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Specialties MDS

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I have a patient within looking back period of his QRTLY assessment I coded him with NO pressure ulcer, since on his weekly skin assessment revealed only wound on his Right gluteal fold. Now I am working on Annual Assessment and weekly skin assessment revealed pressure ulcer of right gluteal fold, stage 3 . same area went from wound to pressure ulcer is this correct? How to code my M section I am lost. Please help

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Specializes in ER CCU MICU SICU LTC/SNF.

If during the Quarterly look back period the skin assessment designated the site as a wound, without additional documentation to disprove it wasn't, then you coded it correctly as such. In other words there is no need to create a Significant correction of a prior assessment.

A skin tear due to shearing on a pressure point left unattended can lead to a pressure ulcer. Since it's now identified as a St III then code it in the MDS as a new pressure ulcer. You may also want to check whether 2 areas of decline for a Sig Change is met. The emergence of a new pressure ulcer at St II or higher is one. Another area of decline will validate changing the MDS type from Annual to SCSA.

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Thank you so much for taking time and responding.

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Talino should I also coded it as worsening since its was wound and it's now a pressure ulcer ?

Thank you so much for your help.

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Specializes in ER CCU MICU SICU LTC/SNF.
Talino should I also coded it as worsening since its was wound and it's now a pressure ulcer ?

Worsening” is actually defined in the RAI as a pressure ulcer that has progressed in stage, from 1-4. Since yours was initially a "wound" it doesn't meet the definition.

However, you will still code it in M0800 as a Stage 3 because it is "new" or it was not present on the prior assessment.

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State is coming toour Facility soon. I am so scared this is my first state survey as an MDSC. Wehave one patient I am very scared we are going to get tag because we didn'topen a SCSA for a new pressure ulcer of sacrum stage 3 on time. During thatperiod when I found out, that I closed my QRTLY assessment without coding M0100A as yes (I though patient still w/out skin impairment) I just went back andmodified QRTLY assessment and coded it in Section M without changing QRTLY toSCSA. Now i am working on annual assessment and I am thinkingto the MDS type from Annual to SCSA, since not only St 3 pressure ulcer notheeled yet, another new pressure ulcer of Rt heel, St 2 noted during lookingback period of this annual assessment.

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Specializes in ER CCU MICU SICU LTC/SNF.
I just went back andmodified QRTLY assessment and coded it in Section M without changing QRTLY toSCSA. Now i am working on annual assessment and I am thinkingto the MDS type from Annual to SCSA, since not only St 3 pressure ulcer notheeled yet, another new pressure ulcer of Rt heel, St 2 noted during lookingback period of this annual assessment.

Please read the RAI p5-12 to 5-13 regarding "When any significant error is discovered in an OBRA comprehensive or Quarterly assessment..."

Significant correction of a prior assessment is a 2-prong process. If I understand you correctly, you created a modification of a previous quarterly just recently? That would be process #1. The 2nd process is to create either a SCPA or SCSA. By your statement, the SCSA is warranted. From the day you modified the Quarterly and noted it should be a significant change, you have up to 14 days to complete the SCSA. In that case, change your Annual MDS to SCSA now.

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Thank you Talino

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