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

M1311A1

Skip Logic

If 0, Go to M1311B1, 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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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 at most recent SOC/ROC

Observation ID in Form

M1311A2

Form Coding Instructions

Enter how many were noted at the time of most recent SOC/ROC

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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

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

M1311B1

Skip Logic

If 0, Go to M1311C1, 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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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 at most recent SOC/ROC

Observation ID in Form

M1311B2

Form Coding Instructions

Enter how many were noted at the time of most recent SOC/ROC

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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

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

M1311C1

Skip Logic

If 0, Go to M1311D1, Unstageable: Non-removable dressing/device

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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 at most recent SOC/ROC

Observation ID in Form

M1311C2

Form Coding Instructions

Enter how many were noted at the time of most recent SOC/ROC

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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

54893-3 Number of unstageable pressure ulcers/injuries 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

M1311D1

Skip Logic

If 0, Go to M1311E1, Unstageable: Slough and/or eschar

Form Context

Unstageable: Non-removable dressing/device: Known but not stageable due to non-removable dressing/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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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/injuries that were present at most recent SOC/ROC

Observation ID in Form

M1311D2

Form Coding Instructions

Enter how many were noted at the time of most recent SOC/ROC

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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

54946-9 Number of unstageable pressure ulcers/injuries 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

M1311E1

Skip Logic

If 0, Go to M1311F1, Unstageable: Deep tissue injury

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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 at most recent SOC/ROC

Observation ID in Form

M1311E2

Form Coding Instructions

Enter how many were noted at the time of most recent SOC/ROC

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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

54950-1 Number of unstageable pressure injuries presenting as deep tissue injury

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

M1311F1

Skip Logic

If 0, Go to M1324

Form Context

Unstageable: Deep tissue injury

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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 pressure ulcers that were present at most recent SOC/ROC

Observation ID in Form

M1311F2

Form Coding Instructions

Enter how many were noted at the time of most recent SOC/ROC

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

Basic Attributes

Class

SURVEY.CMS

Type

Surveys

First Released

Version 2.27

Last Updated

Version 2.77

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