CMS item guidance

M0300: Current Number of Unhealed Pressure Ulcers/Injuries at
Each Stage
Steps for completing M0300A–G
Step 1: Determine Deepest Anatomical Stage
For each pressure ulcer, determine the deepest anatomical stage. At admission, code based on
findings from the first skin assessment that is conducted on or after and as close to the admission
as possible. Do not reverse or back stage. Consider current and historical levels of tissue
involvement.
1. Observe and palpate the base of any identified pressure ulcers present to determine the
anatomic depth of soft tissue damage involved.
2. Ulcer staging should be based on the ulcer’s deepest anatomic soft tissue damage that is
visible or palpable. If a pressure ulcer’s tissues are obscured such that the depth of soft tissue
damage cannot be observed, it is considered to be unstageable (see Step 2 below).
3. Review the history of each pressure ulcer in the medical record. If the stageable pressure
ulcer has ever been classified at a higher numerical stage than what is observed now, it
should continue to be classified at the higher numerical stage until healed unless it becomes
unstageable. Nursing homes that carefully document and track pressure ulcers will be able to
more accurately code this item.
4. Pressure ulcers do not heal in a reverse sequence, that is,
the body does not replace the types and layers of tissue
(e.g., muscle, fat, and dermis) that were lost during pressure
ulcer development before they re-epithelialize. Stage 3 and
4 pressure ulcers fill with granulation tissue. This
replacement tissue is never as strong as the tissue that was
lost and hence is more prone to future breakdown.
5. Clinical standards do not support reverse staging or back-
staging as a way to document healing, as it does not
accurately characterize what is occurring physiologically as
the ulcer heals. For example, over time, even though a
Stage 4 pressure ulcer has been healing and contracting
such that it is less deep, wide, and long, the tissues that
were lost (muscle, fat, dermis) will never be replaced with
the same type of tissue. Previous standards using reverse
staging or back-staging would have permitted identification
of such a pressure ulcer as a Stage 3, then a Stage 2, and so
on, when it reached a depth consistent with these stages.
Clinical standards now would require that this ulcer
continue to be documented as a Stage 4 pressure ulcer until it has completely healed unless it
becomes unstageable. Nursing homes can document the healing of pressure ulcers using
descriptive characteristics of the wound (i.e., depth, width, presence or absence of
granulation tissue, etc.) or by using a validated pressure ulcer healing tool.
DEFINITIONS
EPITHELIAL TISSUE
New skin that is light pink
and shiny (even in persons
with darkly pigmented skin).
In Stage 2 pressure ulcers,
epithelial tissue is seen in the
center and at the edges of
the ulcer. In full thickness
Stage 3 and 4 pressure
ulcers, epithelial tissue
advances from the edges of
the wound.
GRANULATION TISSUE
Red tissue with
“cobblestone” or bumpy
appearance; bleeds easily
when injured.
M0300: Current Number of Unhealed Pressure Ulcers/Injuries at
Each Stage (cont.)
Once a pressure ulcer has healed, it is documented as a healed pressure ulcer at its highest
numerical stage—in this example, a healed Stage 4 pressure ulcer. For care planning
purposes, this healed Stage 4 pressure ulcer would remain at increased risk for future
breakdown or injury and would require continued monitoring and preventative care.
6. A previously closed pressure ulcer that opens again should be reported at its worst stage,
unless currently presenting at a higher stage or unstageable.
Step 2: Identify Unstageable Pressure Ulcers
1. Visualization of the wound bed is necessary for accurate staging.
2. If, after careful cleansing of the pressure ulcer/injury, a pressure ulcer’s/injury’s anatomical
tissues are obscured such that the extent of soft tissue damage cannot be observed or
palpated, the pressure ulcer/injury is considered unstageable.
3. Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or
brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized
or palpated in the wound bed, should be classified as unstageable, as illustrated at
https://cdn.ymaws.com/npiap.com/resource/resmgr/NPIAP-Staging-Poster.pdf.
4. If the wound bed is only partially covered by eschar or slough, and the anatomical depth of
tissue damage can be visualized or palpated, numerically stage the ulcer, and do not code this
as unstageable.
5. A pressure injury with intact skin that is a deep tissue injury (DTI) should not be coded as a
Stage 1 pressure injury. It should be coded as unstageable, as illustrated at
https://cdn.ymaws.com/npiap.com/resource/resmgr/NPIAP-Staging-Poster.pdf.
6. Known pressure ulcers/injuries covered by a non-removable dressing/device (e.g., primary
surgical dressing, cast) should be coded as unstageable. “Known” refers to when
documentation is available that says a pressure ulcer/injury exists under the non-removable
dressing/device.
Step 3: Determine “Present on Admission”
For each pressure ulcer/injury, determine if the pressure
ulcer/injury was present at the time of admission/entry or
reentry and not acquired while the resident was in the care of
the nursing home. Consider current and historical levels of
tissue involvement.
1. Review the medical record for the history of the ulcer/injury.
2. Review for location and stage at the time of admission/entry or reentry.
3. If the pressure ulcer/injury was present on admission/entry or reentry and subsequently
increased in numerical stage during the resident’s stay, the pressure ulcer is coded at that
higher stage, and that higher stage should not be considered as “present on admission.”
4. If a numerically stageable pressure ulcer/injury was present on admission/entry or reentry
and becomes unstageable due to slou