58214-8 Unhealed Pressure Ulcer(s). Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher?

Observation ID in Form

M0210

Skip Logic

If 0, Skip to M1030, Number of Venous and Arterial Ulcers. If 1, Continue to M0300, Current Number of Unhealed Pressure Ulcers at Each Stage.

Fully-Specified Name

Component

One or more unhealed pressure injuries stage 1 or higher

Property

Find

Time

RptPeriod

System

^Patient

Scale

Ord

Method

CMS Assessment

Long Common Name

One or more unhealed pressure injuries stage 1 or higher during assessment period [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: 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

Normative Answer List LL251-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• i
• Ordinal
• Pressure ulcer
• Pressure Ulcers
• QL
• Qual
• Qualitative
• Report period
• Screen
• Survey

Related Codes

Third Party Copyright

This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.

This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.

Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.

86892-7 Current Number of Unhealed Pressure Ulcers at Each Stage

Observation ID in Form

M0300

Fully-Specified Name

Component

MDS v3.0 - RAI v1.17.2 - Current number of unhealed pressure injuries at each stage - IPA

Property

-

Time

RptPeriod

System

^Patient

Scale

-

Method

CMS Assessment

Long Common Name

MDS v3.0 - RAI v1.17.2 - Current number of unhealed pressure injuries at each stage - IPA during assessment period [CMS Assessment]

Basic Attributes

Class

PANEL.SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.78 (PANEL)

Change Reason

Release 2.77: TIME_ASPCT: Decision by CMS to update the Timing to RptPeriod from Pt for all CMS Assessments; Release 2.68: COMPONENT: Assessment version number was updated to reflect the most recent version.; Previous Releases: This panel is in version 1.14.1 and 1.15.1, so "v1.15.1" was added to the Component; v1.16.1 was added to the Component; "Pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP and as approved by the Clinical LOINC.; Current convention (as approved by the joint CMS LTPAC & LOINC project team) will list only the most current assessment in the Component for CMS Assessment panels.

Order vs. Observation

Subset

Panel Type

Organizer

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• No
• Num
• Pan
• Panel
• PANEL.SURVEY.CMS
• Panl
• Pnl
• Pressure ulcer
• Pressure Ulcers
• Report period
• Survey

Related Codes

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

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

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

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

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

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

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

Form Context

Unstageable - Slough and/or eschar: Known but not stageable 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

54970-9 Number of Venous and Arterial Ulcers

Observation ID in Form

M1030

Form Coding Instructions

Enter the total number of venous and arterial ulcers present

Fully-Specified Name

Component

Number of venous and arterial ulcers in last 7D

Property

Num

Time

7D

System

^Patient

Scale

Qn

Method

CMS Assessment

Long Common Name

Number of venous and arterial ulcers in last 7 days [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.63 (MIN)

Change Reason

Changed Property from NRat to Num because the number is not a count over time. 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.

Order vs. Observation

Observation

Member of these Panels

Related Names

• # venous and arterial ulcers in last 7D
• Centers for Medicare and Medicaid Assessment
• Cnt
• Count
• No
• Num
• Number
• Past
• QNT
• Quan
• Quant
• Quantitative
• Survey

Example Units

Related Codes

86747-3 Other Ulcers, Wounds and Skin Problems

Observation ID in Form

M1040

Form Coding Instructions

Check all that apply.

Fully-Specified Name

Component

Ulcers, wounds and skin problems

Property

Find

Time

Pt

System

^Patient

Scale

Nom

Method

CMS Assessment

Long Common Name

Deprecated Ulcers, wounds and skin problems [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.77 (DEL)

Order vs. Observation

Observation

Normative Answer List LL4583-2

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Integument
• Nominal
• Point in time
• Random
• Survey

Related Codes

86748-1 Skin and Ulcer Treatments

Observation ID in Form

M1200

Form Coding Instructions

Check all that apply.

Fully-Specified Name

Component

Skin and pressure injury &or injury treatments during assessment period

Property

Find

Time

RptPeriod

System

^Patient

Scale

Nom

Method

CMS Assessment

Long Common Name

Skin and ulcer/injury treatments during assessment period [CMS Assessment]

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.63

Last Updated

Version 2.73 (NAM)

Change Reason

Release 2.73: COMPONENT: Update older "ulcer" terms to "pressure injury"; Release 2.70: TIME_ASPCT: Updated Timing to align with the new model representing various reporting periods across CMS assessment.; COMPONENT: Removed "7D"; Previous Releases: "Injury" was added to the Componet because "pressure ulcer" has been updated to "pressure injury" according to the new guidelines by the NPUAP.

Order vs. Observation

Observation

Normative Answer List LL4584-0

Member of these Panels

Related Names

• Centers for Medicare and Medicaid Assessment
• Finding
• Findings
• Integument
• Nominal
• pressure injury
• Pressure ulcer
• Pressure Ulcers
• Report period
• Survey
• Tx
• Txs
• Ulcer

Related Codes