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n this issue, we will discuss a recent change to the Outcome and Assessment Information Set (OASIS) instructions by the Centers for Medicare & Medicaid Services (CMS). This change is related to how OASIS question M0488, Status of Most Problematic (Observable) Surgical Wound, should be answered. It is important because it can impact reimbursement as well as one of the Outcome-Based Quality Improvement (OBQI) outcome measures. There are other minor changes, all of which can be found in Chapter 8 of the OASIS User Manual (available at www.cms.gov).
       CMS is making this change following the Wound, Ostomy and Continence Nurses (WOCN) Society’s revision of its “Guidance Document on OASIS Skin and Wound Status M0 Items.” This document, originally published in 2001, was recently revised after a review of the latest evidence in the literature (available at www.wocn.org). Since 2001, the guidance document has been used as official CMS instructions for answering OASIS wound and skin questions.
       So, let us focus our attention on the change to answering M0488. The choices are “Fully granulating,” “Early/partial granulation,” or “Not healing.” The answer to M0488 documented during the start (or resumption) of care establishes a baseline of the most problematic surgical wound and is compared to the answer at discharge; it provides an objective measure of whether the wound improved.
       In the recent update of the WOCN Society’s OASIS guidance document, all references to the phrase “healing ridge” were removed because of the lack of scientific evidence supporting this finding in the assessment of surgical wounds closed by primary intention. The healing ridge is a palpable induration along the edges of a closed surgical incision believed to be due to collagen synthesis under the skin; it is a positive sign. The problem is that a healing ridge is not a conclusive finding, but the good news is that the revised document is much clearer without it.
       Let us review how the WOCN Society’s OASIS guidance document suggests that caregivers answer question M0488 for surgical wounds healing by primary intention (closed incisions):

(M0488) Status of Most Problematic (Observable) Surgical Wound:
1 - Fully granulating
2 - Early/partial granulation
3 - Not healing
NA - No observable surgical wound

       Answer question M0488 for a closed surgical incision as “Fully granulating” when:
• The incision is well approximated and there is complete epithelialization of incision, and
• There are no signs or symptoms of infection.
       Answer M0488 for a closed surgical incision as “Early/partial granulation” when:
• The incision is well approximated but not completely epithelialized, and
• There are no signs or symptoms of infection.
       Answer M0488 for a closed surgical incision as “Not-healing” when:
• The incision is separated, or
• There is incisional necrosis, or
• There are signs or symptoms of infection.
       Let us cover a few key terms as well. Complete epithelialization would be noted when resurfacing had been accomplished. A closed incision resurfaces when the sides of the incision fuse together and no areas of separation can be observed. Signs or symptoms of infection include purulent exudate and redness and tenderness in surrounding skin. Incisional separation would be noted when the sides of the incision have pulled apart in one or more areas. Incisional necrosis would be noted when slough or eschar were present along the incision. Slough may appear as yellow or white material and be either loose or adherent. Eschar may appear as black or brown and may be loose or adherent as well.
       While change is never easy, we feel that most clinicians will find the revised WOCN Society’s OASIS guidance document clearer and the OASIS wound and skin questions easier to answer—and everyone can be confident that it was revised in 2006 to reflect the latest evidence available.

Questions and Answers

       Question: How should the wound and skin “M0” items be marked when the patient’s surgical wound heals during the course of care?
       Answer: If the patient’s surgical incision on admission is well approximated but not completely epithelialized and no signs and symptoms of infection are present, question M0488 should be answered “Early/partial granulation.” If the patient is on service for some time and the wound heals, it would be considered a scar on the discharge or follow-up OASIS assessment. Question M0440 (Does this patient have a Skin Lesion or an Open Wound?) would be answered “Yes,” and M0482 (Does this patient have a Surgical Wound?) would be answered “No.”
       Question: Why was consideration of the “healing ridge” eliminated in answering M0488 during this update?
       Answer: When the WOCN Society conducted its periodic review of the literature and update of the guidance document, it found that there was a lack of scientific evidence supporting the finding of the healing ridge in the assessment of surgical wounds closed by primary intention.
       Question: What if the physician does not want the surgical dressing to be removed and the wound is not observable?
       Answer: Select “NA - No observable surgical wound” for M0488. You know there is a surgical wound present, but you are unable to describe the wound status because the wound cannot be observed. Remember that CMS allows an OASIS assessment to be completed over more than one visit. This is one of the primary reasons for this guideline. It is better to hold off completion of the OASIS and have a complete and accurate assessment than to present an incomplete picture of the patient status.
       Question: Will this change result in surgical incisions having a negative impact on our OBQI results related to “Improvement in status of surgical wounds”?
       Answer: This will not have a negative impact as long as your admitting clinicians accurately document when an uncomplicated surgical incisions progresses from early/partial granulation to fully granulating or to a scar.
       Question: How long does it take a closed incision to completely reepithelialize?
       Answer: It is difficult to define a specific timeframe for reepithelialization of a closed incision because it varies depending on factors like age, nutrition, comorbidities, and activity level.