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 a result of
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 the tissue adjacent to, or surrounding, the blister does not show signs of tissue damage
(e.g., color change, tenderness, bogginess or firmness, warmth or coolness), do not code as a
deep tissue injury.
4. In dark-skinned individuals, the area of injury is probably not purple/maroon, but rather
darker than the surrounding tissue.
5. Determine the number of pressure injuries that are unstageable related to deep tissue injury.
6. Identify the number of these pressure injuries that were present on admission/entry or reentry
(see page M-7 for instructions).
7. Clearly document assessment findings in the resident’s medical record, and track and
document appropriate wound care planning and management.
Manual page M-27RAI Manual v1.20.1Coding Instructions
for M0300G
M0300G1
•
Enter the number of unstageable pressure injuries related to deep tissue injury. Based
on skin tone, the injured tissue area may present as a darker tone than the surrounding
intact skin. These areas of discoloration are potentially areas of deep tissue injury.
•
Enter 0 if no unstageable pressure injuries related to deep tissue injury are present and
skip to M1030, Number of Venous and Arterial Ulcers.
M0300G2
•
Enter the number of these unstageable pressure injuries related to deep tissue injury
that were first noted at the time of admission/entry AND—for residents who are reentering
the facility after a hospital stay, that were acquired during the hospitalization (i.e., the
unstageable pressure injury related to deep tissue injury was not acquired in the nursing
facility prior to admission to the hospital).
•
Enter 0 if no unstageable pressure injuries related to deep tissue injury were first noted
at the time of admission/entry or reentry.
M0300G: Unstageable Pressure Injuries Related to Deep Tissue
Injury (cont.)
Manual page M-27RAI Manual v1.20.1Coding Tips
•
Once deep tissue injury has opened to an ulcer, reclassify the ulcer into the appropriate
stage. Then code the ulcer for the reclassified stage.
•
Deep tissue injury may be difficult to detect in individuals with dark skin tones.
•
Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.
•
When a lesion due to pressure presents with an intact blister AND the surrounding or
adjacent soft tissue does NOT have the characteristics of deep tissue injury, do not code
here (see definition of Stage 2 pressure ulcer on page M-12).
Example
1. A resident is admitted with a blood-filled blister on the right heel. After further assessment of
the surrounding tissues, it is determined that the heel blister is a DTI. Four days after
admission, the right heel blister is drained and conservatively debrided at the bedside. After
debridement, the right heel is assessed and staged as a Stage 3 pressure ulcer. On the
subsequent assessment, the right heel remains a Stage 3.
Coding: On admission, the pressure injury to the right heel would be coded at
M0300G1 as 1, and at M0300G2 as 1, present on admission/entry or
reentry. On the subsequent assessment, the pressure ulcer is coded at M0300C1,
Stage 3 pressure ulcer and at M0300C2 as 1, present on admission/entry
or reentry.
Rationale: After a thorough clinical and skin examination, an assessment of the right
heel and surrounding tissues revealed skin injury consistent with a DTI, which was
observed at the time of admission. The heel DTI blister is drained, tissue is debrided, and
the ulcer is subsequently numerically staged as a Stage 3. Because this was the first time
the ulcer was able to be assessed and numerically staged, and it remained at that same
stage at the time of the current assessment, it is considered to have been present on
admission.
Manual page M-27 