From Texas RAI Manager: Reversal of previous CMS position on "present on admission"

CMS Clarifies Coding “Present on Admission” for Pressure Ulcers in MDS Item M0300

Question:

A resident was admitted with a pressure ulcer that was “present on admission”. The resident both discharged return anticipated to the hospital and then returned to the facility within 30 days with the same pressure ulcer at the same stage. Can the pressure ulcer be coded in item M0300 as present upon admission/entry or reentry?

Clarification:

The MDS 3.0 RAI User's Manual, Chapter 3, page M-7 contains the following instructions for determining if a pressure ulcer was “present on admission”:

“For each pressure ulcer, determine if the pressure ulcer was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement…

Step 4: If a resident who has a pressure ulcer is hospitalized and returns with that pressure ulcer at the same numerical stage, the pressure ulcer should not be coded as "present on admission" because it was present at the facility prior to the hospitalization.”

• If the resident was admitted to the facility with a pressure ulcer, was subsequently transferred to the hospital with the same pressure ulcer at the same stage as it was at the time of admission, and then returned to the facility with that same pressure ulcer at the same stage, it should be coded as “present on admission” in item M0300. It is coded as “present on admission” because it was not acquired while the resident was in the care of nursing home staff.
• If the pressure ulcer was not “present on admission” when it was identified by nursing home staff or if a pressure ulcer that was “present on admission” increased in stage while receiving nursing home care, it would NOT be coded as “present on admission” when the resident returned from the hospital with the ulcer at the same stage as it was when they left. This is because the ulcer was either acquired or worsened to a higher stage while under the care of nursing home staff.

As required on page 5-10 of the MDS 3.0 RAI User's Manual, nursing home staff should correct all MDS that were not appropriately coded in this fiscal year (since 10/1/15) within 14 days of reading this clarification and noting the error. Modifications to correct the errors must be made, even though there will be no impact on the Resource Utilization Group (RUG) used for payment and no impact on nursing home quality measures.

Posted: 12/30/2015