Step-by-Step Guide to Coding MDS Item M0300B1: "Stage 2 Pressure Ulcers: Number Present"

1. Overview: M0300B1 is used to record the number of Stage 2 pressure ulcers currently present on a resident. This item is critical for tracking pressure ulcer development, guiding care interventions, and preventing further skin breakdown.

2. Item Purpose:

• Identifies the number of Stage 2 pressure ulcers present during the assessment period.
• Ensures that appropriate care plans are developed to promote healing and prevent complications.

3. Steps for Coding M0300B1:

• Step 1: Perform a Head-to-Toe Skin Assessment

  • Conduct a full skin assessment focusing on areas prone to pressure ulcers, such as the sacrum, buttocks, and heels.
  • Identify any pressure ulcers and determine if they are Stage 2 ulcers based on clinical criteria.

• Step 2: Define Stage 2 Pressure Ulcers

  • Definition: A Stage 2 pressure ulcer presents as a partial-thickness loss of dermis, usually appearing as a shallow open ulcer with a red-pink wound bed, or as an intact or ruptured blister. There is no slough or bruising present​.
  • Do not include skin conditions such as skin tears, tape burns, or moisture-associated skin damage.

• Step 3: Enter the Number of Stage 2 Pressure Ulcers

  • Record the exact number of Stage 2 pressure ulcers present. If there are no Stage 2 ulcers, enter 0 and skip to M0300C.
  • Be sure the ulcers are primarily caused by pressure, not other factors.

4. Coding Examples:

• Example 1: No Stage 2 Pressure Ulcers Present
  A resident with no skin breakdown is examined, and no pressure ulcers are found.
  • Coding: M0300B1 would be coded 0.
• Example 2: One Stage 2 Pressure Ulcer
  The resident has a Stage 2 ulcer on their heel, with no other pressure ulcers found.
  • Coding: M0300B1 would be coded 1.

5. Documentation Tips:

• Carefully document the assessment in the medical record, noting the location and characteristics of any pressure ulcers.
• Ensure that interventions aimed at healing the ulcers are reflected in the resident’s care plan, including regular reassessment.

6. Strategies for Care Planning:

• Integrate a detailed skin care regimen, including repositioning, nutritional support, and use of pressure-relieving devices.
• Monitor the healing progress of the ulcers and modify care interventions as necessary.

The Step-by-Step Coding Guide for item M0300B1 in MDS 3.0 Section M is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, it is crucial for healthcare professionals to ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.