DiraChart MDS item reference
M0300BSection Mv1.20.1Manual page M-12
Stage 2 Pressure Ulcers
Item Rationale
Quick codingAnswer Codes
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Response format: Instruction / group heading
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Item-specific instructionsCoding Guidance
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RAI Manual v1.20.1Steps for Assessment
1. Perform head-to-toe assessment. Conduct a full body skin assessment focusing on bony
prominences and pressure-bearing areas (sacrum, buttocks, heels, ankles, etc.).
2. For the purposes of coding, determine that the lesion being assessed is primarily related to
pressure and that other conditions have been ruled out. If pressure is not the primary cause,
do not code here.
3. Examine the area adjacent to or surrounding an intact blister for evidence of tissue
damage. If other conditions are ruled out and the tissue adjacent to or surrounding the
blister demonstrates signs of tissue damage (e.g., color change, tenderness, bogginess or
firmness, warmth or coolness), these characteristics suggest a deep tissue injury (DTI)
rather than a Stage 2 pressure ulcer.
4. Stage 2 pressure ulcers will generally lack the surrounding characteristics found with a deep
tissue injury.
5. Identify the number of these pressure ulcers that were present on admission/entry or reentry
(see instructions on page M-8).
Manual page M-12RAI Manual v1.20.1Coding Instructions
for M0300B
M0300B1
•
Enter the number of pressure ulcers that are currently present and whose deepest
anatomical stage is Stage 2.
•
Enter 0 if no Stage 2 pressure ulcers are present and skip to M0300C, Stage 3.
M0300B2
•
Enter the number of these Stage 2 pressure ulcers that were first noted at the time of
admission/entry AND—for residents who are reentering the facility after a hospital stay,
enter the number of Stage 2 pressure ulcers that were acquired during the hospitalization
(i.e., the Stage 2 pressure ulcer was not acquired in the nursing facility prior to admission
to the hospital).
•
Enter 0 if no Stage 2 pressure ulcers were first noted at the time of admission/entry or
reentry.
Manual page M-12RAI Manual v1.20.1Coding Tips
•
Stage 2 pressure ulcers by definition have partial thickness loss of the dermis.
Granulation tissue, slough, and eschar are not present in Stage 2 pressure ulcers.
•
Do not code skin tears, tape burns, moisture associated skin damage, or excoriation here.
•
When a pressure ulcer presents as an intact blister, examine the adjacent and surrounding
area for signs of deep tissue injury. When a deep tissue injury is determined, do not code
as a Stage 2.
Manual page M-12 MDS item matrixAssessment Applicability
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