54886-7 Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister

Observation ID in Form

M1308.2a

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

54887-5 Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling

Observation ID in Form

M1308.2b

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

54890-9 Stage IV: Full thickness tissue loss with visible bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling

Observation ID in Form

M1308.2c

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

54894-1 Unstageable: Known or likely but unstageable due to non-removable dressing or device

Observation ID in Form

M1308.2d1

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

54947-7 Unstageable: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar

Observation ID in Form

M1308.2d2

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

54951-9 Unstageable: Suspected deep tissue injury in evolution.

Observation ID in Form

M1308.2d3

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