L0200E. Dental: inflamed/ bleeding gums or loose teeth, step-by-step

Step-by-Step Coding Guide for Item Set: L0200E. Dental: Presence of Mouth or Facial Pain due to Dental Problems

1. Review of Medical Records

   • Begin with an extensive review of the resident’s medical and dental records, focusing on any documented complaints or observations of mouth or facial pain that might be attributed to dental problems. Look for notes from dental examinations, pain assessments, reports from nursing staff, and any resident complaints about mouth or facial pain.

2. Understanding Definitions

   • Mouth or Facial Pain Due to Dental Problems: Refers to discomfort or pain in the mouth, jaws, or face area that is directly related to dental conditions such as cavities, gum disease, impacted teeth, infections, or abscesses.

3. Coding Instructions

   • Code 0: No - If the resident has not reported or shown signs of mouth or facial pain due to dental problems.
   • Code 1: Yes - If the resident has experienced mouth or facial pain attributed to dental conditions.
   • Base your coding decision on documented evidence of dental-related pain in the resident’s medical records.

4. Coding Tips

   • Pay attention to resident behaviors that may indicate pain, especially in those with communication challenges, such as refusing food, grimacing, or frequently touching their face or mouth.
   • Regular oral health assessments can help identify potential sources of pain early, even if the resident has not verbally complained.

5. Documentation

   • Document the coding decision in the MDS accurately. Also, detail in the resident's care plan and medical records any instances of mouth or facial pain, including the suspected dental cause, any diagnostic findings, and interventions or treatments provided.
   • Record the outcomes of any treatments or referrals to dental professionals, including changes in the resident’s pain level and any follow-up care planned.

6. Common Errors to Avoid

   • Failing to investigate non-verbal signs of discomfort as potential indicators of dental-related pain.
   • Overlooking the need for, or outcomes of, dental referrals and treatments in the resident’s documentation.

7. Practical Application

   • Example: Mrs. Patel began showing signs of discomfort while eating and occasionally would hold her cheek, grimacing. Upon inquiry, she complained of a constant throbbing pain in her lower jaw. A dental examination facilitated by the facility revealed a deep cavity in one of her molars that was causing the pain. For L0200E, Mrs. Patel is coded as "1" for Yes, indicating the presence of mouth or facial pain due to a dental problem. Her care documentation includes the dental findings, treatment received (tooth extraction and medication for infection), and her pain management plan following the procedure.

The Step-by-Step Coding Guide for item L0200E in MDS 3.0 Section L 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.