin (no change)
- 707.0 Decubitus (pressure) ulcer (no change)
*707.2 Decubitus (pressure) ulcer stages*
*707.20 – NOS, unstageable*
*707.21 – Stage I*
*707.22 – Stage II*
*707.23 – Stage III*
*707.24 – Stage IV*

- FOR OFFICIAL USE ONLY

## Support for the proposal

- CMS – multiple op-divs (survey and certification, clinical standards and quality, Medicare management, etc.)
- CDC – multiple op-divs (healthcare quality promotion, surveys, classifications)
- Experts from the professional wound care community

- FOR OFFICIAL USE ONLY