Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
Injury (cont.)
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
Matrix values are not attached yet, but the page is ready for them when governance data is added.
No governed answer rows are attached yet. Add sub-items to populate the answer-codes view.
Injury (cont.)
Use this item when the facility is completing content tied to Section M and needs to stay anchored to v1.20.1.
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Injury (cont.) Coding Tips Once deep tissue injury has opened to an ulcer, reclassify the ulcer into the appropriate stage. Then code the ulcer for the reclassified stage. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. When a lesion due to pressure presents with an intact blister AND the surrounding or adjacent soft tissue does NOT have the characteristics of deep tissue injury, do not code here (see definition of Stage 2 pressure ulcer on page M-12). Example 1. A resident is admitted with a blood-filled blister on the right heel. After further assessment of the surrounding tissues, it is determined that the heel blister is a DTI. Four days after admission, the right heel blister is drained and conservatively debrided at the bedside. After debridement, the right heel is assessed and staged as a Stage 3 pressure ulcer. On the subsequent assessment, the right heel remains a Stage 3.
Coding: On admission, the pressure injury to the right heel would be coded at
M0300G1 as 1, and at M0300G2 as 1, present on admission/entry or reentry. On the subsequent assessment, the pressure ulcer is coded at M0300C1, Stage 3 pressure ulcer and at M0300C2 as 1, present on admission/entry or reentry.
Rationale: After a thorough clinical and skin examination, an assessment of the right
heel and surrounding tissues revealed skin injury consistent with a DTI, which was observed at the time of admission. The heel DTI blister is drained, tissue is debrided, and the ulcer is subsequently numerically staged as a Stage 3. Because this was the first time the ulcer was able to be assessed and numerically staged, and it remained at that same stage at the time of the current assessment, it is considered to have been present on admission.