Step-by-Step Coding Guide for Item Set M0210: Resident Has Stage 1 or Higher Pressure Ulcers

1. Review of Medical Records

• Objective: To determine if the resident has any documented pressure ulcers of Stage 1 or higher.
• Process:
  • Review skin assessment reports from the nursing or wound care team documented upon admission and during routine checks.
  • Examine treatment plans and physician's orders related to skin care, especially for wound care management.
  • Check progress notes for any references to skin integrity issues, particularly pressure ulcers.

2. Understanding Definitions

• Pressure Ulcer: A localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear. A variety of contributing or confounding factors are also associated with pressure ulcers; the primary cause is unrelieved pressure.
• Stages of Pressure Ulcers:
  • Stage 1: Non-blanchable erythema of intact skin.
  • Stage 2: Partial-thickness skin loss with exposed dermis.
  • Stage 3: Full-thickness skin loss.
  • Stage 4: Full-thickness skin and tissue loss.

3. Coding Instructions

• Code M0210:
  • 0: No—If the resident does not have any documented Stage 1 or higher pressure ulcers.
  • 1: Yes—If the resident has one or more documented Stage 1 or higher pressure ulcers.
• Example: If a resident is documented to have a Stage 2 pressure ulcer upon admission, code M0210 as '1'.

4. Coding Tips

• Pay careful attention to the stages of pressure ulcers to ensure they are coded correctly.
• Regularly review and update the MDS to reflect any changes in the resident's skin condition.

5. Documentation

• Required Documentation:
  • Detailed descriptions of each identified pressure ulcer, including size, location, stage, and the date first identified.
  • Photographic documentation, when possible, for accurate tracking of progress or deterioration.
  • Documentation of all care plans and interventions aimed at treating or managing pressure ulcers.
• Ensure all documentation is up-to-date and reflects current skin assessments.

6. Common Errors to Avoid

• Failing to differentiate between other types of wounds and pressure ulcers.
• Overlooking early signs of pressure ulcers, such as persistent redness in individuals with darker skin tones.
• Inadequate documentation leading to misstaging or failure to report existing pressure ulcers.

7. Practical Application

• Scenario: During a routine skin assessment, a nurse identifies a non-blanchable redness on a resident's heel, classifying it as a Stage 1 pressure ulcer. This finding is documented in the resident's medical record, including a description of the ulcer's location and characteristics. The care plan is updated to include increased monitoring, repositioning schedules, and the use of a pressure-relieving device. For MDS coding, the nurse correctly codes M0210 as '1', reflecting the presence of a Stage 1 pressure ulcer.

Please note that the information provided in this guide for MDS 3.0 Item set M0210 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. 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.