Step-by-Step Coding Guide for Item Set M0300C2

1. Review of Medical Records

Start by meticulously reviewing the resident's medical records upon their admission or reentry. Look for documentation of any pressure ulcers, paying special attention to those identified as Stage 3. Document the number and condition of these ulcers as precisely as possible.

2. Understanding Definitions

Stage 3 Pressure Ulcers are defined as full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. Undermining and tunneling might also be observed .

3. Coding Instructions

For M0300C2, enter the number of Stage 3 pressure ulcers that were first noted at Stage 3 at the time of admission/entry. Additionally, for residents reentering the facility after a hospital stay, include the number of Stage 3 pressure ulcers that were acquired during the hospitalization .

4. Coding Tips

• Stage 3 pressure ulcers can appear shallow, especially in areas without subcutaneous tissue.
• It's crucial not to confuse moisture-associated skin damage or other types of wounds as Stage 3 pressure ulcers.
• When a pressure ulcer increases in stage, it should not be considered as "present on admission."

5. Documentation

Document the presence and stage of each pressure ulcer, including those that are unstageable due to non-removable dressings/devices. This documentation should be thorough and include photographic evidence, when possible, as well as a detailed description of the ulcer's location, size, and characteristics.

6. Common Errors to Avoid

• Failing to properly identify the stage of pressure ulcers.
• Incorrectly coding a pressure ulcer that has increased in the numerical stage after admission as "present on admission."
• Not reassessing unstageable pressure ulcers once they become stageable.

7. Practical Application

Consider a resident who was admitted with no pressure ulcers but develops a Stage 2 pressure ulcer during their stay. If this resident is hospitalized and returns with the ulcer now classified as Stage 3, it would be coded as "present on admission/entry or reentry" for M0300C2.

Please note that the information provided in this guide for MDS 3.0 Item set M0300C2 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.