Is It a Surgical Wound? (M1340 / M1040)

This is one of the highest-error items on OASIS, because clinical instinct and the OASIS definition do not agree. A wound that obviously came from surgery is often not a surgical wound for this item, and a device site that looks like nothing at all often is.

Answer the item by the list, not by intuition.

Yes — this is a surgical wound

• A surgical takedown or reversal of a previous ostomy, which creates a wound
• Orthopedic pin sites
• An abscess treated with incision and drainage — only if a drain has been placed
• Central line sites, Mediport sites, portacath sites, implanted venous access devices — even if the implantation site has healed, and whether or not the device is functional or currently accessed
• Implanted infusion devices, even if not presently functional
• Peritoneal dialysis catheters and AV shunts — even if abandoned
• Muscle flap, skin advancement flap, or rotational flap used to surgically replace a pressure ulcer
• Shave, punch, or excisional biopsy to remove or diagnose a lesion
• Skin graft donor site
• Skin graft applied to a burn or a pressure ulcer
• A surgical procedure performed via arthroscopy
• Total surgical excision of pressure ulcer damage
• Paracentesis site, if a drain was placed
• I&D with drain placement
• Wounds with drain placement — even after the drain is removed, if the opening was created percutaneously or the drain was inserted into a puncture site such as a stab wound
• Procedures beyond simple I&D, such as excision of necrotic mass, mesh, or other appliances or structures
• Surgical repair of traumatic injury — ruptured organs, torn tendons, ligaments, or muscles, and fractures — beyond simple suture of a laceration
• LVAD exit site
• An incision or "cut down" created to perform a procedure, such as a femoral sheath
• Incision site until healed for a pacemaker, internal defibrillator, VP shunt, or balloon catheter
• A procedure beyond simple excision of a toenail

No — this is not a surgical wound

• All ostomies — any opening ending in "-stomy", with or without a drain
• An ostomy site closing on its own, without surgical reversal
• Chest tube site, with or without a drain or tube
• The surgical line around a fresh ostomy stoma — the peristomal or mucocutaneous suture line
• Debridement — it does not turn a burn, pressure ulcer, stasis ulcer, or traumatic wound into a surgical wound
• Simple I&D of an abscess without drain placement
• Simple closure of a traumatic laceration by sutures or stitches
• Cardiac catheterization performed via needle puncture, even if a stent was placed
• PICCs — even if insertion required fluoroscopy
• Implanted pacemakers and internal defibrillators after the original incision has healed
• External infusion device infusing medication subcutaneously
• Arthrocentesis, thoracentesis, and paracentesis sites used for simple aspiration of fluid
• I&D with bone biopsy within a diabetic foot ulcer
• Peripheral IVs sutured in place
• A pressure ulcer sutured shut
• Cataract surgery
• Surgery to a mucosal membrane
• Gynecological surgery via a vaginal approach
• Skin graft recipient site — unless it already qualifies as a surgical wound on OASIS, such as a grafted pressure ulcer or grafted burn
• Enterocutaneous fistula
• Pressure ulcers treated with surgical debridement
• VP shunt after the original incision heals
• Removal of a callus
• Removal or simple excision of a toenail
• Needle puncture sites without a drain
• Needle aspiration of fluid without drain placement

The pattern worth memorising

Three ideas explain most of the list:

1. A drain makes the difference. I&D with a drain is a surgical wound. I&D without one is not. Paracentesis with a drain counts; paracentesis for simple aspiration does not.
2. Implanted vascular access counts, percutaneous access does not. Central lines, ports, and implanted infusion devices are surgical wounds. PICCs and peripheral IVs are not, and neither is a cardiac cath via needle puncture.
3. Donor site yes, recipient site no. The graft donor site is a surgical wound. The recipient site is only a surgical wound if the underlying wound already qualified.

A fourth, worth stating on its own because it changes two items at once:

A pressure ulcer closed with a skin graft or a muscle, advancement, or rotational flap is captured as a surgical wound — and is no longer reported as a pressure ulcer.

Report it in one place, not both. Counting the same wound twice misstates the agency's pressure injury data.

And the one nearly everybody gets wrong:

A central line is captured as a surgical wound even if the agency is providing no related care at all, and even if the site has healed over.

When does it stop being a surgical wound?

A surgical wound is considered a scar once it has been completely epithelialized for more than 30 days. Until then, it is still a surgical wound.

Two more rules on M1040

• Capture only surgery on the integument. Not eyes, not mucous membranes, not surgeries via a vaginal approach.
• Bowel ostomies are excluded, including ostomies being allowed to close on their own.

Non-observable

"Non-observable" means a physician ordered that the dressing or device not be removed, or steri-strips completely obstruct the view of the incision.

If you select non-observable, the response must be supported by a physician order indicating not to remove the dressing. Selecting it without that order in the chart is an audit finding.

Try it

A patient is receiving six weeks of IV antibiotics via a central line for VRE sepsis. She has an abandoned dialysis shunt in her left arm and another shunt in her left thigh currently in use for dialysis. Wound care is also recommended for an abscess that formed six inches proximal to the abandoned shunt, with an I&D performed two days earlier. You are able to observe all wounds.

Does this patient have at least one observable surgical wound?

Yes. The central line counts, the abandoned dialysis shunt counts, and the shunt in use for dialysis counts — three qualifying surgical wounds before you even get to the abscess. (The abscess itself only counts if a drain was placed.)

Reference

CMS OASIS Guidance Manual, Chapter 3. Adapted from the agency's Quality Assurance and Coding OASIS education materials.