0
No
if the resident did not have a pressure ulcer/injury in the 7-day look-back
period. Then skip to M1030, Number of Venous and Arterial Ulcers.
DiraChart MDS item reference
M0210Section Mv1.20.1Manual page M-4
Unhealed Pressure Ulcers/Injuries
Item Rationale
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Coded response
1
Yes
if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or
unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of
Unhealed Pressure Ulcers/Injuries at Each Stage.
Item-specific instructions
Coding Guidance
Review what the item asks, how to choose the response, and what should be verified before submission.
Steps for Assessment
1. Review the medical record, including skin care flow sheets or other skin tracking forms.
2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical
record review.
3. Examine the resident and determine whether any skin ulcers/injuries are present.
•
Key areas for pressure ulcer/injury development include the sacrum, coccyx, trochanters,
ischial tuberosities, and heels. Other areas, such as bony deformities, skin under braces,
and skin subjected to excess pressure, shear, or friction, are also at risk for pressure
ulcers/injuries.
•
Without a full body skin assessment, a pressure ulcer/injury can be missed.
•
Examine the resident in a well-lit room. Adequate lighting is important for detecting skin
changes. For any pressure ulcers/injuries identified, measure and record the deepest
anatomical stage.
4. Identify any known or likely unstageable pressure ulcers/injuries.
Coding Instructions
Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days.
•
Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back
period. Then skip to M1030, Number of Venous and Arterial Ulcers.
•
Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or
unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of
Unhealed Pressure Ulcers/Injuries at Each Stage.
Coding Tips
•
If an ulcer/injury arises from a combination of factors that are primarily caused by
pressure, then the area should be included in this section as a pressure ulcer/injury.
•
Mucosal ulcers caused by pressure should not be coded in Section M. Oral mucosal
ulcers are captured in item L0200C, Abnormal mouth tissue.
•
Mucosal pressure ulcers are not staged using the skin pressure ulcer staging system
because anatomical tissue comparisons cannot be made. Therefore, mucosal ulcers (for
example, those related to nasogastric tubes, nasal oxygen tubing, endotracheal tubes,
urinary catheters, etc.) should not be coded here.
M0210: Unhealed Pressure Ulcers/Injuries (cont.)
•
If a pressure ulcer is surgically closed with a flap or graft, it should be coded as a surgical
wound and not as a pressure ulcer. If the flap or graft fails, continue to code it as a
surgical wound until healed.
•
Residents with diabetes mellitus (DM) can have a pressure, venous, arterial, or diabetic
neuropathic ulcer. The primary etiology should be considered when coding whether a
resident with DM has an ulcer/injury that is caused by pressure or other factors.
•
If a resident with DM has a heel ulcer/injury from pressure and the ulcer/injury is present
in the 7-day look-back period, code 1 and proceed to code items in M0300 as appropriate
for the pressure ulcer/injury.
•
If a resident with DM has an ulcer on the plantar (bottom) surface of the foot closer to the
metatarsals and the ulcer is present in the 7-day look-back period, code 0 and proceed to
M1040 to code the ulcer as a diabetic foot ulcer. It is not likely that pressure is the primary
cause of the resident’s ulcer when the ulcer is in this location.
•
Scabs and eschar are different both physically and chemically. Eschar is a collection of
dead tissue within the wound that is flush with the surface of the wound. A scab is made
up of dried blood cells and serum, sits on the top of the skin, and forms over exposed
wounds such as wounds with granulating surfaces (like pressure ulcers, lacerations,
evulsions, etc.). A scab is evidence of wound healing. A pressure ulcer that was staged as
a 2 and now has a scab indicates it is a healing stage 2, and therefore, staging should not
change. Eschar characteristics and the level of damage it causes to tissues is what makes it
easy to distinguish from a scab. It is extremely important to have staff who are trained in
wound assessment and who are able to distinguish scabs from eschar.
•
If two pressure ulcers/injuries occur on the same bony prominence and are separated, at
least superficially, by skin, then count them as two separate pressure ulcers/injuries. Stage
and measure each pressure ulcer/injury separately.
•
If a resident had a pressure ulcer/injury that healed during the look-back period of the
current assessment, do not code the ulcer/injury on the assessment.
•
Skin changes at the end of life (SCALE), also referred to as Kennedy Terminal Ulcers
(KTUs) and skin failure, are not primarily caused by pressure and are not coded in Section
M.
MDS item matrixAssessment Applicability
See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.
16 relationships7 groups+
Assessment Applicability
See where this item applies across Nursing Home, Swing Bed, discharge, required-use, OBRA, and program or policy columns.
Nursing Home Subsets
Swing Bed Subsets
Shared NH/SB Subsets
OBRA Stand Alone Assessments
OBRA Admission A=01, B=99, F=99, G=^, H=0
MDS Item Matrix v1.20.1 v4
OBRA Quarterly A=02, B=99, F=99, G=^, H=0
MDS Item Matrix v1.20.1 v4
OBRA Annual / Sig Chg A=03, B=99, F=99, G=^, H=0 A= 04, B=99, F=99, G=^, H=0
MDS Item Matrix v1.20.1 v4
OBRA Discharge A=99, B=99, F=10, 11, G=1, 2, H=0
MDS Item Matrix v1.20.1 v4
Program and Policy Use
D/C Items (Only when A0310F = 10 or 11)
Item Subset Required Use ISC Skip Patterns
Official CMS source
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