Step-by-Step Coding Guide for Item Set: L0200G. Dental: Unable to Examine

1. Review of Medical Records

   • Initiate by thoroughly reviewing the resident's medical and dental records. Focus on any previous attempts to conduct dental examinations and notes regarding the resident's cooperation, cognitive status, or any physical limitations that might have prevented a thorough dental examination.

2. Understanding Definitions

   • Unable to Examine: This category is used for residents who cannot be examined due to behavioral issues, severe cognitive impairment, physical limitations, or refusal to participate in a dental examination.

3. Coding Instructions

   • Code 0: No - If the resident was able to be examined, and there is documentation of a completed dental examination.
   • Code 1: Yes - If there were attempts to examine the resident's dental health, but the examination could not be completed due to the resident's condition or refusal.
   • Base your decision on the most recent attempts and documentation related to dental examinations.

4. Coding Tips

   • Document any specific reasons provided for why the resident could not be examined, as this information can be crucial for future care planning and attempts at examination.
   • Consider interdisciplinary strategies to facilitate future examinations, such as involving a familiar caregiver or using desensitization techniques for anxious residents.

5. Documentation

   • Document the coding decision in the MDS precisely. In the resident’s care plan and medical record, include detailed notes on the attempts made to examine the resident's dental health, specifying the reasons the examination could not be completed.
   • Ensure that any observations made during attempted examinations, even if incomplete, are recorded, along with plans to address potential dental care needs.

6. Common Errors to Avoid

   • Incorrectly coding a resident as "unable to examine" without making adequate attempts or exploring all possible strategies to facilitate an examination.
   • Failing to document specific reasons why an examination could not be conducted, which is essential for understanding the resident's needs and planning future care.

7. Practical Application

   • Example: Mr. Gomez, a resident with advanced dementia, becomes extremely agitated and uncooperative when approached for dental examinations, despite gentle attempts and the involvement of familiar staff. Previous notes indicate that examinations have been attempted on multiple occasions but have not been successful. For L0200G, Mr. Gomez is coded as "1" for Yes, indicating that he has been unable to be examined. His care documentation includes detailed accounts of these attempts, observations of his oral health that could be made without a full examination, and a care plan that includes strategies for managing his oral hygiene to the best extent possible under the circumstances.

The Step-by-Step Coding Guide for item L0200G 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.