Wound Care Documentation: Updates for Hospice Clinicians

What’s Changing: A Look at Section M of HOPE

You’ll likely recognize HIS, the Hospice Item Set, as part of standard hospice data collection since 2017.  Now, the Centers for Medicare & Medicaid Services (CMS) has developed a new patient assessment tool as its replacement: Hospice Outcomes and Patient Evaluation, or HOPE.

HOPE builds on the previous information collected in HIS, including several new sections. One particular part of interest  is Section M, which documents “the presence, type and current treatment of various skin conditions” and “identifies patients at risk for further complications.” ¹

Here’s a look at the top areas of focus:

M1190: Skin Conditions

If  “yes” is selected to this question, that means that the clinician has identified a skin issue.  Additionally, they will need to answer the following two questions. Marking “no” indicates there are no relevant skin conditions present at the time of assessment and the following two questions will be skipped.

M1195: Types of Skin Conditions

To correctly respond to this subsection, the clinician will need to identify if any of the eight skin condition categories are present, as explained by the HOPE Guidance Manual¹:

A. Diabetic foot ulcer(s)

Diabetic foot ulcers are open wounds or sores that are often difficult to heal. Caused by the neuropathic and blood vessel complications of diabetes, they can often progress because patients have decreased pain awareness in the feet and dry, cracked skin.

B. Open lesion(s) other than ulcers, rash, or skin tear

Lesions falling into this category can include those that develop as part of a disease — such as boils, cysts and vesicles. Note that trauma-related lesions are excluded.

C. Pressure ulcer(s)/injuries

The National Pressure Injury Advisory Panel (NPIAP) defines pressure injuries as “localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device,” occurring “as a result of intense and/or prolonged pressure or pressure in combination with shear.”²

These injuries can present differently depending on NPIAP-defined stages:

• Stage 1: In this initial stage, the skin remains intact but shows a persistent, non-blanchable redness when pressed. In individuals with darker skin tones, the area may appear discolored rather than red. The affected area may also be painful, firm, soft, warmer, or cooler compared to adjacent tissue.
• Stage 2: This stage involves partial-thickness loss of the dermis, presenting as a shallow open ulcer with a red-pink wound bed, without slough (dead tissue). It may also appear as an intact or open/ruptured serum-filled blister. The injury does not extend past the level of the dermis.
• Stage 3: At this stage, there is full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Necrotic tissue, like slough,  may be present but does not obscure the depth of tissue loss.
• Stage 4: This stage involves full-thickness tissue loss with exposed bone, tendon, cartilage, ligament or muscle. Slough or eschar (a dark, necrotic tissue) may be present on some parts of the wound bed.
• Unstageable pressure injuries.
• Deep tissue pressure injuries.
• Medical device-related pressure injuries. 
• Mucosal membrane pressure injuries.

D. Rash(es)

According to the National Cancer Institute, rashes are skin areas showing texture or color changes. They may be red, warm, scaly, bumpy, dry, itchy, swollen, cracked or painful and can appear in multiple areas or just one.³

E. Skin tear(s)

This category includes all partial or full-thickness tears, which are a result of shearing, friction or trauma causing skin layer separation. The International Skin Tear Advisory Panel (ISTAP) defines three types:

• Type 1: No skin loss.
• Type 2: Partial flap loss.
• Type 3: Total flap loss.

F. Surgical wound(s)

A surgical wound is an incision or cut made through the skin and tissues during a surgical procedure. According to the HOPE guidance, surgical wounds don’t include:

• Healed surgical sites and stomas.
• Lacerations that require suturing or butterfly closure.
• Peripherally inserted central catheter (PICC), central line and peripheral IV sites.

G. Ulcers other than diabetic or pressure ulcers (e.g. venous stasis ulcer, Kennedy ulcer)

Other examples of ulcers that might be included in this category are non-diabetic neuropathic and arterial/ischemic ulcers.

H. Moisture Associated Skin Damage (MASD)

MASD is superficial skin damage caused by sustained exposure to moisture; it’s a risk factor for pressure ulcer/injury development.  This moisture can be from a variety of sources, such as perspiration, wound exudate, effluent, urine, saliva, etc.

Z. None of the above were present

Keep in mind that, by this point, M1190 was checked “yes”  to indicate that some kind of skin condition is present. Therefore, checking this box is stating that a skin condition is present but it isn’t listed above.

M1200: Skin and Ulcer/Injury Treatments

This section asks the clinician to identify treatments and interventions being utilized.  Only interventions used at the time of the assessment should be chosen. This is a multi-select response, so all interventions should be identified, including:

A. Pressure reducing device for chair

B. Pressure reducing device for bed

C. Turning/repositioning program

D. Nutrition or hydration intervention to manage skin problems

E. Pressure ulcer/injury care

F. Surgical wound care

G. Application of nonsurgical dressings (with or without topical medications) other than to feet

H. Application of ointments/medications other than to feet

I. Application of dressings to feet (with or without topical medications)

J. Incontinence management

Z. None of the above were provided

Note that by marking “Z,” a clinician is stating that a skin condition does exist but no interventions have been utilized. This would not be an optimal situation.

Why it Matters?

Understanding the above questions and responses is crucial for complete and correct Medicare documentation — which, in turn, is necessary for compliance, future funding and most-importantly patient quality of life. Because this level of focus on skin conditions is new, hospice clinicians may not be familiar with the nuances of wound identification and differentiation.  It is therefore necessary to analyze knowledge gaps in hospice teams and train accordingly. Ultimately, these new requirements may require additional research, training and support.