Another guest blog post by Elizabeth A. Ayello, PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN
Good news! Since the educational training programs held last March and April, CMS has reconsidered its original guidance regarding how to code blister pressure ulcers on the revised Minimum Data Set (MDS) version 3.0. Previously, CMS directed that any pressure ulcer that presents as a blister regardless of what type of fluid seen (serous, sero-anguineous, or blood filled) was to be coded as a stage 2 . This is no longer true, not all pressure ulcer blisters are coded as stage 2 for MDS 3.0.
This July, CMS posted new information on its website that shifts the coding of pressure ulcer blisters to differentiate between those that are stage 2 (M0300B) from those that are unstageable suspected deep tissue injury (M0300G) based on a more comprehensive assessment of the resident and ulcer site. Visual observation of the type of fluid in the blister is not enough; you must now do a complete staging assessment that includes determining if the tissue adjacent to or surrounding the blister has any signs of tissue injury. These can include skin color changes (darker than surrounding skin), differences in tissue consistency (bogginess or firmness), tenderness, or skin temperature changes (warm or cool). Remember that despite an adequate lighting source, assessment of deep tissue injury may be difficult in residents with darkly pigmented skin.
CMS has stated in the updated RAI manual that “Stage 2 ulcers will generally lack the surrounding characteristics found with a deep tissue injury” while “blood-filled blisters related primarily to pressure are more likely than serous filled blisters to be associated with a suspected deep tissue injury.” “Do not code M0300G when a lesion related to pressure presents with an intact blister and the surrounding or adjacent soft tissue does not have the characteristics of Deep Tissue Injury.”
While CMS continues to use the adapted NPUAP 2007 pressure ulcer staging definitions in section M for MDS 3.0, this most recent coding change brings long term care staging guidance more closely in alignment with pressure ulcer staging in other care settings.
MDS 3.0 is brand new, and we will continue to have late breaking updates, so please be patient and understand that standards are continuing to evolve. Continue to visit the official CMS website for any other changes or updates as we countdown the days to the planned MDS 3.0 implementation date of October 1, 2010.
* * * * * * * * * * * * * * * *
To view all blog posts on revised Minimum Data Set 3.0 click on the MDS 3.0 blog archive.
Thank you for this! Would you elaborate on causes of blisters, nursing home residents, heels in particular that would not be related to pressure (deep tissue injury), other than friction; do you believe the occlusion of a vessel (acute) could lead to blister formation? Thank you
Reply written by Dr. Jeffrey M Levine.
Thanks for the comment Karen. There is a disease called bullous pemphogoid that causes blisters of the lower extremity in older people, although these are not commonly on the heel. Occlusion of a vessel from atherosclerotic disease or embolus will more likely cause bluish discoloration and pain at rest, followed by development of gangrene. Certain organisms that cause celluliltis such as Streptococci can cause blister formation, but you will observe surrounding erythema indicative of skin infection.
WHEN A CLEAR FLUID FILLED BLISTER IS REABSORBING AND CAPS WITH 95PERCENT BEING CLEAR AND THE OTHER BEING DARK BROWN DOES IT NOW NEED TO BE CODED AS UNSTAGEABLE. THE PERIWOUND IN NON REDDENED, NON BOGGY.
Thanks for the comment. If you have a healing clear fluid filled blister, and there is a small dark area at the periphery, and the peri-wound tissue looks good, I would code this as a healing stage 2.