Step-by-Step Coding Guide for Item Set M0300B2: Stage 2 Pressure Ulcers - Number at Admit/Reentry

1. Review of Medical Records

• Thoroughly review the resident’s medical record upon admission or reentry for documentation of existing pressure ulcers. Focus on skin assessments, hospital transfer documents, and physician notes that may indicate the presence of Stage 2 pressure ulcers.

2. Understanding Definitions

• Stage 2 Pressure Ulcer: Identified by partial thickness loss of dermis, presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured blister .

3. Coding Instructions

• M0300B2: Enter the number of Stage 2 pressure ulcers that were first noted at the time of admission/entry. For residents reentering the facility after a hospital stay, include Stage 2 pressure ulcers that were acquired during the hospitalization .

4. Coding Tips

• Ensure accurate differentiation between Stage 2 pressure ulcers and other types of wounds or injuries. Remember that granulation tissue, slough, and eschar are not present in Stage 2 pressure ulcers.
• Document and code accurately to reflect if the ulcer was present upon admission or developed after admission.

5. Documentation

• Document each Stage 2 pressure ulcer's location, size, appearance, and any changes observed since admission or reentry. Documentation should support coding choices and reflect accurate wound assessment.

6. Common Errors to Avoid

• Misclassifying wounds as Stage 2 pressure ulcers when they do not meet the specific criteria.
• Failing to document pressure ulcers present at admission/reentry, leading to inaccurate representation of the resident's condition and potentially impacting care plans and interventions.

7. Practical Application

• Use case studies in staff training to practice identifying and documenting Stage 2 pressure ulcers. Encourage the interdisciplinary team to communicate effectively regarding the identification and documentation of pressure ulcers at the time of admission/reentry.

Please note that the information provided in this guide for MDS 3.0 Item M0300B2: Type of Record 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.