Understanding and Coding MDS 3.0 Item M0300E2: Unstaged Due to Dressing – Number at Admit/Reentry

Introduction

Purpose:
Pressure ulcers that are unstageable due to non-removable dressings or devices present a unique challenge for wound care, as the wound beneath cannot be fully assessed. MDS Item M0300E2, Unstaged Due to Dressing – Number at Admit/Reentry, is used to document the number of pressure ulcers that are covered by non-removable dressings or devices at the time of admission or reentry, preventing the full staging of the ulcer. Correct coding of this item ensures that these wounds are carefully monitored and managed appropriately. This article provides a detailed guide on how to code M0300E2 based on the latest MDS 3.0 guidelines.

What is MDS Item M0300E2?

Explanation:
MDS Item M0300E2, Unstaged Due to Dressing – Number at Admit/Reentry, refers to the number of pressure ulcers that cannot be assessed because they are covered by a non-removable dressing or device when the resident is admitted or reenters the facility.

• These dressings or devices are typically used to protect wounds or manage conditions that require specialized care, and they prevent healthcare professionals from fully examining the ulcer and determining its stage.

Proper documentation of these unstageable ulcers ensures that they are closely monitored for potential complications and receive appropriate care, even though the wound itself cannot be directly evaluated at the time.

Guidelines for Coding M0300E2

Coding Instructions:
To correctly code Item M0300E2, follow these steps:

1. Review the Resident’s Skin Assessment at Admission or Reentry:

   • Conduct a detailed assessment of the resident’s skin. Identify any pressure ulcers covered by a non-removable dressing or device, which prevents direct examination and staging of the ulcer.

2. Determine the Number of Unstageable Pressure Ulcers Due to Non-Removable Dressing or Device:

   • Code “0” if no unstageable pressure ulcers due to dressings or devices are present at the time of admission or reentry.
   • Enter the number of pressure ulcers that are unstageable due to non-removable dressings or devices present at the time of admission or reentry (e.g., 1, 2, 3, etc.).

3. Enter the Response in Item M0300E2:

   • Record the exact number of pressure ulcers unstageable due to dressings or devices identified at admission or reentry. If none are present, enter “0.”

Example Scenario:
A resident reenters the facility with a pressure ulcer on the heel covered by a non-removable cast. Since the wound cannot be fully examined and staged due to the cast, it is documented as unstageable. In this case, 1 would be entered in Item M0300E2 to reflect the unstageable pressure ulcer due to the dressing. If no such ulcers were present, 0 would be entered.

Best Practices for Accurate Coding

Documentation:

• Ensure that all pressure ulcers unstageable due to non-removable dressings or devices are clearly documented in the resident’s medical records, including the type of dressing or device used and its reason for use.
• Monitor the condition surrounding the dressing or device, and document any changes or signs of deterioration. Include details about plans for dressing changes or device removal, if applicable.

Communication:

• Foster communication between nursing staff, wound care specialists, and physicians to ensure that pressure ulcers under non-removable dressings or devices are monitored closely and addressed as soon as the dressing can be removed.
• Include these wounds in care planning discussions to ensure appropriate treatment plans are in place for pressure relief and infection prevention.

Regular Audits:

• Conduct regular audits to ensure that unstageable pressure ulcers due to non-removable dressings or devices are accurately documented at admission or reentry and that appropriate interventions are being provided.
• Review the care plan regularly to ensure that pressure ulcers under dressings or devices are being managed appropriately and that the dressing or device removal schedule is adhered to, when applicable.

Conclusion

Summary:
MDS Item M0300E2 is critical for documenting the number of unstageable pressure ulcers covered by non-removable dressings or devices at the time of admission or reentry. Proper coding ensures that these wounds are closely monitored, even though they cannot be fully staged. By following the guidelines and best practices outlined in this article, healthcare professionals can ensure effective care for residents with unstageable pressure ulcers due to dressings or devices in long-term care settings.

Click here to see a detailed step-by-step on how to complete this item set 

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 3, Page 3-165] for detailed guidelines on documenting unstageable pressure ulcers due to non-removable dressings or devices.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item M0300E2: Unstaged Due to Dressing – Number at Admit/Reentry was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.