MDS Alert

Published on Mon May 13, 2013 PDF

Check out these 4 scenarios to code tricky situations.

You may not be able to stage the unstageable pressure ulcer, but you can properly record and categorize it in the MDS.

When you have unstageable pressure ulcers, there are three possible MDS 3.0 categories in which to code them:

·         M0300E: Unstageable Pressure Ulcers Related to Non-Removable Dressing/Device

·         M0300F: Unstageable Pressure Ulcers Related to Slough and/or Eschar

·         M0300G: Unstageable Pressure Ulcers Related to Suspected Deep Tissue Injury

You’ll code the number of each type of pressure ulcer, as well as the number of each type present upon admission/reentry.

No-Brainer: Code M0300E When You Obviously Can’t See It

“M0300E is unstageable because it’s underneath a non-removable device,” Jeff Levine, MD, a geriatric and wound-care specialist in New York City, said in a Centers for Medicare & Medicaid Services (CMS) instructional session. “We know it’s there, but we don’t know what stage it is.”

Scenario #1: The resident has a pressure ulcer and is undergoing negative pressure therapy. You don’t know what stage the pressure ulcer is because it’s covered by a non-removable device.

Coding: Code this under M0300F, because you know the resident has a pressure ulcer, but you can’t see it to determine the stage.

Look for Total Slough/Eschar Coverage to Code M0300F

M0300F is an unstageable pressure ulcer due to slough or eschar. “It’s probably full thickness tissue loss, and the base of the ulcer is completely covered by slough that’s either gray, yellow, brown, green, tan in the wound bed,” Levine explained. Or the base of the ulcer is covered by eschar that’s tan, brown or black in the wound bed.

“Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and stage cannot be determined,” according to the National Database of Nursing Quality Indicators (NDNQI). But once removed, the pressure ulcer will likely be a Stage 3 or Stage 4.

Scenario #2: The resident had a pressure ulcer on his sacrum, which was present upon admission and was 100-percent covered with black eschar. On the admission assessment, you coded this as M0300F and present on admission.

Later, the pressure ulcer is debrided. After four weeks, the pressure ulcer has 50 to 75 percent eschar present. Now you can see that the damage extends down to the bone.

Coding: Instead of coding this again as M0300F, you would change it to a Stage 4 pressure ulcer, because you can now observe the ulcer, Levine instructed. So you would code on the MDS: M0300D1 Number of Stage 4 pressure ulcer as 1, and M0300D2 as 1 present on admission.

Scenario #3: The resident was admitted with one small Stage 2 pressure ulcer. Despite treatment, the pressure ulcer is not improving and now appears deeper than before. The wound bed is now covered with slough.

Coding: For this situation, you would code M0300F1; Number of unstageable pressure ulcers related to coverage of wound bed by slough and/or eschar as 1, Levine said. Instead of coding this pressure ulcer as a Stage 2, you would code it as unstageable because the wound bed is now covered by slough. Code M0300F2 as 0 (not present on admission), because on admission the resident had a Stage 2 pressure ulcer, not an unstageable one.

M0300G: Don’t Confuse Blisters with Deep Tissue Injury

A deep tissue injury is a “purple or maroon localized area of discolored skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear,” according to the National Pressure Ulcer Advisory Panel (NPUAP).

The discolored area is usually darker than the surrounding intact skin. “So in other words to have deep tissue injury, you need to have intact skin and you need to see a purplish discoloration underneath,” Levine noted. “And this discoloration, when you touch it, can be firm, mushy, boggy, warm, or cooler [than the adjacent tissue], and can be difficult to determine in patients with dark skin tones.”

“For deep tissue injury, we want to clearly document your assessment findings in the medical record,” Levine stressed. “You want to track and document your care planning and management.”

Scenario #4: The resident presents with a purplish blister. Aside from the discoloration, the surrounding skin does not appear to have any different texture or temperature than the blister.

Coding: “When a lesion related to pressure presents with an intact blister and the surrounding or adjacent soft tissue does not have the characteristics of deep tissue injury,” you would not code M0300G, Levine stated. This is not deep tissue injury. Instead, you would code this under M0300B Unhealed Pressure Ulcers — Stage 2.