Step-by-Step Coding Guide for Item Set M0300G2: Unstageable Pressure Injuries Related to Deep Tissue Injury at Admit/Reentry

1. Review of Medical Records

• Begin with an in-depth review of the resident's medical records upon their admission or reentry, specifically looking for any documentation that mentions or describes conditions indicative of deep tissue injuries (DTIs) that could not be staged due to their nature upon arrival.

2. Understanding Definitions

• Deep Tissue Injury (DTI): Defined as a localized area of discolored (purple or maroon) intact skin or a blood-filled blister resulting from damage to underlying soft tissue from pressure and/or shear. The area may also be painful, firm, mushy, boggy, warmer, or cooler compared to adjacent tissue .

3. Coding Instructions

• M0300G2: Enter the number of unstageable pressure injuries related to deep tissue injury that were first identified at the time of admission/entry, and for residents reentering after a hospital stay, include those acquired during the hospitalization. If none are present, enter '0' .

4. Coding Tips

• It's important to distinguish DTIs from other types of pressure injuries or conditions and to accurately code them based on their unique characteristics. DTIs may be harder to detect, especially in individuals with darker skin tones, where the injury might not present as purple/maroon but as a darker shade compared to the surrounding area.

5. Documentation

• Document the presence, location, size, and specific characteristics of the DTI. Include any known information from previous care settings about the condition of these injuries upon admission or reentry.

6. Common Errors to Avoid

• Not coding a DTI as unstageable if it was identifiable upon admission/reentry but lacked visible damage due to the nature of the injury.
• Misclassifying DTIs as other types of injuries or failing to recognize them in individuals with darker skin tones.

7. Practical Application

• Implement training sessions for staff to recognize and document DTIs, emphasizing the importance of detailed assessments and the specific challenges posed by DTIs, including the potential for rapid deterioration.

Please note that the information provided in this guide for MDS 3.0 Item M0300G2: 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.