Step-by-Step Coding Guide for Item Set M0300F2: Unstageable Pressure Ulcers/Injuries Related to Slough and/or Eschar at Admit/Reentry

1. Review of Medical Records

• Begin with a comprehensive review of the resident’s medical records upon their admission or reentry, looking for any mentions of pressure ulcers or injuries that are covered by slough and/or eschar. This includes initial skin assessments, hospital transfer documentation, and physician's orders.

2. Understanding Definitions

• Slough: Soft, moist, non-viable tissue that may be white, yellow, tan, or green. It often obscures the wound bed.
• Eschar: Hard or soft necrotic tissue that is black or brown and may cover the wound bed, making it difficult to assess the actual depth of the wound.

3. Coding Instructions

• M0300F2: Record the number of unstageable pressure ulcers/injuries due to slough and/or eschar that were present at the time of admission/entry or reentry. This includes any ulcers/injuries that developed during a hospital stay for residents reentering the facility .

4. Coding Tips

• Ensure accurate documentation and coding of any ulcers/injuries obscured by slough and/or eschar as unstageable upon the resident's admission or reentry.
• Differentiate between unstageable ulcers/injuries due to slough/eschar and those covered by a non-removable dressing/device.

5. Documentation

• Clearly document the presence, location, and characteristics of the unstageable pressure ulcers/injuries. Include any available information from previous care settings or during the admission process regarding the condition of these ulcers/injuries.

6. Common Errors to Avoid

• Failing to code pressure ulcers/injuries as unstageable if they were covered by slough and/or eschar upon admission/reentry.
• Incorrectly coding ulcers/injuries as unstageable due to slough/eschar when enough of the wound bed is visible for staging.

7. Practical Application

• Scenario: A resident is admitted with a pressure ulcer on the sacrum that is 100% covered with black eschar. The ulcer should be coded as M0300F1 as 1 (unstageable due to slough/eschar) and M0300F2 as 1 (present on admission/entry or reentry) .

Please note that the information provided in this guide for MDS 3.0 Item set M0300F2 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.