58215-5 Stage 1 [MDSv3]

Fully-Specified Name

Component

Stage 1

Property

-

Time

Pt

System

^Patient

Scale

-

Method

MDSv3

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.68 (MIN)

Panel Type

Panel

Member of these Panels

Related Names

• i
• MDS version 3
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Random
• Survey
• SURVEY.MDS

54884-2 Number of pressure injuries - stage 1 during assessment period [CMS Assessment]

Term Description

A stage 1 pressure injury/ulcer is defined as intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300A

Form Context

Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues

Fully-Specified Name

Component

Number of pressure injuries - stage 1

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• i
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54576-4 Stage 2

Term Description

Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300B

Fully-Specified Name

Component

Pressure injuries - stage 2

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Long Common Name

Pressure injuries - stage 2

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Change Reason

"Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Panel Type

Panel

Member of these Panels

Related Names

• II
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• SURVEY.MDS

55124-2 Number of Stage 2 pressure ulcers

Term Description

A stage 2 pressure ulcer is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300B1

Skip Logic

If 0, Skip to M0300C, Stage 3.

Form Context

Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister

Fully-Specified Name

Component

Number of pressure injuries - stage 2

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries - stage 2 during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• II
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54886-7 Number of these Stage 2 pressure ulcers that were present upon admission/reentry

Observation ID in Form

M0300B2

Form Coding Instructions

Enter how many were noted at the time of admission

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - stage 2

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries present upon admission/reentry - stage 2 during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• II
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

58123-1 Date of Pressure injury.oldest non-epithelialized stage 2 [CMS Assessment]

Observation ID in Form

M0300B3

Fully-Specified Name

Component

Date of oldest stage 2 pressure injury

Property

Date

Time

RptPeriod

System

Pressure injury.oldest non-epithelialized stage 2

Scale

Qn

Method

CMS Assessment

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from MDSv3 to CMS Assessment to use across CMS instruments as approved by the Clinical LOINC committee; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• II
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey
• Ulcer

Example Units

Related Codes

54577-2 Stage 3

Observation ID in Form

M0300C

Form Context

Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Fully-Specified Name

Component

Pressure injuries - stage 3

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Long Common Name

Pressure injuries - stage 3

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Change Reason

"Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Panel Type

Panel

Member of these Panels

Related Names

• III
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• SURVEY.MDS

55125-9 Number of Stage 3 pressure ulcers

Term Description

A stage 3 pressure ulcer is defined as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300C1

Skip Logic

If 0, Skip to M0400C, Stage 4.

Form Context

Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Fully-Specified Name

Component

Number of pressure injuries - stage 3

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries - stage 3 during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• III
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54887-5 Number of these Stage 3 pressure ulcers that were present upon admission/reentry

Observation ID in Form

M0300C2

Form Coding Instructions

Enter how many were noted at the time of admission

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - stage 3

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries present upon admission/reentry - stage 3 during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• III
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54578-0 Stage 4

Observation ID in Form

M0300D

Form Context

Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling

Fully-Specified Name

Component

Pressure injuries - stage 4

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Long Common Name

Pressure injuries - stage 4

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Change Reason

"Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Panel Type

Panel

Member of these Panels

Related Names

• Pan
• Panel
• Panl
• Pnl
• Point in time
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• SURVEY.MDS

55126-7 Number of Stage 4 pressure ulcers

Term Description

A stage 4 pressure ulcer is defined as full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300D1

Skip Logic

If 0, Skip to 0300E, Unstageable: Non-removable dressing

Form Context

Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling

Fully-Specified Name

Component

Number of pressure injuries - stage 4

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries - stage 4 during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD from MDSv3 to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Removed "at assessment" from COMPONENT because it is implied by the TIMING=Pt; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54890-9 Number of these Stage 4 pressure ulcers that were present upon admission/reentry

Observation ID in Form

M0300D2

Form Coding Instructions

Enter how many were noted at the time of admission

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - stage 4

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries present upon admission/reentry - stage 4 during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54579-8 Unstageable: Known or likely but not stageable due to non-removable dressing/device

Observation ID in Form

M0300E

Fully-Specified Name

Component

Pressure injuries - unstageable due to non-removable dressing

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Long Common Name

Pressure injuries - unstageable due to non-removable dressing

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Change Reason

"Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Panel Type

Panel

Member of these Panels

Related Names

• Pan
• Panel
• Panl
• Pnl
• Point in time
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• SURVEY.MDS

54893-3 Number of unstageable pressure ulcers due to non-removable dressing/device

Term Description

A pressure ulcer that is unstageable due to a non-removable dressing is defined as a known pressure ulcer that is covered by a non-removable dressing or device, such as a surgical dressing, cast, other orthopedic device, or dressing not to be removed per physician's order.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300E1

Skip Logic

If 0, Skip to M00300F Unstageable: Slough and/or eschar.

Description

Unstageable: Known or likely but unstageable due to non-removable dressing or device

Fully-Specified Name

Component

Number of pressure injuries - unstageable due to non-removable dressing or device

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries - unstageable due to non-removable dressing or device during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt".; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54894-1 Number of these unstageable pressure ulcers that were present upon admission/reentry

Observation ID in Form

M0300E2

Form Coding Instructions

Enter how many were noted at the time of admission

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - unstageable due to non-removable dressing

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries present upon admission/reentry - unstageable due to non-removable dressing during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

55089-7 Unstageable: Known or likely but not stageable due to coverage of wound bed by slough and/or eschar

Observation ID in Form

M0300F

Fully-Specified Name

Component

Pressure injuries - unstageable due to coverage of wound bed by slough &or eschar

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Long Common Name

Pressure injuries - unstageable due to coverage of wound bed by slough/eschar

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Change Reason

"Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Panel Type

Panel

Member of these Panels

Related Names

• Pan
• Panel
• Panl
• Pnl
• Point in time
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• SURVEY.MDS

54946-9 Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar

Term Description

Slough tissue is defined as non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Eschar tissue is defined as dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scablike.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300F1

Skip Logic

If 0, Skip to M0300G, Unstageable: Deep tissue

Description

Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar.

Fully-Specified Name

Component

Number of pressure injuries - unstageable due to coverage of wound bed by slough &or eschar

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries - unstageable due to coverage of wound bed by slough/eschar during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt";Updated COMPONENT from "and or" to "&or" to match convention; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54947-7 Number of these unstageable pressure ulcers that were present upon admission/reentry

Observation ID in Form

M0300F2

Form Coding Instructions

Enter how many were noted at the time of admission

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - unstageable due to coverage of wound bed by slough &or eschar

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries present upon admission/reentry - unstageable due to coverage of wound bed by slough/eschar during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

55088-9 Pressure injuries - unstageable with suspected deep tissue injury in evolution

Observation ID in Form

M0300G

Fully-Specified Name

Component

Pressure injuries - unstageable with suspected deep tissue injury in evolution

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.68 (MIN)

Change Reason

"Pressure ulcers" has been updated to "pressure injuries" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.

Panel Type

Panel

Member of these Panels

Related Names

• Pan
• Panel
• Panl
• Pnl
• Point in time
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• SURVEY.MDS
• Ulcer

54950-1 Number of unstageable pressure ulcers with suspected deep tissue injury in evolution

Term Description

A pressure ulcer that is unstageable due to deep tissue injury has purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Source: Centers for Medicare & Medicaid Services

Observation ID in Form

M0300G1

Skip Logic

If 0, Skip to M0610, Dimension of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar

Form Context

Unstageable: Suspected deep tissue injury in evolution

Fully-Specified Name

Component

Number of pressure injuries - unstageable with suspected deep tissue injury in evolution

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries - unstageable with suspected deep tissue injury in evolution during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; Removed "at assessment" from COMPONENT because it is implied by TIMING of "Pt"; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey
• Ulcer

Example Units

Related Codes

54951-9 Number of these unstageable ulcers that were present upon admission/reentry

Observation ID in Form

M0300G2

Form Coding Instructions

Enter how many were noted at the time of admission

Fully-Specified Name

Component

Number of pressure injuries present upon admission &or reentry - unstageable with suspected deep tissue injury in evolution

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of pressure injuries present upon admission/reentry - unstageable with suspected deep tissue injury in evolution during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey
• Ulcer

Example Units

Related Codes

52477-7 Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers Or Eschar

Observation ID in Form

M0610

Skip Logic

Complete only if M0300C1, M0300D1, or M0300F1 is greater than 0.

Form Coding Instructions

If the patient has one or more unhealed (non-epithelialized) Stage 3 or 4 pressure ulcers or an eschar, identify the pressure ulcers with the longest dimension and record in centimeters:

Form Coding Instructions

If the patient has one or more unhealed (non-epithelialized) Stage 3 or 4 pressure ulcers or an unstageable pressure ulcer due to slough or eschar, identify the pressure ulcer with the largest surface area (length x width) and record in centimeters

Fully-Specified Name

Component

Largest pressure ulcer measurements

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Long Common Name

Largest Ulcer Measurements

Basic Attributes

Class

PANEL.SURVEY.MDS

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.73 (NAM)

Change Reason

Release 2.73: COMPONENT: update older "ulcer" terms in panels;

Panel Type

Panel

Member of these Panels

Related Names

• Injury
• Pan
• Panel
• Panl
• Pnl
• Point in time
• Pressure injuries
• pressure injury
• Random
• Survey
• SURVEY.MDS

52728-3 Pressure ulcer length

Observation ID in Form

M0610A

Fully-Specified Name

Component

Diameter.any.max

Property

Len

Time

Pt

System

Pressure injury.largest stage 3 or 4

Scale

Qn

Method

CMS Assessment

Long Common Name

Diameter.any.max Pressure injury.largest stage 3 or 4 [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.63 (MIN)

Change Reason

Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee. Changed CLASS from SURVEY.CARE to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• DIA
• Diam
• Diam.any.max
• III
• Largest
• Length
• Maximal
• Maximum
• Peak
• Point in time
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Random
• Survey
• Ulcer

Example Units

52729-1 Pressure ulcer width

Observation ID in Form

M0610B

Form Coding Instructions

Widest width of the same pressure ulcer, side to side perpendicular (90-degree angle) to length

Fully-Specified Name

Component

Diameter.transverse

Property

Len

Time

Pt

System

Pressure injury.largest stage 3 or 4

Scale

Qn

Method

CMS Assessment

Long Common Name

Diameter transverse Pressure injury.largest stage 3 or 4 [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.26

Last Updated

Version 2.63 (MIN)

Change Reason

Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• DIA
• Diam
• Diam transverse
• III
• Length
• Point in time
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Random
• Survey
• Ulcer

Example Units

57228-9 Pressure ulcer depth

Term Description

Depth of same unhealed ulcer or eschar

Observation ID in Form

M0610C

Form Coding Instructions

Depth of the same pressure ulcer from the visible surface to the deepest area (if depth is unknown, enter a dash in each box)

Form Coding Instructions

Enter 99.9 if the largest ulcer is unstageable and is not eschar

Fully-Specified Name

Component

Depth

Property

Len

Time

RptPeriod

System

Pressure injury.largest stage 3 or 4

Scale

Qn

Method

CMS Assessment

Long Common Name

Depth during assessment period [CMS Assessment] Pressure injury.largest stage 3 or 4

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.29

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee. Changed CLASS from SURVEY.OASIS to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Dpth
• III
• Length
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey
• Ulcer

Example Units

Related Codes

55073-1 Most Severe Tissue Type for Any Pressure Ulcer

Observation ID in Form

M0700

Form Coding Instructions

Select the best description of the most severe type of tissue present in any pressure ulcer bed

Fully-Specified Name

Component

Tissue type

Property

Type

Time

RptPeriod

System

Pressure injury.Largest at most advanced stage

Scale

Nom

Method

CMS Assessment

Long Common Name

Tissue type during assessment period [CMS Assessment] Pressure injury.Largest at most advanced stage

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Updated METHOD to CMS Assessment to use term across CMS instruments as approved by the Clinical LOINC committee; Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments.; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Normative Answer List LL674-3

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Nominal
• Pressure ulcer
• Pressure Ulcers
• Report period
• Survey
• Typ
• Ulcer

54952-7 Worsening in pressure injury status since last assessment (OBRA, PPS, or Discharge)

Observation ID in Form

M0800

Skip Logic

Complete only if A0130E = 0

Form Coding Instructions

Indicate the number of current pressure ulcers that were not present or were at a lesser stage on prior assessment (OBRA, PPS, or Discharge). If no current pressure ulcer at a given stage, enter 0

Fully-Specified Name

Component

Worsening in pressure injury status since last assessment (OBRA, PPS, or Discharge)

Property

-

Time

Pt

System

^Patient

Scale

-

Method

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.75 (PANEL)

Change Reason

Changed CLASS from SURVEY.MDS to PANEL.SURVEY.CMS; Pressure ulcer has been updated to pressure injury according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Disch
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Past
• Pnl
• Point in time
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• Random
• Survey
• Ulcer

Related Codes

54953-5 Stage 2

Observation ID in Form

M0800A

Skip Logic

If No, Skip to M1020, Other Ulcers, Wounds and Skin Problems . If Yes, Continue to M0900B, Stage 2.

Fully-Specified Name

Component

Number of current pressure injuries not present or were at a lesser stage on prior assessment - stage 2

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of current pressure injuries not present or were at a lesser stage on prior assessment - stage 2 during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG;Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• II
• No
• Num
• Number
• Pressure ulcer
• Pressure Ulcers
• QNT
• Quan
• Quant
• Quantitative
• Report period
• Survey

Example Units

Related Codes

54954-3 Stage 3

Observation ID in Form

M0800B

Fully-Specified Name

Component

Number of current pressure injuries not present or were at a lesser stage on prior assessment - stage 3

Property

Num

Time

RptPeriod

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of current pressure injuries not present or were at a lesser stage on prior assessment - stage 3 during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77 (MAJ)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Previous Releases: Changed method from MDSv3 so term can be used across CMS assessments per decision by the Clinical LOINC committee and CMS HITWG;Changed CLASS from SURVEY.MDS to SURVEY.CMS because term is used across CMS assessments; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC

Order vs. Observation

Observation

Member of these Panels