Step-by-Step Coding Guide for Item Set M0300E1: Unstageable Pressure Ulcers/Injuries Related to Non-removable Dressing/Device

1. Review of Medical Records

• Thoroughly review the resident's medical records for any documentation of pressure ulcers or injuries that are covered by a non-removable dressing or device. Such dressings/devices might include primary surgical dressings that cannot be removed, orthopedic devices, or casts that are not to be removed per physician's order.

2. Understanding Definitions

• Non-removable Dressing/Device: Includes items like primary surgical dressings, orthopedic devices, or casts that cannot be removed. These coverings prevent the direct assessment of the wound bed, making the pressure ulcer/injury unstageable.

3. Coding Instructions

• M0300E1: Enter the number of pressure ulcers/injuries that are unstageable due to being covered by a non-removable dressing/device. If there are no such ulcers or injuries, enter '0' .

4. Coding Tips

• Ensure to differentiate between pressure ulcers/injuries covered by a non-removable device and those that are unstageable for other reasons (e.g., due to slough or eschar).
• Regularly review and update the medical record documentation to reflect any changes in the status of the dressing/device and the underlying pressure ulcer/injury.

5. Documentation

• Clearly document the presence of any non-removable dressing/device covering a pressure ulcer/injury. Include details about the type of dressing/device, reasons for its use, and any observations of the surrounding skin for signs of infection or deterioration.

6. Common Errors to Avoid

• Not updating the medical records if the status of a non-removable dressing/device changes (e.g., if it is removed and the ulcer beneath becomes visible and stageable).
• Misclassifying pressure ulcers/injuries as unstageable due to non-removable dressings/devices when they are actually stageable.

7. Practical Application

• Scenario: A resident is admitted with a leg cast covering a suspected pressure ulcer. The medical records from the transferring hospital note the presence of the ulcer but do not provide a stage due to the cast. Upon cast removal two weeks later, a Stage 3 pressure ulcer is identified. The initial admission documentation and subsequent assessments should accurately reflect the ulcer's unstageable status due to the non-removable dressing/device and its staging post-removal.

Please note that the information provided in this guide for MDS 3.0 Item set M0300E1  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.