M1040A: Other Skin Problems - Infection of the Foot, Step-by-Step

Step-by-Step Coding Guide for M1040A: Other Skin Problems - Infection of the Foot

1. Review of Medical Records

Objective: Confirm if the resident has a foot infection during the assessment period.
Actions:

• Access the resident’s medical records, including wound care assessments, progress notes, and physician documentation.
• Identify any foot infections present in the past 7-day look-back period. Common signs of infection include cellulitis, purulent drainage, or redness with swelling in the foot.

2. Understanding Definitions

M1040A: Infection of the Foot: This item refers to any infection of the foot, including conditions such as cellulitis or infected ingrown toenails. These infections must be present within the 7-day look-back period and require treatment or monitoring​​.

Illustration 1:

Scenario: A resident has an infected ingrown toenail, resulting in redness, swelling, and pus drainage from the nail bed.

Result: M1040A is coded "Yes", as the infection is present and documented.

3. Coding Instructions

Step-by-Step:

• Step 1: Review the resident’s medical records to confirm the presence of any foot infection during the last 7 days.
• Step 2: Look for signs such as purulent drainage, redness, or swelling indicative of infection.
• Step 3: If a foot infection is documented, mark M1040A as "Yes".
• Step 4: If no such infection is present, mark M1040A as "No".

Illustration 2:

Scenario: A resident is diagnosed with cellulitis in the foot, which has been treated with antibiotics during the look-back period.

Result: M1040A is coded "Yes".

4. Coding Tips

• Exclude Non-Infectious Conditions: Ensure that only infectious conditions like cellulitis or infected wounds are coded here. Non-infectious lesions or conditions (e.g., diabetic foot ulcers or venous ulcers) should be coded under different M1040 subcategories​.
• Signs of Infection: Look for documentation of specific signs of infection, such as fever, localized heat, pain, and drainage from the affected foot.

5. Documentation

Objective: Ensure that the infection and its treatment are well-documented in the resident’s medical record.
Actions:

• Record the type of infection, affected foot, and any wound care or antibiotic therapy being provided.
• Document any relevant physician notes or nursing assessments showing the infection’s status and treatment response.

Illustration 3:

Scenario: The resident’s chart includes documentation of an infected ingrown toenail, treated with antibiotics and regular dressing changes.

Documentation: The treatment plan and the presence of infection are clearly noted, and M1040A is coded "Yes".

6. Common Errors to Avoid

• Coding Non-Infections: Do not code non-infectious conditions like diabetic foot ulcers under M1040A; these should be coded separately.
• Missing Infection Details: Ensure that documentation includes the clinical signs of infection. Lack of specificity could lead to incorrect coding.

Illustration 4:

Scenario: A resident has a pressure ulcer on the foot but no signs of infection. It should be coded as a pressure ulcer, not under M1040A.

Error: Do not code pressure ulcers or non-infected foot conditions here.

7. Practical Application

• Example 1: A resident has cellulitis in their left foot, with swelling, redness, and purulent drainage documented during the look-back period. M1040A is coded "Yes".
• Example 2: A resident’s foot is being monitored for pressure ulcers but shows no signs of infection. M1040A is coded "No".

Please note that the information provided in this guide for MDS 3.0 Item set M1040A 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.