I2500: Wound Infection (Other Than Foot), Step-by-Step
Step-by-Step Coding Guide for I2500: Wound Infection (Other Than Foot)
1. Review of Medical Records
Objective: Identify if the resident has a current wound infection (excluding infections on the foot) during the assessment period.
Actions:
- Access the resident’s medical records, including wound care flow sheets, physician notes, and nursing assessments.
- Confirm the presence of any wound infection, excluding infections specific to the foot. This can include infections in surgical wounds, pressure ulcers, or other skin breakdowns.
2. Understanding Definitions
I2500: Wound Infection (Other Than Foot): This item captures any non-foot wound infections that are actively being treated or managed.
Examples of Other Wound Infections:
- Infected surgical wounds
- Infected pressure ulcers
- Infected traumatic wounds
Illustration 1:
- Scenario: A resident has a Stage 3 pressure ulcer on their sacrum that shows signs of infection (e.g., redness, pus, increased temperature).
- Result: I2500 is coded "Yes" to reflect the presence of an infected wound (non-foot).
3. Coding Instructions
Step-by-Step:
- Step 1: Review the medical records to determine whether any wound infections (excluding the foot) are present in the past seven days.
- Step 2: Confirm that the infection is active and is being treated or managed (e.g., with antibiotics, debridement, or other wound care).
- Step 3: If an active wound infection (other than foot) is present, check I2500 as "Yes".
- Step 4: If no such wound infection is present, check I2500 as "No".
Illustration 2:
- Scenario: A resident has a surgical wound from a hip replacement, which has become infected. The care team is actively treating it with antibiotics.
- Result: I2500 is coded "Yes" to document the surgical wound infection.
4. Coding Tips
- Exclude Foot Wound Infections: Ensure that foot-specific infections, such as diabetic foot ulcers, are excluded from I2500. These are coded elsewhere in the MDS.
- Check for Active Treatment: Only code infections that are actively being treated (e.g., with antibiotics, wound care). Do not code past infections that are no longer active.
5. Documentation
Objective: Ensure the presence of a wound infection (other than foot) is properly documented in the medical record.
Actions:
- Record the type of wound, the location (e.g., surgical site, pressure ulcer), and the signs of infection (e.g., drainage, redness, warmth, or swelling).
- Document any wound care treatments (e.g., antibiotics, wound debridement, or dressing changes) being provided for the infection.
Illustration 3:
- Scenario: A resident has a traumatic wound on their arm that has developed an infection. Wound care notes indicate redness, drainage, and that antibiotics are being administered.
- Documentation: Ensure that the infection and treatment are clearly noted in the medical record, and code I2500 as "Yes".
6. Common Errors to Avoid
- Misclassifying Foot Infections: Ensure that foot infections, such as diabetic foot ulcers, are not mistakenly coded under I2500. These should be classified elsewhere.
- Incomplete Documentation: Avoid coding I2500 unless there is clear documentation in the medical record confirming the wound infection and the treatment being provided.
Illustration 4:
- Scenario: A resident’s chart lists a foot infection caused by a diabetic ulcer. No other wound infections are present.
- Error: Do not code I2500 for foot infections. This should be classified under a different section.
7. Practical Application
- Example 1: A resident with a surgical wound on the abdomen has developed an infection during the assessment period. I2500 is coded "Yes".
- Example 2: A resident with an old scar from a healed wound shows no signs of infection. I2500 is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set I2500 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0.
The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding.
Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.
