SNF QRP Part 3: Pressure Ulcers that are New or Worsened

This measure, selected by CMS as part of the SNF QRP, will measure the percentage of residents with Stage 2 – 4 pressure ulcers that are new or worsened since admission to the SNF. This measure is identical to the short stay measure currently in place, for short stay residents, that measures the same quality data.

This Quality Measure (QM) was adopted to meet the requirements of the IMPACT Act of 2014 addressing the domain of skin integrity and changes in skin integrity.

Pressure ulcers are a serious medical condition that can have a profound effect not only on the resident’s quality of life but also a significant financial burden on the health care system. SNF providers need to have strong clinical systems in place to prevent development of or worsening of pressure ulcers.

Calculating the Pressure Ulcers that are New or Worsened Quality Measure

As with all QRP Quality Measures the data used for calculating this QM will come from the MDS. Specifically, data will be derived primarily from MDS item M0800.

The actual measure will be calculated as follows:

Denominator: Number of short stay residents with one or more MDS 3.0 assessments that are eligible for a look-back scan except those with exclusions.

Exclusions: Dashes in M0800, short stay resident with no initial assessment available to derive data for risk adjustment (covariates).

Numerator: The numerator is the number of short stay residents with an MDS 3.0 assessment during the selected time period who have one or more Stage 2-4 pressure ulcers reported in M0800 as new or worsened, based on a review of all assessments completed for this resident during their episode of care.

Stage 2 (M0800A) > 0, or

Stage 3 (M0800B) > 0, or

Stage 4 (M0800C) > 0

To determine which residents that will be included in the numerator all scheduled PPS assessments, OBRA Assessments, Discharge Assessments and SNF PPS Part A Discharge Assessments will be reviewed.   This is known as the look back scan.

This measure also has several risk adjustments (covariates) that will also be factored into the calculation of the QM.  Each of the following covariates will be determined based on the coding of the initial assessment (first assessment) completed for the resident:

  • Requiring limited or more assistance in bed mobility self performance.
  • Bowel incontinence at least occasionally.
  • Diagnosis of diabetes or peripheral vascular disease.
  • Low Body Mass Index (BMI)

Resident’s who meet any of the covariate requirements will still be included in the overall QM calculation (they are not exclusions) however the facility overall score will be adjusted to account for these resident characteristics that place the resident at higher risk of developing pressure ulcers.

Example 1: Mr. Jones was admitted to the SNF directly from a 3-day hospital stay. Mr. Jones was in the SNF for a total of 75 days and then discharged to home. His initial assessment (Admission/5-day) indicates that he had no pressure ulcers. His 30-day assessment indicates that he developed a Stage 2 pressure ulcer that was appropriately coded in M0300B and M0800A. This would be considered a new or worsened pressure ulcer and Mr. Jones would meet the criteria for this quality measure.

Example 2: Mrs. Smith is admitted to the SNF after an extended hospital stay of 2 weeks. Mrs. Smith was noted to have a Stage 3 pressure ulcer of the right heel upon admission and was appropriately coded on the initial assessment (Admission/5-day) in M0300C as present on admission. The pressure ulcer remained a stage 3 during the entire stay. Mrs. Smith would not qualify for this QM as she was admitted with the pressure ulcer and it did not worsen nor did she develop any other new pressure ulcers (M0800).

Quality Measure Accuracy

Since all QM data is derived from the MDS 3.0 it is important that the SNF staff responsible for coding of Section M have a clear understanding of the current coding rules related to this section.

The CMS Survey and Certification Memo (S&C 15-25-NH) has identified several areas in Section M that contain significant % of inaccuracies, including M0800, as shown here.

Assessing for and identifying pressure ulcers upon admission and assigning an accurate stage will be a key ingredient to accurate calculation of the QM for this domain.

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In addition, understanding the coding rules for M0800, which can be somewhat tricky, will ensure a more accurate QM outcome. For accuracy in coding of M0800 there are 2 main things to know:

  • Pressure ulcers coded as “present on admission” in M0300 should not also be coded as a new or worsened pressure ulcer in M0800.

Example: Resident has a stage 2 pressure ulcer and is sent to the hospital. Upon their return, the stage 2 pressure ulcer has evolved into a stage 3 pressure ulcer while in the hospital. This ulcer would be coded as “present on admission” in M0300C and would not be coded in M0800B as a worsened pressure ulcer.

  • Definition of “worsened pressure ulcer”:

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