Centers for Medicare & 
Medicaid Services (CMS) 
Special Open Door Forum (SODF) 

Patient Protection and Affordable Care Act (ACA) 
Section 3004: Quality Reporting Program for 
Long-Term Care Hospitals 

Section M Update and Commonly Asked Questions 

Thursday, August 30, 2012 
2:00-3:30 pm EST 


Presentation Overview 

This presentation will provide: 
.Updates to Section M: Skin Conditions 
.Review answers to select commonly asked 
questions for Section M 
.Review answers to select commonly asked 
questions for Section A and Section Z 






Objectives 

Understand clarifications and changes 
made to Section M. 
Code Section M items correctly and 
accurately. 
Review answers to commonly asked 
questions. 



Key Updates to Section M 

72 hours has been changed to 3 calendar 
days. 
Look-back period has been changed to 
assessment period. 
Definitions of numerical staging and 
unstageable pressure ulcers have been 
clarified. 
Slough and eschar are both considered necrotic 
tissue. Therefore, necrotic (eschar) was 
changed to eschar. 



Overview of Section M Items 

M0210. Unhealed Pressure Ulcer(s) 
M0300. Current Number of Unhealed Pressure 
Ulcers at Each Stage 
M0610. Dimensions of Unhealed Pressure 
Ulcers 
M0700. Most Severe Tissue Type for Any 
Pressure Ulcer 
M0800. Worsening in Pressure Ulcer Status 
(Discharge Data Sets) 



Item M0300 

Current Number of 
Unhealed Pressure Ulcers 
at Each Stage 


M0300 Current Number of Unhealed 
Pressure Ulcers at Each Stage 

This measure documents 
the current number of 
unhealed pressure ulcers 
for each stage. 
Numerical stages 2-4 and 
unstageable ulcers 
require the long-term care 
hospital (LTCH) to 
document ulcers that are 
present on admission 
(POA). 


Image of MO300 Current Number of Unhealed Pressure Ulcers at Each Stage. Shows the boxes in which number of ulcers, by stage, should be entered. None of the boxes are coded.

Steps for Completing M0300 
A-G  Step 3: POA 

Two clarifying statements have been 
added: 
.The first refers to adhering to clinical 
standards of practice for clinical admission 
assessments. 
.The second refers to how the 3-day 
assessment period is reconciled with the 
POA definition. 






M0300 Scenario 

Per facility policy, initial clinical admission skin 
assessment was completed on new patient Miss 
J. on day 1 of her stay. It was identified that Miss 
J. has one Stage 2 pressure ulcer. 
By day 3, the wound has worsened and is 
restaged as a Stage 3 pressure ulcer. 
How should Items M0300B1 and M0300B2 be 
coded on the LTCH Continuity Assessment 
Record and Evaluation (CARE) Data Set 
Admission Assessment? 



Scenario Coding 

Code M0300B1 Number of Stage 2 
Pressure Ulcers as 1. 
Code M0300B2 as 1 Present on 
Admission. 
.Rationale: The Stage 2 pressure ulcer is the 
ulcer that was initially staged on the clinical 
admission skin assessment as POA. 






Item M0700 

Most Severe Tissue Type 
for Any Pressure Ulcer 


M0700 Most Severe Tissue Type 
for Any Pressure Ulcer 

This measure documents the most severe 
tissue type present in any pressure ulcer 
bed. 
Each tissue type refers to tissue that is 
visible in different stages as wounds 
evolve and heal. 
The list in M0700 is arranged from the 
healthiest types of tissues to the most 
devitalized. 



Necrotic Tissue 

There are two types of necrotic tissue: 
.Slough  which is nonviable yellow, tan, 
gray, green, or brown tissue. It is usually 
moist, and can be soft, stringy, mucinous 
with adherence to the base of the wound or 
present in clumps in the wound bed. 





Image of slough on a pressure ulcer.

Necrotic Tissue (cont.) 

.Eschar  which is dead or devitalized tissue; 
hard or soft in texture and is usually black, 
brown, or tan. It may appear scab-like and is 
usually firmly adherent to the base of the 
wound and often to the sides/edges of the 
wound. 


Image of a pressure ulcer filled with eschar.

M0700 Scenario 

A patient has two pressure ulcers. One is 
a Stage 2 pressure ulcer on the right 
ischial tuberosity that is healing. It has 
epithelial tissue that has resurfaced 25% 
of the ulcer. The second is a Stage 3 
pressure ulcer on the sacrum that is filled 
with 75% granulation tissue. How should 
item M0700 be coded? 



Scenario Coding 

Code as 2. Granulation Tissue. 
Coding is based on the sacral ulcer, which has 
the most severe tissue type. 
.Rationale: Granulation tissue is the most severe 
tissue type present in the wound. 





Item M0700 Most Severe Tissue Type from the LTCH CARE data set. The item is coded as 2.

Item M0800 

Worsening Pressure 
Ulcer Status 
(Discharge Data Sets) 


M0800 Worsening 
Pressure Ulcer Status 

This measure documents, on the discharge 
assessment, the number of pressure ulcers that 
have worsened as compared to the prior 
assessment. 
The worsened definition includes 
.Number of new pressure ulcers 
AND/OR 


.Number of pressure ulcer(s) that have increased 
(worsened) in numerical stage. 






M0800 Coding Guidelines 

Text was added to this item to further 
clarify coding for numerically staged POA 
pressure ulcers that become stageable, 
are debrided, and can be numerically 
staged. 



M0800 Scenario 

A patients admission assessment documented an 
unstageable pressure ulcer due to slough on the 
right ischial tuberosity. 
Five days into the LTCH stay, the patients 
pressure ulcer was debrided and was numerically 
staged as a Stage 3. 
On discharge, it is noted that the pressure ulcer 
was reassessed and has increased in numerical 
stage (i.e., worsened) to a Stage 4. 
How should item M0800 be coded? 



Scenario Coding 

Code M0800A, Worsening  Stage 2, as 0. 
Code M0800B, Worsening  Stage 3, as 0. 
Code M0800C, Worsening  Stage 4, as 1. 
.Rationale: The Stage 3 is not considered in the 
worsening item because it was the first time the 
pressure ulcer was numerically staged. 
Subsequently, the pressure ulcer increased in 
numerical stage and is therefore documented as 
worsened at M0800C Stage 4. 






Section M - FAQs 

Q. Why has CMS adapted National Pressure Ulcer 
Advisory Panel (NPUAP) guidelines related to blisters 
and Deep Tissue Injury (DTI)? 

A. CMS consulted subject matter experts for clinical 
validation of pressure ulcer coding. At the time these 
items were finalized, it was determined that there was 
much that current science was unable to confirm 
regarding DTI. CMS opted for an holistic approach to 
pressure ulcer assessment that included characteristics 
of surrounding skin instead of a pure focus on what 
color fluid was visible inside of an intact blister. 


Section M  FAQs (cont.) 

Q.POA pressure ulcers are only allowed to be coded in 
acute hospitals when physicians or those with legal 
authority to make medical diagnoses have 
documented a POA pressure ulcer. So why is 
nursing documentation allowed in LTCH for coding 
POA pressure ulcers? 

A.POA coding for short-stay acute hospitals focuses 
on billing codes specifically for purposes of 
Medicare payment under the Inpatient Prospective 
Payment System (IPPS). There are no CMS POA 
regulations related to Medicare payment in LTCHs 
at this time. 


Section M  FAQs (cont.) 

Furthermore, State Nurse Practice Acts 
differ among states as to who can stage 
pressure ulcers. 
The American Nurses Association has 
confirmed that it is within the scope of the 
nurse to stage pressure ulcers. 



Section M  FAQs (cont.) 

Q. Why are pressure ulcers that have been repaired with 
grafting procedures considered surgical wounds and not 
coded as pressure ulcers? 

A. Due to the surgical intervention tissue has been moved 
from the patient to close the pressure ulcer. Grafting 
provides the tissue to assist in that closure. Therefore, 
this is a surgical closure of the wound and no longer able 
to be staged or classified as a pressure ulcer if this 
surgical wound dehisced. Therefore, for purposes of 
coding the LTCH CARE Data assessments, a pressure 
ulcer that has been repaired by a grafting procedure is 
considered a surgical wound and is not coded on the 
LTCH CARE Data assessment as a pressure ulcer. 


Section M  FAQs (cont.) 

Q. How are Kennedy Ulcers to be 
documented in the LTCH CARE Data 
Set? 

A. Kennedy Ulcers are considered pressure 
ulcers; therefore, they should be coded 
as pressure ulcers in the LTCH CARE 
Data Set, Section M, at the appropriate 
stage. 


Section M  FAQs (cont.) 

Q. If a patient had an identified Stage 2 pressure ulcer on the 
clinical admission assessment and on Day 2, the 
pressure ulcer was now a Stage 3, as I understand it, it is 
coded as Stage 3, not POA. Is that correct? 

A. No, the LTCH CARE Data Set requires that the skin 
condition documented be from the skin assessment 
obtained as close to the time of admission as possible, so 
in this case, the Stage 2 is what would be coded on the 
Admission Assessment as POA. 

 If on the Discharge Assessment, this pressure ulcer is still 
a Stage 3, it would be coded as a Stage 3, worsened, and 
not POA. 


Section M  FAQs (cont.) 

Q. What do we do if a pressure ulcer worsens during the first 3 days of 
the patients admission to the LTCH? How do we code the wound? 

A. The patient assessment reflected in the Admission Assessment 
data set should coincide with the patients Admission Assessment 
for the purposes of determining if a pressure ulcer was POA. A 
wound determined to be POA would specifically need to be on 
admission. Thus, if a POA wound worsened during the 3 days, the 
admission assessment record should capture the wounds stage at 
admission and the stage to which it worsened. On the discharge 
record, the wound would be captured in the stage to which it 
worsened, if it had not healed. Still, the wound, because it 
worsened, would no longer be captured as POA. 


Section M  FAQs (cont.) 

Q. On Day 2 of the 3-day assessment period, a pressure ulcer was 
assessed as unstageable. On Day 5, the wound was debrided 
and staged as a Stage 3. On Day 24, the day of discharge, the 
wound was restaged as a Stage 4. How would this scenario be 
coded on the Admission and Discharge Assessments? 

A. On the Admission Assessment, it would be coded as 
unstageable and POA. On the Discharge Assessment, it would 
be coded as a Stage 4, worsened, not POA. This is because the 
first time it was able to be numerically staged after debridement, 
it was staged as a Stage 3 then subsequently increased in 
numerical staging (worsened) to a Stage 4 prior to discharge. 


General  FAQs 

Q. I need clarification on the definition of LTCH. Are these long-term 
acute care hospitals or long-term care hospitals? 

A. Long-term care hospitals (LTCHs) and long-term acute care 
hospitals are different names for the same type of 
hospital. Medicare uses the term long-term care hospitals. These 
hospitals are certified as acute care hospitals that treat patients 
requiring extended hospital-level care, typically following initial 
treatment at a general acute care hospital. If a hospital is classified 
as an LTCH for purposes of Medicare payments (as denoted by the 
last 4 digits of its 6-digit CMS Certification Number [CCN] in the 
range of 20002299), it is subject to the requirements of the 
LTCH Quality Reporting Program. If your critical access hospital 
(CAH) has long-term care beds that either provide skilled nursing 
facility-level or nursing facility-level care, it is not required to comply 
with a requirement that was mandated for LTCHs, which are 
hospitals. 


General  FAQs (cont.) 

Q. Where can I find the definitions for the LTCH quality measures? 

A. For most current and up-to-date definitions for the three LTCH 
quality measures  catheter-associated urinary tract infection 
(CAUTI; NQF#0138), central line-associated bloodstream 
infection (CLABSI; NQF#0139), and pressure ulcer (#0678)  
please refer to the LTCH Quality Reporting Program Manual 
available for download at: http://www.cms.gov/Medicare/Quality-
Initiatives-Patient-Assessment-Instruments/LTCH-Quality-
Reporting/index.html. 

 We also invite you to visit this Web site for updates to measure 
specifications for each of these measures that may result from 
the National Quality Forums review of these measures. 


General  FAQs (cont.) 

Q. Do we report patients with all payer sources for CAUTI, CLABSI, 
and pressure ulcers for LTCH or just patients admitted with 
Medicare payer source? 

A. For the pressure ulcer measure, the LTCH CARE Data Set 
applies to all patients receiving inpatient services in a facility 
certified as a hospital and designated as an LTCH under the 
Medicare program. Data collection using the LTCH CARE Data 
Set applies regardless of patients age, diagnosis, length of stay, 
or payment/payer source (Chapter 2, Section 2.1). 

 For the CLABSI and CAUTI measures, each LTCH must submit 
data for these measures on all patients from all inpatient 
locations, regardless of payer source (Chapter 5, Section 5.1). 


General  FAQs (cont.) 

Q. Are all demographic information items required? 

Q: Are GG0160C (Functional Mobility: Lying to Sitting on Side 
of Bed); H0400 (Bowel Incontinence); I0900. (PVD/PAD 
[peripheral vascular disease/peripheral arterial disease]); 
I2900 (Diabetes); K0200A (Height); and K0200B (Weight; 
required only for admission assessments)? 

A. Please refer to the LTCH Quality Reporting (QR) Program 
Manual, available for download at 
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/LTCH-Quality-
Reporting/index.html. Appendix E provides item-specific 
guidance on requirements for the completion of the LTCH 
CARE Data Set. 


Section A  FAQs 

Q. What is the definition for planned discharge? 

A.A planned discharge is one in which the patient is 
nonemergently, medically released from care at the LTCH 
due to some reason arranged for in advance. 


Section A  FAQs (cont.) 

Q. What is the definition for unplanned discharge? 

A: An unplanned discharge is: 

A transfer of the patient to be admitted to another hospital/facility that results 
in the patients absence from the LTCH for longer than 3 days (including the 
date of transfer); or 
A transfer of the patient to an emergency department of another hospital in 
order to either stabilize a condition or determine if an acute-care admission 
is required based on emergency department evaluation, resulting in the 
patients absence from the LTCH for longer than 3 days; or 
When a patient unexpectedly leaves the LTCH against medical advice; or 
When a patient unexpectedly decides to go home or to another setting (e.g., 
due to the patient deciding to complete treatment in an alternate setting). 
Unplanned discharges do not include planned transfers to acute-care 
inpatient hospitals for admission for planned interventions, treatments, or 
procedures, unless the patient does not return to the LTCH within 3 days. 



Section A  FAQs (cont.) 

Q. Can CMS please clarify whether there is a 72-hour rule or a 3-
calendar-day rule in the following instances: 
1. When a patient leaves an LTCH to go to another facility and 
then returns to the LTCH, for purposes of determining whether 
to submit a discharge assessment? 
2. When a patient dies within 72 hours or 3 days after leaving an 
LTCH for another facility? 

A. The 3-day interrupted stay is in accordance with the payment 
policies that have been established. If the policy states that day 
1 of 3 begins on the day of transfer, then that day plus 2 would 
dictate the definition of the 3 days. If a patient dies during an 
interrupted stay, then the LTCH should submit an Expired data 
set. If the patient dies afterward, the LTCH should have 
submitted a Discharge item set because the patient did not 
return within 3 days. 


Section A  FAQs (cont.) 

Q. If patients planned discharge is Friday, but the discharge 
is delayed until Sunday, what should the assessment 
reference date (ARD) be? 

A. The ARD on discharge assessment will always be the 
patients actual discharge date (Chapter 2). The LTCH 
has 5 days to complete the Discharge Assessment. 

Q: If patient dies during the Assessment Period, should you 
fill out both Admission and Expired Assessments? 

A: Yes, both admission and expired assessments should be 
completed. The ARD for Expired Assessment would be 
the date of death. 


Section Z  FAQs 

Q. Should the signature sections be filed and held at the 
hospital? If so, how long should they be kept? 

Q: Do I have to retain Section Z? 

A. CMS will not be receiving the signatures provided in 
Section Z, Z0400 and Z0500. We will receive the 
submission date. We strongly suggest that you retain 
what you submit to CMS, including Section Z, according 
to your facility and State regulations and requirements. 
Facilities should comply with their requirements pertaining 
to electronic signatures, if they require them. 


Section Z  FAQs (cont.) 

Q. Does the LTCH CARE Data Set require the signature of a 
registered nurse? 

A. No. CMS has removed the language surrounding and 
requirement for a registered nurses signature for the 
LTCH CARE Data Sets submission. 

Q. Does the LTCH CARE Data Set require that the LTCH 
have an assessment coordinator on staff? 

A. No. CMS has removed language pertaining to an 
assessment coordinator. 


Materials from LTCH SODF 

 Presentation slides will be posted at the following site: 
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/LTCH-Quality-Reporting/index.html 

 Transcript and audio file will be posted at the following site: 
http://www.cms.gov/Outreach-and-
Education/Outreach/OpenDoorForums/ODFSpecialODF.html 

 For SODF updates and call-in information, please refer to the 
following site: http://www.cms.gov/Outreach-and-
Education/Outreach/OpenDoorForums/ODF_SNFLTC.html 

 Please submit your questions regarding the LTCHQR 
Program to CMS at: LTCHQualityQuestions@cms.hhs.gov 


