Step-by-Step Coding Guide for Item Set: M0100A. Risk Determination: Has Ulcer, Scar, or Dressing

1. Review of Medical Records

   • Begin by thoroughly reviewing the resident's medical records, focusing on skin assessments, wound care notes, physician orders, and nursing documentation. Look for any mention of skin ulcers (pressure ulcers, venous ulcers, etc.), scars from previous wounds or surgeries, and current dressings covering wounds or surgical sites.

2. Understanding Definitions

   • Ulcer: A break in the skin or sore that may be caused by different factors, including pressure, shear, friction, or vascular issues, leading to loss of the epidermis and often portions of the dermis and even subcutaneous fat.
   • Scar: A mark left on the skin or within body tissue where a wound, burn, or sore has not healed completely and fibrous connective tissue has developed.
   • Dressing: A protective covering placed over a wound, typically to keep it clean and to facilitate healing.

3. Coding Instructions

   • Code 0: No - If the resident currently has no ulcers, scars from healed wounds, or dressings covering wounds.
   • Code 1: Yes - If the resident currently has one or more ulcers, scars from previous wounds or surgeries, or dressings covering wounds.
   • Base your coding decision on the most recent comprehensive skin assessment and any relevant treatment documentation.

4. Coding Tips

   • Pay close attention to skin assessments conducted upon admission, during routine care, and at regular intervals as defined by the facility's protocols.
   • Ensure communication with the interdisciplinary team, including nurses and wound care specialists, to obtain a full picture of the resident's skin integrity and wound history.

5. Documentation

   • Document the coding decision in the MDS accurately. In the resident's care plan and medical record, include detailed notes on any identified ulcers, scars, or wounds requiring dressings. Describe the location, size, appearance, and any treatment plans or interventions in place.
   • Record any changes in the condition of the skin, ulcers, scars, or wounds, including healing progress or worsening conditions, and update the care plan accordingly.

6. Common Errors to Avoid

   • Overlooking small or less obvious wounds or scars that might impact the resident's skin integrity or risk for further skin breakdown.
   • Failing to update the MDS and care plan as the condition of the resident's skin changes or as wounds heal or worsen.

7. Practical Application

   • Example: Mr. Lee, a resident with limited mobility, has a history of pressure ulcers. During the latest skin assessment, a small pressure ulcer was noted on his left heel, and a dressing was in place. Additionally, Mr. Lee has a surgical scar on his abdomen from a previous operation. For M0100A, Mr. Lee is coded as "1" for Yes, indicating he has both an ulcer and a scar. His care documentation includes a detailed description of the pressure ulcer's location, size, and stage, along with the treatment plan involving regular dressing changes and offloading techniques. The surgical scar is noted as healed, with no further treatment required, but its presence is documented as part of his skin integrity history.

The Step-by-Step Coding Guide for item M0100A  in MDS 3.0 Section M 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.