A resident was admitted with a pressure injury (PI) that was unstageable because it was covered with slough and eschar. I coded it on the admission MDS under M0300F(Unstageable Pressure Ulcers Related to Slough and/or Eschar). I’m now doing a quarterly and the slough has been debrided, but there is still a lot of eschar. Do I still code it as unstageable on the MDS?
An unstageable pressure ulcer does not have to be fully debrided to reclassify the stage. Page M-22 of the RAI Manual: “Pressure ulcers that are covered with slough and/or eschar, and the wound bed cannot be visualized, should be coded as unstageable because the true anatomic depth of soft tissue damage (and therefore stage) cannot be determined. Only until enough slough and/or eschar is removed to expose the anatomic depth of soft tissue damage involved, can the stage of the wound be determined.”
When coding subsequent MDS’s the previously unstageable PI would be coded under the reclassified stage and coded as ‘present on admission’.