MDS Alert

But you can use both systems, as some facilities did for the MDS 2.0.

The MDS 3.0 did away with backstaging pressure ulcers, a practice that flew in the face of National Pressure Ulcer Advisory Panel guidelines.

Yet to avoid coding confusion, facilities need to understand that the RAI User's Manual instructions in Section M are "adapted from the NPUAP 2007 staging definitions/guidelines," says Teresa Mota, RN, CALA, RAC-CT, senior program coordinator for Quality Partners of Rhode Island. Thus the manual instructions don't "match the current NPUAP definitions verbatim." Key: "CMS has made sure in the [RAI] manual that everyone knows that clinicians doing the pressure ulcer staging can adopt the NPUAP staging guidelines," but facilities have to follow the MDS 3.0 instructions for coding Section M, says Rena Shephard, MHA, RN, RAC-MT, C, founding chair and executive editor for the American Association of Nurse Assessment Coordinators, and president and CEO of RRS Healthcare Consulting Services in San Diego.

The biggest difference between the MDS 3.0 and NPUAP staging definitions involves how you stage and code blisters, says Shephard.

The NPUAP staging system defines suspected Deep Tissue Injury (DTI) as "a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue."

And the NPUAP system defines a stage 2 pressure ulcer, in part, as one that may present "as an intact or open/ruptured serum-filled blister." By contrast, the MDS 3.0 instructions for Section M note that if the tissue adjacent to, or surrounding, an intact blister does not show signs of tissue damage indicative of suspected DTI, you would code it as a stage 2 pressure ulcer.

Another difference: The NPUAP doesn't classify suspected DTI as unstageable as the MDS 3.0 does, says Diane Langemo, RN, PhD, FAAN, a wound care consultant in Grand Forks, N.D. Instead, NPUAP puts suspected DTI in a separate category.

On the MDS 3.0, however, you code suspected DTI at item M0300G: Unstageable: deep tissue - suspected DTI in evolution (see the coding tips for this item below).

Using the MDS and NPUAP staging definitions was more important when the MDS 2.0 was in effect because the MDS 2.0 required nursing facilities to backstage pressure ulcers, says Langemo. NPUAP guidelines say you never backstage a pressure ulcer -- and the MDS 3.0 doesn't require you to do so.

The problem with backstaging is that if you indicated that a stage IV pressure ulcer had healed to a stage II, future caregivers might not recognize how vulnerable that area is to skin breakdown, Langemo points out.

Real-world practice: Kindred Healthcare nursing facilities use Barbara Bates' weekly assessment tool (BWAT) for wounds, which incorporates the NPAUP definitions, relays Barbara Baylis, RN, senior VP of clinical operations for Kindred Healthcare in Louisville, Ky. And Kindred Healthcare plans to continue to use the descriptions on the BWAT to assess pressure ulcers, including suspected DTI, and wound healing. But "we will also follow the MDS 3.0 Section M coding guidelines" for coding the MDS 3.0, adds Baylis. Check out the BWAT tool at www.geronet.med.ucla.edu/centers/borun/modules/Pressure_ulcer_prevention/puBWAT.pdf.