Step-by-Step Coding Guide for Item Set M0300E2: Unstageable Pressure Ulcers/Injuries Related to Non-removable Dressing/Device at Admit/Reentry

1. Review of Medical Records

• Thoroughly review the resident’s medical records upon admission or reentry for documentation of pressure ulcers/injuries covered by a non-removable dressing/device. Pay special attention to physician's orders, hospital transfer documentation, and initial skin assessments that may indicate the presence of such ulcers or injuries.

2. Understanding Definitions

• Unstageable Pressure Ulcer/Injury Related to Non-removable Dressing/Device: A pressure ulcer or injury that cannot be visually assessed for stage due to coverage by a non-removable dressing or device, such as a cast, brace, or heavily adhered surgical dressing.

3. Coding Instructions

• M0300E2: Enter the number of unstageable pressure ulcers/injuries related to a non-removable dressing/device that were present at the time of admission/entry or reentry. This includes ulcers/injuries identified upon admission as well as those acquired during a hospital stay prior to reentry into the facility .

4. Coding Tips

• Ensure that the dressing/device truly cannot be removed for the assessment of the wound bed. Non-removable is typically indicated by physician's orders or safety concerns for the resident.
• Document any verbal or written communication from the transferring facility or healthcare provider regarding the condition under the dressing/device.

5. Documentation

• Clearly document the presence of the non-removable dressing/device, the rationale for its use, and any known information about the pressure ulcer/injury it covers. Include documentation from the transferring facility if available.

6. Common Errors to Avoid

• Failing to code an unstageable pressure ulcer/injury because the dressing/device was eventually removed. If it was non-removable at the time of admission/entry or reentry, it should be coded as such.
• Incorrectly coding a pressure ulcer/injury as unstageable due to a non-removable dressing/device when the dressing/device could have been safely removed for assessment.

7. Practical Application

• Scenario: A resident reenters the facility with a surgical wound covered by a primary surgical dressing that the hospital staff has indicated should not be disturbed. The wound site is known to have a pressure injury prior to surgery but is now unstageable due to the dressing. This should be coded in M0300E2 based on the information provided at reentry.

Please note that the information provided in this guide for MDS 3.0 Item set M0300E2 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.