DiraChart MDS item reference
M0300CSection Mv1.20.1Manual page M-14
Stage 3 Pressure Ulcers
Item Rationale
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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. Identify all Stage 3 pressure ulcers currently present.
4. Identify the number of these pressure ulcers that were present on admission/entry or reentry.
DEFINITION
STAGE 3 PRESSURE
ULCER
Full thickness tissue loss.
Subcutaneous fat may be
visible but bone, tendon or
muscle is not exposed.
Slough may be present but
does not obscure the depth
of tissue loss. May include
undermining or tunneling
(see definition of
undermining and tunneling
on page M-20).
M0300C: Stage 3 Pressure Ulcers (cont.)
Manual page M-14RAI Manual v1.20.1Coding Instructions
for M0300C
M0300C1
•
Enter the number of pressure ulcers that are currently present and whose deepest
anatomical stage is Stage 3.
•
Enter 0 if no Stage 3 pressure ulcers are present and skip to M0300D, Stage 4.
M0300C2
•
Enter the number of these Stage 3 pressure ulcers that were first noted at Stage 3 at
the time of admission/entry AND—for residents who are reentering the facility after a
hospital stay, enter the number of Stage 3 pressure ulcers that were acquired during the
hospitalization (i.e., the Stage 3 pressure ulcer was not acquired in the nursing facility
prior to admission to the hospital).
•
Enter 0 if no Stage 3 pressure ulcers were first noted at the time of admission/entry or
reentry.
Manual page M-14RAI Manual v1.20.1Coding Tips
•
The depth of a Stage 3 pressure ulcer varies by anatomical location. Stage 3 pressure
ulcers can be shallow, particularly on areas that do not have subcutaneous tissue, such as
the bridge of the nose, ear, occiput, and malleolus.
•
In contrast, areas of significant adiposity can develop extremely deep Stage 3 pressure
ulcers. Therefore, observation and assessment of skin folds should be part of overall skin
assessment. Do not code moisture-associated skin damage or excoriation here.
•
Bone/tendon/muscle is not visible or directly palpable in a Stage 3 pressure ulcer.
M0300C: Stage 3 Pressure Ulcers (cont.)
Manual page M-14 MDS item matrixAssessment Applicability
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