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CMS Updates on MDS 3.0 Section M: Skin Conditions-Change in Coding of Blister Pressure Ulcers

Ayello, Elizabeth A. PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN; Levine, Jeffrey M. MD, AGSF, CMD, CWS; Roberson, Sharon RN

doi: 10.1097/01.ASW.0000383214.03535.6a
Features: Special Report

Elizabeth A. Ayello PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN, is faculty, Excelsior College, School of Nursing, Albany, New York, and is clinical associate editor, Advances in Skin and Wound Care journal, Ambler, Pennsylvania. Jeffrey M. Levine, MD, AGSF, CMD, CWS, is an internist and geriatrician, Wound Care Center, Beth Israel Medical Center, New York, New York. Sharon Roberson, RN, Northeast Consortia Technical Lead, Survey and Certification, Centers for Medicare & Medicaid Services, Boston, Massachusetts.

Editor's Note: The article "Essentials of MDS 3.0 Section M: Skin Conditions" was published in the June 2010 issue of Advances in Skin & Wound Care. Since the article's publication, the Centers for Medicare & Medicaid has announced additional updates to its guidelines affecting this section. This special report addresses those changes.

Following the posting of the revised Minimum Data Set (MDS) 3.0 on its Web site in November 2009, the Centers for Medicare & Medicaid (CMS) has continued to update the guidelines and resources needed for its implementation. Earlier this year, the CMS held educational programs to train surveyors and stakeholders on MDS 3.0. Based on information that was current at that time, an interdisciplinary team of authors, including a nurse from the CMS, authored an article in this journal on the essentials of MDS 3.0 regarding Section M: Skin Conditions.1 Since the article was published, revisions to these guidelines were posted on the CMS Web site. These revisions were based on concerns of attendees at the training sessions and continued dialogue with clinical experts to provide the best evidence-based practices.

As of June 2010, the MDS 3.0 RAI manual had instructed the clinician to code all "blisters" related to pressure as Stage 2 pressure ulcers (PrUs). However, since that time, it was decided after continued consultation with clinical experts in wound care to further clarify coding related to Stage 2 PrUs (M0300B) and suspected deep tissue injuries (sDTIs) (M0300G) to emphasize the assessment findings of the wound and the surrounding tissue areas, rather than the presence or absence of a pressure-related blister (eg, blood filled). Thus, the former instruction to code all pressure-related "blisters" was updated in July 2010 to code according to the surrounding tissue.

The emphasis is on complete and comprehensive assessment of the resident and the type of skin injury rather than just solely on the type of fluid in the blister. The first step is to determine if the ulcer being assessed is primarily as a result of pressure, which requires the clinician to rule out other conditions. If pressure is not the primary cause, then the clinician should not stage it as a PrU and not code it in Section M under the 300 subsections. Examples of this include blistering diseases, such as bullous pemphigoid.

It is believed that blood-filled blisters related primarily to pressure may show signs of sDTI. Therefore, examination of the area adjacent to or surrounding the blisters for evidence of tissue damage is needed. The clinician is instructed to look for signs of tissue damage, such as color change, tenderness, bogginess or firmness, and warmth or coolness. Hence, if a pressure-related "blister" is associated with signs and symptoms of an sDTI as described above, code this lesion as "unstageable, suspected deep tissue injury" under subsection M0300G. On the other hand, if a pressure-related "blister" lacks any of the characteristics of an sDTI, then the clinician is instructed to code the lesion as a Stage 2 PrU under section M0300B.

Section M: Skin Conditions is greatly expanded in MDS 3.0, as it now has 11 subsections. These essential changes have been described elsewhere in the literature,1 as well as in the Resident Assessment Instrument Manual. In accordance with the additional CMS July 2010 changes, the authors have revised the figures from the previously published article.1 The currently posted manual and all Section M training materials provided by CMS have been updated accordingly.2 New to the training materials are patient clinical scenarios for coding. Another educational training session by CMS was held in August. The authors continue to urge professionals to check the CMS Web site for revisions and updates. In addition, the authors believe that the enhanced educational training materials available on the CMS Web site will be a valuable resource as individuals and facilities prepare for this change in MDS 3.0, which is still scheduled for implementation on October 1, 2010.

The fact that MDS 3.0 incorporates more current terminology and requires the user to use the expanded staging categories will hopefully bring consistency in staging across all care settings. This will enhance clinical communication and, most important, standardize staging terminology regardless of where the person with the PrU is being treated. The authors also believe that this July 2010 coding change by CMS, coupled with all the other revisions in Section M 3.0 previously described earlier this year, will lead to better care and outcomes for residents.

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The authors thank and acknowledge the input, review of the information contained in this article, and helpful comments from the following individuals: Stella Mandl, BSW, BSN, RN, PHN; Teresa M. Mota, RN, CALA; Ann M. Spenard, MSN, RN; Ellen Berry, PT; Shari Ling, MD; Steven Levenson, MD; Rosemary C. Dunn, RN; and Debra Saliba, MD, MPH.

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1. Levine JM, Roberson S, Ayello EA. Essentials of MDS 3.0 Section M: skin conditions. Adv Skin Wound Care 2010;23:273-83.
2. RAI Manual Version 3.0 and MDS Forms. Last accessed July 13, 2010.
© 2010 Lippincott Williams & Wilkins, Inc.