Understanding and Coding MDS 3.0 Item M1030: Number of Venous and Arterial Ulcers

Introduction

Purpose:
Venous and arterial ulcers are chronic wounds commonly found in residents with poor circulation, such as those with peripheral artery disease or chronic venous insufficiency. These ulcers require specialized care, including wound management and prevention strategies to promote healing and avoid complications. MDS Item M1030, Number of Venous and Arterial Ulcers, is used to document the presence and number of these ulcers during the assessment period. Accurate coding of this item is essential for tracking the resident’s condition and ensuring appropriate care is provided. This article outlines how to properly code M1030 based on the latest MDS 3.0 guidelines.

What is MDS Item M1030?

Explanation:
MDS Item M1030, Number of Venous and Arterial Ulcers, records the number of ulcers resulting from venous or arterial insufficiency. These ulcers differ from pressure ulcers as they are caused by poor circulation rather than prolonged pressure on the skin.

• Venous ulcers are usually located on the lower legs or ankles and occur due to poor blood return from the legs.
• Arterial ulcers often occur on the toes, feet, or lower legs and are caused by poor arterial blood flow.

By documenting the number of venous and arterial ulcers, healthcare teams can ensure proper treatment and monitor the resident’s healing progress.

Guidelines for Coding M1030

Coding Instructions:
To correctly code Item M1030, follow these steps:

1. Review the Resident’s Skin and Wound Assessment:

   • Conduct a thorough skin examination focusing on the lower extremities to identify the presence of venous or arterial ulcers. Review the resident’s medical history for diagnoses of arterial or venous insufficiency.

2. Determine the Number of Venous and Arterial Ulcers:

   • Code “0” if no venous or arterial ulcers are present during the assessment period.
   • Enter the number of venous and/or arterial ulcers present during the assessment period (e.g., 1, 2, 3, etc.).

3. Enter the Response in Item M1030:

   • Record the exact number of venous or arterial ulcers the resident has. If none are present, enter “0.”

Example Scenario:
A resident with chronic venous insufficiency develops two venous ulcers on their lower legs. The ulcers are cleaned and dressed daily to prevent infection and promote healing. In this case, 2 would be entered in Item M1030 to document the number of venous ulcers. If no venous or arterial ulcers are present, 0 would be entered.

Best Practices for Accurate Coding

Documentation:

• Ensure that each venous or arterial ulcer is documented in the resident’s medical records, including the location, size, and severity, as well as the treatment provided (e.g., compression therapy, wound care).
• Regularly assess the ulcers and document any changes in size, appearance, or signs of infection to track healing progress or deterioration.

Communication:

• Collaborate with wound care specialists, nurses, and physicians to ensure that venous and arterial ulcers are properly managed and that all team members are aware of the resident’s wound care needs.
• Discuss the resident’s ulcers during interdisciplinary care planning meetings to ensure appropriate preventive measures, such as compression therapy or proper foot care, are in place.

Regular Audits:

• Conduct regular audits of care records to verify that venous and arterial ulcers are being documented accurately and that the appropriate treatment is being provided.
• Review the care plan regularly to ensure that residents with venous or arterial ulcers are receiving timely and effective wound care interventions.

Conclusion

Summary:
MDS Item M1030 is essential for documenting the number of venous and arterial ulcers present during the assessment period. Proper coding ensures that these ulcers are accurately tracked and managed, allowing healthcare professionals to provide appropriate treatment and monitor healing. By adhering to the guidelines and best practices outlined in this article, healthcare teams can ensure optimal care for residents with venous or arterial ulcers in long-term care settings.

Click here to see a detailed step-by-step on how to complete this item set 

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 3, Page 3-165] for detailed guidelines on documenting venous and arterial ulcers.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item M1030: Number of Venous and Arterial Ulcers was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.