Step-by-Step Coding Guide for B1200: Corrective Lenses

Introduction

Corrective lenses, such as eyeglasses or contact lenses, play a crucial role in improving residents' quality of life by enhancing their vision. Proper coding of B1200 is essential for accurate assessment and care planning in long-term care settings.

Step 1: Review the Resident's History and Current Use

• Objective: Identify any historical or current use of corrective lenses.
• Action: Review medical records, consult with the resident, family, or caregivers, and observe the resident's use of eyeglasses or other visual aids.

Step 2: Assess the Need and Use of Corrective Lenses

• Objective: Determine if the resident uses corrective lenses and the extent to which they rely on them.
• Action: Ask the resident about their use of glasses or contact lenses, including situations where they might not use them but should.

Step 3: Coding for B1200

• Objective: Accurately code the resident's use of corrective lenses.
• Instructions:
  • Code 0 (No): If the resident does not use any corrective lenses.
  • Code 1 (Yes): If the resident uses corrective lenses, including glasses or contact lenses.

Step 4: Documentation

• Objective: Document the assessment findings and coding rationale.
• Action: Note the type of corrective lenses used and any observations regarding the resident's vision with and without the lenses.

Step 5: Incorporate Findings into Care Planning

• Objective: Utilize assessment data to inform care planning.
• Action: Ensure that the care plan addresses the resident's vision needs, including maintenance, replacement, and updating of corrective lenses.

Examples

• A resident who recently started using glasses for reading.
• A resident who has stopped wearing contact lenses due to discomfort, affecting their daily activities.

Common Errors to Avoid

• Overlooking temporary situations where the resident might not use their lenses.
• Failing to update the resident's records when changes in vision or corrective lens use occur.

The Step-by-Step Coding Guide for item B1200 in MDS 3.0 Section B is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.