Understanding and Coding MDS 3.0 Item M0300G2: Unstageable - Deep Tissue: Number at Admission/Reentry

Introduction

Purpose:
Unstageable pressure ulcers, particularly those classified as deep tissue injuries, are severe wounds that affect the deeper layers of the skin and underlying tissues. These ulcers are often difficult to assess due to their depth and are highly prone to infection and complications. MDS Item M0300G2, Unstageable - Deep Tissue: Number at Admission/Reentry, documents the number of unstageable deep tissue pressure injuries a resident had at the time of admission or reentry. Correct coding of this item ensures appropriate monitoring and care to manage these injuries effectively. This article provides comprehensive guidance on how to code M0300G2 based on the MDS 3.0 standards.

What is MDS Item M0300G2?

Explanation:
MDS Item M0300G2, Unstageable - Deep Tissue: Number at Admission/Reentry, records the number of deep tissue injuries (DTIs) present at the time of the resident's admission or reentry to the facility. Deep tissue injuries are characterized by purple or maroon discoloration of intact skin or a blood-filled blister resulting from damage to underlying soft tissue from pressure and/or shear. These injuries can deteriorate quickly and require careful monitoring and treatment.

By documenting the number of unstageable deep tissue injuries upon admission or reentry, healthcare providers ensure that these wounds are properly tracked and treated from the start of the resident's care.

Guidelines for Coding M0300G2

Coding Instructions:
To correctly code Item M0300G2, follow these steps:

1. Review the Resident’s Admission or Reentry Assessment:

   • Examine the resident’s skin for any signs of deep tissue injury, including areas of purple or maroon discoloration, or blood-filled blisters that indicate underlying tissue damage.

2. Determine the Number of Deep Tissue Injuries at Admission/Reentry:

   • Code “0” if no unstageable deep tissue injuries were present at the time of admission or reentry.
   • Enter the number of deep tissue injuries that were present at admission or reentry (e.g., 1, 2, 3, etc.).

3. Enter the Response in Item M0300G2:

   • Record the number of unstageable deep tissue injuries identified upon admission or reentry. If no such injuries were present, enter “0.”

Example Scenario:
A resident admitted to the facility has two unstageable deep tissue injuries on their heels, both showing purple discoloration and swelling, but with intact skin. The deep tissue injuries are carefully documented, and a treatment plan is initiated. In this case, 2 would be entered in Item M0300G2 to reflect the number of deep tissue injuries at admission. If no deep tissue injuries were present at admission, 0 would be entered.

Best Practices for Accurate Coding

Documentation:

• Ensure that each deep tissue injury is thoroughly documented in the resident’s medical records, including its location, size, and appearance. This documentation should be made at the time of admission or reentry and updated as necessary.
• Record any interventions or treatment plans initiated to manage the deep tissue injuries, such as pressure relief or wound care.

Communication:

• Encourage open communication between nursing staff, wound care specialists, and physicians to ensure that unstageable deep tissue injuries are properly managed from the time of admission or reentry.
• Discuss residents with deep tissue injuries during care planning meetings to ensure that proper prevention and treatment protocols are in place.

Regular Audits:

• Conduct regular audits of medical records to verify that deep tissue injuries are accurately documented at the time of admission or reentry, and that appropriate care is provided.
• Review the care plan regularly to ensure that residents with deep tissue injuries are receiving timely interventions to prevent further deterioration of their wounds.

Conclusion

Summary:
MDS Item M0300G2 is essential for documenting the number of unstageable deep tissue injuries a resident has at admission or reentry. Accurate coding of this item ensures that these injuries are tracked from the start of the resident’s care, allowing healthcare providers to implement appropriate interventions and monitor healing progress. By following the guidelines and best practices outlined in this article, healthcare professionals can ensure optimal care for residents with deep tissue injuries 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 deep tissue injuries at admission or reentry.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item M0300G2: Unstageable - Deep Tissue: Number at Admission/Reentry 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.