Understanding and Coding MDS 3.0 Item M0300E1: Unstaged Due to Dressing -Number Present

Understanding and Coding MDS 3.0 Item M0300E1: Unstaged Due to Dressing – Number Present

Introduction

Purpose:
Pressure ulcers covered by non-removable dressings or devices can be difficult to assess, as the full extent of the wound is obscured. These ulcers, categorized as unstageable, pose unique challenges in wound care management. MDS Item M0300E1, Unstaged Due to Dressing – Number Present, is used to record the number of pressure ulcers that cannot be staged because they are covered by a non-removable dressing or device during the assessment period. Accurate coding of this item ensures that these ulcers are monitored, even though they cannot be directly assessed. This article outlines how to properly code M0300E1 based on the latest MDS 3.0 standards.

What is MDS Item M0300E1?

Explanation:
MDS Item M0300E1, Unstaged Due to Dressing – Number Present, documents the number of pressure ulcers that are unstageable because they are covered with a non-removable dressing or device during the assessment period.

• These dressings or devices are often used to protect or treat the wound, making it impossible to fully assess the depth or severity of the ulcer.

By recording the number of such ulcers, healthcare providers ensure that these wounds are still being monitored and treated, even though a full examination is not possible at that time.

Guidelines for Coding M0300E1

Coding Instructions:
To correctly code Item M0300E1, follow these steps:

1. Conduct a Thorough Skin Assessment:

   • Examine the resident's skin, noting any pressure ulcers covered by non-removable dressings or devices that cannot be staged. These areas should be clearly documented during the assessment period.

2. Determine the Number of Unstageable Pressure Ulcers Due to Dressing or Device:

   • Code “0” if no unstageable pressure ulcers due to dressing or device are present during the assessment period.
   • Enter the number of unstageable pressure ulcers covered by dressings or devices that prevent staging (e.g., 1, 2, 3, etc.).

3. Enter the Response in Item M0300E1:

   • Record the exact number of unstageable pressure ulcers covered by a non-removable dressing or device that is present during the assessment period. If none are present, enter “0.”

Example Scenario:
A resident develops a pressure ulcer on the heel that is covered by a non-removable cast. Since the dressing cannot be removed for assessment, the ulcer is classified as unstageable. In this case, 1 would be entered in Item M0300E1 to reflect the unstageable pressure ulcer due to dressing. If no such ulcers were present during the assessment period, 0 would be entered.

Best Practices for Accurate Coding

Documentation:

• Ensure that pressure ulcers unstageable due to non-removable dressings or devices are clearly documented in the resident’s medical records, including the type of dressing or device and the reason it cannot be removed.
• Monitor the surrounding skin for any signs of deterioration or complications, such as infection or breakdown of the tissue.

Communication:

• Encourage clear communication between the interdisciplinary team, including nurses, wound care specialists, and physicians, to ensure that unstageable pressure ulcers are being managed appropriately.
• Discuss these wounds during care planning meetings to ensure that appropriate monitoring and preventive care measures are being implemented.

Regular Audits:

• Conduct audits to ensure that all unstageable pressure ulcers due to dressings or devices are accurately recorded in medical records.
• Regularly review the care plan to ensure that appropriate interventions, including pressure relief and infection prevention, are being followed while the dressing or device is in place.

Conclusion

Summary:
MDS Item M0300E1 is essential for documenting the number of pressure ulcers that are unstageable due to non-removable dressings or devices during the assessment period. Proper coding ensures that these wounds are carefully monitored, even though they cannot be fully assessed. By following the guidelines and best practices outlined in this article, healthcare professionals can ensure effective care for residents with unstageable pressure ulcers in long-term care settings.

Click here to see a detailed step-by-step on how to complete this item set 

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 3, Page 3-165] for detailed guidelines on documenting unstageable pressure ulcers due to non-removable dressings or devices.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item M0300E1: Unstaged Due to Dressing – Number Present was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.