Step-by-Step Coding Guide for Item Set M0300G1: Unstageable Pressure Injuries Related to Deep Tissue Injury

1. Review of Medical Records

• Thoroughly review the resident's medical records, especially focusing on skin assessments and documentation of any areas of discoloration or damage that cannot be staged due to the nature of the injury. Look for any mention of deep tissue injury (DTI), particularly in areas prone to pressure such as heels, sacrum, and buttocks.

2. Understanding Definitions

• Deep Tissue Injury (DTI): A deep tissue injury is characterized by a purple or maroon localized area of discolored intact skin, or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared to adjacent tissue .

3. Coding Instructions

• M0300G1: Enter the number of unstageable pressure injuries related to deep tissue injury. If no such injuries are present, enter '0' .

4. Coding Tips

• Pay attention to the specific characteristics of DTI, especially in residents with darker skin tones where the discoloration may not be purple/maroon but rather a different shade compared to the surrounding skin.
• Document and code based on the initial assessment and any changes observed in the condition of the DTI.

5. Documentation

• Document the location, size, and specific characteristics (color, temperature, texture) of the DTI. Note any progression or changes in the condition, including the development of an ulcer.

6. Common Errors to Avoid

• Not coding a DTI as unstageable when it is covered by intact skin or a blood-filled blister, even if the damage suggests deep tissue involvement.
• Failing to reassess and document changes in the DTI, especially once it opens up or evolves into a more clearly definable pressure injury stage.

7. Practical Application

• Utilize case studies in training sessions to help staff identify and properly document DTI. Regularly review the effectiveness of prevention strategies and interventions for residents at risk of DTI.

Please note that the information provided in this guide for MDS 3.0 Item M0300G1: Type of Record 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.