M0300F: Unstageable Pressure Ulcers Related to Slough and/or Eschar

Item Rationale

Health-related Quality of Life

Although the wound bed cannot be visualized, and hence the pressure ulcer cannot be staged, the pressure ulcer may affect quality of life for residents because it may limit activity, may be painful, and may require time-consuming treatments and dressing changes. Planning for Care

Visualization of the wound bed is necessary for accurate staging.

The presence of pressure ulcers and other skin changes should be accounted for in the interdisciplinary care plan.

Pressure ulcers that present as unstageable require care planning that includes, in the absence of ischemia, debridement of necrotic and dead tissue and restaging once this tissue is removed.

Steps for Assessment

Determine the number of pressure ulcers that are unstageable due to slough and/or eschar.

Identify the number of these pressure ulcers that were present on admission/entry or reentry (see page M-8 for assessment process).

Coding Instructions for M0300F M0300F1

Enter the number of pressure ulcers that are unstageable related to slough and/or eschar.

Enter 0 if no unstageable pressure ulcers related to slough and/or eschar are present and skip to M0300G, Unstageable – Deep tissue injury.

M0300F2

Enter the number of these unstageable pressure ulcers related to slough and/or eschar that were first noted at the time of admission/entry AND—for residents who are reentering the facility after a hospital stay that were acquired during the hospitalization (i.e., the unstageable pressure ulcer related to slough and/or eschar was not acquired in the nursing facility prior to admission to the hospital).

Enter 0 if no unstageable pressure ulcers related to slough and/or eschar were first noted at the time of admission/entry or reentry.

Coding Tips

Pressure ulcers that are covered with slough and/or eschar, and the wound bed cannot be visualized, should be coded as unstageable because the true anatomic depth of soft tissue damage (and therefore stage) cannot be determined. Only until enough slough and/or eschar

is removed to expose the anatomic depth of soft tissue damage involved, can the stage of the wound be determined.

Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heels serves as “the body’s natural (biological) cover” and should only be removed after careful clinical consideration, including ruling out ischemia, and consultation with the resident’s physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws.

Once the pressure ulcer is debrided of slough and/or eschar such that the anatomic depth of soft tissue damage involved can be determined, then code the ulcer for the reclassified stage. The pressure ulcer does not have to be completely debrided or free of all slough and/or eschar tissue in order for reclassification of stage to occur.

Examples

A resident is admitted with a sacral pressure ulcer that is 100% covered with black eschar.

Coding: The pressure ulcer would be coded at M0300F1 as 1, and at M0300F2 as 1, present on admission/entry or reentry.

Rationale: The pressure ulcer depth is not observable because the pressure ulcer is covered with eschar. This pressure ulcer is unstageable and was present on admission.

A pressure ulcer on the sacrum was present on admission and was 100% covered with black eschar. On the admission assessment, it was coded as unstageable and present on admission. The pressure ulcer is later debrided using conservative methods and after 4 weeks the ulcer has 50% to 75% eschar present. The assessor can now see that the damage extends down to the bone.

Coding: The ulcer is reclassified as a Stage 4 pressure ulcer. On the subsequent MDS, it is coded at M0300D1 as 1, and at M0300D2 as 1, present on admission/entry or reentry.

Rationale: After debridement, the pressure ulcer is no longer unstageable because bone is visible in the wound bed. Therefore, this ulcer can be classified as a Stage 4 pressure ulcer and should be coded at M0300D.

Miss J. was admitted with one small Stage 2 pressure ulcer. Despite treatment, it is not improving. In fact, it now appears deeper than originally observed, and the wound bed is covered with slough.

Coding: Code M0300F1 as 1, and M0300F2 as 0, not present on admission/entry or reentry.

Rationale: The pressure ulcer depth is not observable because it is covered with slough. This pressure ulcer is unstageable and is not coded in M0300F2 as present on admission/entry or reentry because it can no longer be coded as a Stage 2.

Resident M was admitted to the nursing facility with pressure ulcers that were unstageable due to eschar on both heels, as well as a Stage 2 pressure ulcer on the coccyx. Resident M’s pressure ulcers were reassessed before the subsequent assessment, and it was noted in the medical record that the Stage 2 coccyx pressure ulcer had healed. The left-heel eschar became fluctuant, showed signs of infection, and had to be debrided at the bedside. The left heel was subsequently numerically staged as a Stage 4 pressure ulcer. The right-heel eschar remained stable and dry (i.e., remained unstageable).

Coding: On admission, code M0300B1, Stage 2 as 1, M0300B2, present on admission/entry or reentry as 1; and M0300F1 Unstageable due to slough/eschar as 2 and M0300F2 as 2, present on admission, entry or reentry. On the subsequent assessment, code M0300D1 as 1, and M0300D2 as 1, present on admission/entry or reentry; and M0300F1 as 1, and M0300F2 as 1, present on admission/entry or reentry.

Rationale: Since both of Resident M’s heels cannot be numerically staged, because the

level of tissue damage cannot be determined as a result of the eschar present, they are coded on admission as unstageable pressure ulcers due to slough/eschar. The left heel eschar was subsequently debrided and is coded as a Stage 4 on the subsequent assessment—since the left heel eschar was debrided, and the first time an unstageable ulcer/injury is staged, it is considered as present on admission/entry or reentry at the stage at which it is initially assessed. The other heel eschar remained unstageable and is coded as present on admission/entry or reentry, and the Stage 2 pressure ulcer on the coccyx healed, so it is not coded on the subsequent assessment.