Step-by-Step Coding Guide for Item Set: M0100B. Risk Determination: Formal Assessment

1. Review of Medical Records

   • Begin with a comprehensive review of the resident’s medical records to identify any formal skin integrity risk assessments that have been completed. Look for completed standardized tools such as the Braden Scale for Predicting Pressure Sore Risk, Norton Scale, or any other assessments used by the facility to evaluate risk for skin breakdown or ulcers.

2. Understanding Definitions

   • Formal Assessment: Refers to the use of standardized, validated tools or scales by healthcare professionals to systematically evaluate a resident's risk for developing skin breakdown, pressure ulcers, or other wound-related complications.

3. Coding Instructions

   • Code 0: No - If no formal skin integrity risk assessment has been conducted on the resident.
   • Code 1: Yes - If a formal skin integrity risk assessment has been completed, regardless of the outcome or identified risk level.
   • Base your coding on the presence of documented evidence that a formal assessment was completed during the assessment reference period.

4. Coding Tips

   • Ensure that all staff involved in resident assessments are aware of which tools constitute a formal risk assessment and are trained in their proper administration and documentation.
   • Regularly review and update training and protocols related to skin integrity risk assessments to ensure compliance with current best practices and standards of care.

5. Documentation

   • Document the coding decision in the MDS accurately. In the resident’s care plan and medical record, include details about the formal assessment tool used, the date of the assessment, the results, and any interventions or care planning decisions made as a result of the assessment.
   • Ensure that the documentation clearly indicates that the assessment was a standardized, formal tool and not informal observations or assessments.

6. Common Errors to Avoid

   • Failing to document the completion of a formal risk assessment, even when it has been conducted, leading to inaccuracies in coding and potential gaps in care planning.
   • Confusing informal skin observations or assessments with formal, standardized risk assessments.

7. Practical Application

   • Example: During her quarterly care plan review, Mrs. Smith was assessed for skin integrity risk using the Braden Scale. The assessment was completed by a trained nurse, and Mrs. Smith was found to be at moderate risk for pressure ulcer development due to her limited mobility and nutritional status. For M0100B, Mrs. Smith is coded as "1" for Yes, indicating a formal skin integrity risk assessment was conducted. Her care documentation includes the date of the assessment, her scores in each Braden Scale category, and the resulting care strategies implemented to mitigate her risk, such as frequent repositioning and nutritional support.

The Step-by-Step Coding Guide for item M0100B 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.