Ask Proactive – Coding a Pressure Injury That Worsened During Hospitalization

Q:

I have a resident with an in-house acquired Stage 2 pressure injury. He went out to the hospital for three days and upon return, it was documented as Stage 4. How should this be coded on the MDS?

The RAI User’s Manual (v1.18.11, effective Oct. 1, 2025) provides clear instructions for coding items M0300A–G (Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage). The coding process involves three steps:

Step 1 – Determine the Deepest Anatomical Stage

Code the pressure ulcer/injury at its current, most severe anatomical stage. Do not reverse or “back stage” a pressure injury that has healed or changed in appearance.

Step 2 – Identify Unstageable Pressure Ulcers/Injuries

If slough or eschar prevents staging, code as unstageable until the wound bed is visible and can be staged.

Step 3 – Determine “Present on Admission (POA)”

The manual outlines multiple POA scenarios. Scenario #8 specifically addresses your situation:

“If a resident who has a pressure ulcer/injury is hospitalized and the ulcer/injury increases in numerical stage or becomes unstageable due to slough or eschar during the hospitalization, it should be coded as present on admission upon reentry.”

— RAI User’s Manual v1.18.11, Chapter 3, Section M, Page M-15 (October 2025)

Therefore, in this case:

• • Code the ulcer at Stage 4 (the current stage on reentry), and
  • Mark it as Present on Admission = Yes, since the worsening occurred while hospitalized.

Documentation Tips:

• • Retain hospital records verifying the wound’s change in stage.
  • Complete and document a comprehensive reentry skin assessment, including date/time, wound location, measurements, and current deepest anatomical stage.
  • Ensure the facility record clearly indicates that the ulcer worsened during hospitalization.

Next steps: Make plans to join Proactive November 11, 2025 for the new webinar training F686: Treatment and Services to Prevent & Heal Pressure Ulcers

Written By:

Angie Hamer, RN, RAC-CT

Senior Consultant

Proactive LTC Consulting