Step-by-Step Coding Guide for Item Set M0300F1: Unstageable Pressure Ulcers/Injuries Related to Slough and/or Eschar

1. Review of Medical Records

• Start with a thorough review of the resident's medical records to identify any documented pressure ulcers that are covered by slough and/or eschar. Focus on nursing and physician's notes, wound care reports, and photographs or diagrams that describe the wound's appearance.

2. Understanding Definitions

• Slough: Non-viable yellow, tan, gray, green, or brown tissue; usually moist, soft, stringy, and may be adherent to the base of the wound or present in clumps throughout the wound bed.
• Eschar: Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color and may appear scab-like, often firmly adherent to the base of the wound .

3. Coding Instructions

• M0300F1: Enter the number of pressure ulcers that are unstageable due to slough and/or eschar. If no such ulcers are present, enter '0' .

4. Coding Tips

• Pressure ulcers covered with slough and/or eschar, where the wound bed cannot be visualized, should be coded as unstageable. The true anatomic depth and therefore stage cannot be determined until enough slough and/or eschar is removed.
• Consider stable eschar on the heels as a natural cover and only debride after careful clinical consideration, including consultation with the resident’s healthcare provider.

5. Documentation

• Clearly document the presence of slough and/or eschar, including the ulcer's location, size, and any observable characteristics. Note any interventions planned or taken to manage the ulcer, such as debridement or specialized wound care protocols.

6. Common Errors to Avoid

• Misclassifying a pressure ulcer as unstageable due to slough and/or eschar when part of the wound bed is visible and can be staged.
• Failing to reassess and update the ulcer's status in the medical record following significant changes, such as after debridement.

7. Practical Application

• Example: A resident is admitted with a pressure ulcer on the sacrum, 100% covered with black eschar. Initially, it is coded as M0300F1 as 1. Following debridement, which revealed damage down to the bone, the ulcer is reclassified and coded as a Stage 4 pressure ulcer.

Please note that the information provided in this guide for MDS 3.0 Item set M0300F1 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.