I recently gave another training session for nursing home professionals for MDS 3.0 Section M: Skin Conditions. In the audience were nurses, directors of nursing, administrators, MDS coordinators and a smattering of physical therapists, doctors, and social workers. After the didactic I fielded questions and decided to share the most common ones with my blog readers.
Question 1: How do I code Section M0700 when a resident’s pressure ulcer presents as a blister?
Answer: Pressure ulcers sometimes present as blisters, particularly in the heel area. Blisters that are filled with clear serous fluid are coded in M0300B: Stage 2. Pressure ulcers that present as a blood-filled blister are coded as Suspected Deep Tissue Injury in M0300G.
Section M0700 asks for “Most severe tissue type,” and gives the following four choices:
1. Epithelial tissue
2. Granulation tissue
4. Necrotic tissue (Eschar)
Epithelial tissue refers to the closely packed cells that cover the entire surface of the body, and separated from underlying tissue by a thin sheet of connective tissue which provides structural support and binds to neighboring structures. Wound healing is characterized in part by the process of epithelialization, which occurs when fresh epithelial cells proliferate and spread over the open wound bed, providing cover for the wound and forming new skin.
When coding a blister in Section M0700, the correct answer is 1. Epithelial tissue.
Question 2: How do I code a superficial re-opening of a healed Stage 4 ulcer?
Answer: The RAI Manual prohibits “back staging” (also called reverse staging or downstaging) of pressure ulcers as they heal. Therefore, when a Stage 4 pressure ulcer heals, it is documented as a “healed Stage 4.” If this ulcer reopens, even if the reopened area is superficial and looks like a Stage 2 ulcer, it should be documented as a “reopened stage 4.”
If this ulcer were coded as a Stage 2 ulcer, you would be effectively downstaging from a “healed Stage 4” to a stage 2, which is prohibited by CMS.
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These answers were verified with Elizabeth Ayello RN, PhD, who developed the education program for MDS 3.0 Section M for CMS, and co-authored our book, Pocket Guide to Pressure Ulcers.