MDS Alert

Is cartilage considered the same as bone when coding Stage 4 ulcers?

If you struggle with coding for pressure ulcers, you’re not alone. Good news: On March 20, the Centers for Medicare & Medicaid Services (CMS) released several MDS 3.0 Provider Update videos, one of which covered Section M and focused on answering five of the most common pressure ulcer coding questions.

How to Code When Pressure Ulcers Merge

Question: On admission, the resident has three small Stage 2 pressure ulcers on her coccyx. Two weeks later, two of the Stage 2 pressure ulcers have merged and the third has increased in numerical stage to a Stage 3 pressure ulcer. How should we address the merged pressure ulcers in M0300, including related to present on admission?

Answer: Even though the two Stage 2 pressure ulcers have merged, they are still considered present on admission because they did not change in numerical staging, answered Jennifer Pettis, RN, BS, WCC, consultant for the CMS Division of Nursing Homes, in the provider update presentation. So you must code the two merged ulcers as one Stage 2 pressure ulcer. 

How to code: Enter 1 for M0300B1 — Number of Stage 2 pressure ulcers, and enter 1 for M0300B2 — Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry, Pettis instructed. Then, enter the date of origin of the older of the two merged ulcers in M0300B3 — Date of oldest Stage 2 pressure ulcer. 

Because the third pressure ulcer increased in numerical stage, from Stage 2 to Stage 3, since admission, you would code this as follows:

• Enter 1 for M0300C1 — Number of Stage 3 pressure ulcers.
• Enter 0 for M0300C2 — Number of these Stage 3 pressure ulcers that were present upon admission/reentry.

Reclassify This Way When You Can’t Determine True Depth

Question: The resident arrived at the nursing home two weeks ago. Upon admission, he had a pressure ulcer on the right metatarsal head that was completely obscured with eschar. On his five-day PPS assessment, which was combined with his admission assessment, we coded the ulcer in M0300F — Unstageable Pressure Ulcers Related to Slough and/or Eschar. In M0300F2, we coded the pressure ulcer as present upon admission. We have been treating the ulcer with an enzymatic debridement agent and it is now approximately 80-percent covered with slough, visually obscuring the ulcer’s true depth, but the metatarsal head is palpable. How should we code this pressure ulcer on the 14-day assessment?

Answer: The pressure ulcer does not have to be completely debrided or free of all slough and/or eschar tissue for you to reclassify the stage, stated Lori Grocholski, MSW, LCSW, with CMS’s Center for Clinical Standards and Quality, in the provider update video. Despite being 80-percent covered by slough, the resident’s bone is directly palpable and the ulcer now meets the definition of a Stage 4 pressure ulcer in M0300D — Stage 4 Pressure Ulcers.

Key: But because the pressure ulcer was unstageable upon admission, you would not report this as worsened, Grocholski noted. That’s because this is the first assessment in which you were able to numerically stage the pressure ulcer. “The pressure ulcer will continue to be considered present on admission,” she added.

Reconsider Stage 2 Classification with Granulation

Question: The resident was admitted to our facility earlier in the week, and he had a Stage 2 pressure ulcer on his right ischial tuberosity as noted on his admission skin assessment. The nurse completing the admission skin assessment described the ulcer as 2 centimeters by 1 centimeter by 0.1 centimeter and recorded that the wound bed contained 100-percent red granulation tissue. But according to the RAI User’s Manual, Stage 2 pressure ulcers do not have granulation tissue, slough or eschar. What should we do to ensure accurate coding of Section M?

Answer: Because Stage 2 pressure ulcers are partial thickness wounds and heal by re-epithelialization, the presence of granulation tissue in the wound would indicate that it is in fact a full thickness wound and not a partial thickness wound, Pettis said. “Therefore, in this example, this pressure ulcer would not be coded as a Stage 2 pressure ulcer.”

Your first step in completing Section M is to review the medical record, including skin care flow sheets and other skin tracking forms, Pettis urged. You must speak with direct-care staff including the treatment nurse to confirm conclusions from the medical record, as well as conduct a physical assessment of the resident.

“For each pressure ulcer, the clinical team must determine the deepest anatomical stage and be sure to consider current and historical levels of tissue involvement,” Pettis stated. “Being able to differentiate tissue types and understand the definitions of the pressure ulcer stages is an essential component to ensuring accuracy of the assessment and subsequent treatment and care.” 

You may also need to review documentation to gain insights into the history of the pressure ulcer, Pettis noted. “If the pressure ulcer has ever been classified at a higher numerical stage than what is observed now, it should continue to be classified at that higher stage.”

Example: If a resident’s transfer records indicated that two months ago the resident had a Stage 3 pressure ulcer on his right ischial tuberosity, you would code this pressure ulcer in M0300C1 as an unhealed Stage 3 pressure ulcer and in M0300C2 as present upon admission, Pettis illustrated.

How to Address Cartilage Vs. Bone & Tunneling/Undermining

Question: In 2012, the National Pressure Ulcer Advisory Panel (NPUAP) issued a position statement stating that pressure ulcers with exposed cartilage are Stage 4 pressure ulcers. Does CMS agree with this when it comes to coding the MDS 3.0?

Answer: CMS does agree with NPUAP’s position statement, Grocholski answered. And in fact, CMS added a coding tip to the RAI User’s Manual that addresses this very issue. The tip states that “cartilage serves the same anatomical function as bone, and therefore, pressure ulcers that have exposed cartilage should be classified as a Stage 4.”

Question: I am the MDS Coordinator in a facility with a wound care nurse who assesses all residents with wounds on a weekly basis. The wound nurse is concerned that the measurements noted on the MDS 3.0 don’t account for undermining or tunneling. She is especially concerned that this is not accounted for in one particular resident with 3 centimeters of undermining from two to nine o’clock on the wound. Should I obtain this resident’s wound measurements only by measuring the distance between healthy skin tissue at each margin for the length and width, or should I somehow include this undermining? 

Answer: “Assessment of the pressure ulcer for tunneling and undermining is an important part of the complete pressure ulcer assessment,” Pettis said. Although you don’t record measurements of tunneling and undermining on the MDS 3.0, your staff should still assess, monitor and treat these as part of the comprehensive care plan.

To ensure that your MDS 3.0 measurements are accurate, measure length as the distance between healthy skin at the longest point head to toe, Pettis instructed. For width, measure between healthy skin perpendicular to the length.

Link: To view the entire video, MDS 3.0 Provider Updates: Section M, go to www.youtube.com/watch?v=Ix6qoV0If0Y&feature=youtu.be.