M0300A: Number of Stage 1 Pressure Injuries

Item Rationale

Health-related Quality of Care

Stage 1 pressure injuries may deteriorate to more severe pressure ulcers/injuries without adequate intervention; as such, they are an important risk factor for further tissue damage.

Planning for Care

Development of a Stage 1 pressure injury should be one of multiple factors that initiate pressure ulcer/injury prevention interventions.

Steps for Assessment

Perform head-to-toe assessment. Conduct a full body skin assessment focusing on bony prominences and pressure- bearing areas (sacrum, buttocks, heels, ankles, etc.).

For the purposes of coding, determine that the lesion being assessed is primarily related to pressure and that other conditions have been ruled out. If pressure is not the primary cause, do not code here.

Reliance on only one descriptor is inadequate to determine the staging of a pressure injury between Stage 1 and deep tissue injury (see definition of “deep tissue injury” on page M-24). The descriptors are similar for these two types of injuries (e.g., temperature [warmth or coolness]; tissue consistency [firm or boggy]).

Check any reddened areas for ability to blanch by firmly pressing a finger into the reddened tissues and then removing it. In non-blanchable reddened areas, there is no loss of skin color or pressure-induced pallor at the compressed site.

Search for other areas of skin that differ from surrounding tissue that may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. Stage 1 may be difficult to detect in individuals with dark skin tones. Visible blanching may not be readily apparent in darker skin tones. Look for temperature or color changes as well as surrounding tissue that may be painful, firm, or soft.

Coding Instructions for M0300A

Enter the number of Stage 1 pressure injuries that are currently present.

Enter 0 if no Stage 1 pressure injuries are currently present.