The question of whether a Percutaneous Endoscopic Gastrostomy (PEG) tube site is classified as a surgical wound for the Outcome and Assessment Information Set (OASIS) is a necessary distinction in home health care. The Centers for Medicare & Medicaid Services (CMS) requires home health agencies to use the OASIS assessment tool to collect standardized patient data, which directly influences payment and quality measures. The specific classification of a PEG site impacts how a clinician assesses the patient’s integumentary status and determines appropriate care planning. This determination hinges on the official regulatory definitions used by OASIS.
Understanding the PEG Tube Insertion Site
A PEG tube insertion site is created through a process that is typically minimally invasive. The procedure involves inserting the tube through the skin and abdominal wall directly into the stomach, usually guided by an endoscope. This is a percutaneous approach, meaning it is done through a puncture rather than a large, open incision. The initial opening is a small, controlled disruption of the skin and tissue layers.
This method differs from traditional open surgery, which involves a scalpel incision that cuts through tissue layers and is then closed with sutures or staples. The PEG site is designed to maintain an open tract, known as a gastrostomy, for the long-term presence of the tube. This physical difference between a puncture/stoma and a closed incision is the primary factor in the regulatory classification.
The Official OASIS Definition of a Surgical Wound
The OASIS assessment tool, specifically items M1340 and M1342, defines a surgical wound based on criteria distinct from a general medical definition. A wound is considered surgical for OASIS purposes if it results from a procedure where the skin or tissue was disrupted, often by an incision, and is expected to heal by either primary or secondary intention. Healing by primary intention occurs when the wound edges are approximated, such as with sutures or staples, and heal quickly with minimal tissue loss.
A key aspect of the OASIS definition is the concept of healing intention. Wounds healing by primary intention are considered surgical until they are fully re-epithelialized for approximately 30 days, after which they are documented as a scar. If a surgical wound separates or dehisces, it then heals by secondary intention, requiring the formation of granulation tissue to close the defect. The distinction often comes down to whether the site was intended to be temporarily open or permanently maintained as an opening.
Classification of the PEG Site Under OASIS
Definitive guidance from CMS excludes a PEG site from the OASIS surgical wound category (M1340/M1342) in most circumstances. A PEG site is considered a gastrostomy, which is a type of ostomy, and ostomies are specifically excluded from the definition of a surgical wound for OASIS reporting. This exclusion applies whether the ostomy is newly created or long-standing.
The rationale is that an ostomy is a surgically created opening that is intended to remain open to the outside, not to heal and close like a typical incision. Therefore, a PEG site is not reported under M1340, “Does this patient have a Surgical Wound?”. This classification holds true even during the initial post-insertion period, as the site’s intended long-term function is to be an established tract.
An exception arises if a separate surgical procedure is performed at the PEG site, such as a formal surgical revision that involves an incision and suture closure intended to heal. If the site becomes severely infected or dehisces to the point that it requires a formal surgical take-down and closure, the resulting wound may temporarily be classified as surgical. However, the routine, newly placed PEG site is not a surgical wound for OASIS purposes.
Documentation and Ongoing Assessment of the Site
Since the PEG site is not a surgical wound, its routine assessment and care are not documented under OASIS items M1340 or M1342. Instead, the PEG site, including the surrounding skin, is monitored as an established stoma. Any issues with the site, such as localized inflammation, leakage, or skin breakdown, are assessed as part of the patient’s overall skin integrity and stoma care needs.
Peristomal skin integrity issues, for example, would be documented in the narrative portion of the comprehensive assessment. If the skin breakdown progresses to a pressure ulcer or a stasis ulcer near the site, those conditions would be reported under their respective OASIS items, such as M1306 for pressure ulcers or M1332/M1334 for stasis ulcers. The gastrostomy itself is acknowledged in other OASIS items, such as those related to nutritional support or the presence of a tube, but not as a wound. This documentation approach ensures that the assessment accurately reflects the site’s function as a permanent opening rather than a healing incision.