M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

Steps for completing M0300A–G

Step 1: Determine Deepest Anatomical Stage

Observe and palpate the base of any identified pressure ulcers present to determine the anatomic depth of soft tissue damage involved.

Ulcer staging should be based on the ulcer’s deepest anatomic soft tissue damage that is visible or palpable. If a pressure ulcer’s tissues are obscured such that the depth of soft tissue damage cannot be observed, it is considered to be unstageable (see Step 2 below).

Review the history of each pressure ulcer in the medical record. If the stageable pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at the higher numerical stage until healed unless it becomes unstageable. Nursing homes that carefully document and track pressure ulcers will be able to more accurately code this item.

Pressure ulcers do not heal in a reverse sequence, that is, the body does not replace the types and layers of tissue (e.g., muscle, fat, and dermis) that were lost during pressure ulcer development before they re-epithelialize. Stage 3 and 4 pressure ulcers fill with granulation tissue. This replacement tissue is never as strong as the tissue that was lost and hence is more prone to future breakdown.

Clinical standards do not support reverse staging or back- staging as a way to document healing, as it does not accurately characterize what is occurring physiologically as the ulcer heals. For example, over time, even though a Stage 4 pressure ulcer has been healing and contracting such that it is less deep, wide, and long, the tissues that were lost (muscle, fat, dermis) will never be replaced with the same type of tissue. Previous standards using reverse staging or back-staging would have permitted identification of such a pressure ulcer as a Stage 3, then a Stage 2, and so on, when it reached a depth consistent with these stages.

Clinical standards now would require that this ulcer

continue to be documented as a Stage 4 pressure ulcer until it has completely healed unless it becomes unstageable. Nursing homes can document the healing of pressure ulcers using descriptive characteristics of the wound (i.e., depth, width, presence or absence of granulation tissue, etc.) or by using a validated pressure ulcer healing tool.

Once a pressure ulcer has healed, it is documented as a healed pressure ulcer at its highest numerical stage—in this example, a healed Stage 4 pressure ulcer. For care planning purposes, this healed Stage 4 pressure ulcer would remain at increased risk for future breakdown or injury and would require continued monitoring and preventative care.

A previously closed pressure ulcer that opens again should be reported at its worst stage, unless currently presenting at a higher stage or unstageable.

Step 2: Identify Unstageable Pressure Ulcers

Visualization of the wound bed is necessary for accurate staging.

If, after careful cleansing of the pressure ulcer/injury, a pressure ulcer’s/injury’s anatomical tissues are obscured such that the extent of soft tissue damage cannot be observed or palpated, the pressure ulcer/injury is considered unstageable.

Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable, as illustrated at https://npiap.com/page/PressureInjuryStages.

If the wound bed is only partially covered by eschar or slough, and the anatomical depth of tissue damage can be visualized or palpated, numerically stage the ulcer, and do not code this as unstageable.

A pressure injury with intact skin that is a deep tissue injury (DTI) should not be coded as a Stage 1 pressure injury. It should be coded as unstageable, as illustrated at https://npiap.com/page/PressureInjuryStages.

Known pressure ulcers/injuries covered by a non-removable dressing/device (e.g., primary surgical dressing, cast) should be coded as unstageable. “Known” refers to when documentation is available that says a pressure ulcer/injury exists under the non-removable dressing/device.

Step 3: Determine “Present on Admission”

Review the medical record for the history of the ulcer/injury.

Review for location and stage at the time of admission/entry or reentry.

If the pressure ulcer/injury was present on admission/entry or reentry and subsequently increased in numerical stage during the resident’s stay, the pressure ulcer is coded at that higher stage, and that higher stage should not be considered as “present on admission.”

If the pressure ulcer/injury was present on admission/entry or reentry and becomes unstageable due to slough or eschar, during the resident’s stay, the pressure ulcer/injury is coded at M0300F and should not be coded as “present on admission.”

If the pressure ulcer/injury was unstageable on admission/entry or reentry, then becomes numerically stageable later, it should be considered as “present on admission” at the stage at which it first becomes numerically stageable. If it subsequently increases in numerical stage, that higher stage should not be coded as “present on admission.”

If a resident who has a pressure ulcer/injury that was originally acquired in the facility is hospitalized and returns with that pressure ulcer/injury at the same numerical stage, the pressure ulcer/injury should not be coded as “present on admission” because it was present and acquired at the facility prior to the hospitalization.

If a resident who has a pressure ulcer/injury that was “present on admission” (not acquired in the facility) is hospitalized and returns with that pressure ulcer/injury at the same numerical stage, the pressure ulcer is still coded as “present on admission” because it was originally acquired outside the facility and has not changed in stage.

If a resident who has a pressure ulcer/injury is hospitalized and the ulcer/injury increases in numerical stage or becomes unstageable due to slough or eschar during the hospitalization, it should be coded as “present on admission” upon reentry.

If a pressure ulcer was numerically staged, then became unstageable, and is subsequently debrided sufficiently to be numerically staged, compare its numerical stage before and after it was unstageable. If the numerical stage has increased, code this pressure ulcer as not present on admission.

If a resident has a pressure ulcer/injury that was documented on admission then closed that reopens at the same stage (i.e., not a higher stage), the ulcer/injury is coded as “present on admission.”

If two pressure ulcers merge, that were both “present on admission,” continue to code the merged pressure ulcer as “present on admission.” Although two merged pressure ulcers might increase the overall surface area of the ulcer, there needs to be an increase in numerical stage or a change to unstageable due to slough or eschar in order for it to be considered not “present on admission.”

Examples

Resident K is admitted to the facility without a pressure ulcer/injury. During the stay, they develop a stage 2 pressure ulcer. This is a facility acquired pressure ulcer and was not “present on admission.” Resident K is hospitalized and returns to the facility with the same stage 2 pressure ulcer. This pressure ulcer was originally acquired in the nursing home and should not be considered as “present on admission” when they return from the hospital.

Resident J is a new admission to the facility and is admitted with a stage 2 pressure ulcer. This pressure ulcer is considered as “present on admission” as it was not acquired in the facility. Resident J is hospitalized and returns with the same stage 2 pressure ulcer, unchanged from the prior admission/entry. This pressure ulcer is still considered “present on admission” because it was originally acquired outside the facility and has not changed.