M0100Z. Risk determination: none of the above, Step-by-Step

Step-by-Step Coding Guide for Item Set: M0100Z. Risk Determination: None of the Above

1. Review of Medical Records

   • Start by comprehensively reviewing the resident’s medical records, including skin assessments, physician and nursing notes, and any other relevant documentation. Your focus is to verify whether any formal assessments, clinical evaluations, or documentation related to skin integrity risk factors have been conducted or noted.

2. Understanding Definitions

   • None of the Above: This category is selected when none of the previously listed risk determination methods or findings (such as having an ulcer, a formal assessment, or a clinical assessment) have been documented or apply to the resident.

3. Coding Instructions

   • Code 0: No - If any risk determination method (formal assessment, clinical assessment, or documentation of ulcers, scars, or dressings) has been applied or documented.
   • Code 1: Yes - If after a thorough review of medical records, no risk determination methods have been applied or documented for the resident.
   • Base your decision on a comprehensive review of the resident’s current and historical documentation regarding skin integrity and risk assessments.

4. Coding Tips

   • Ensure that you have access to and review all possible sources of information within the resident's medical records that could indicate a risk assessment for skin integrity has been conducted.
   • Regularly update and review documentation practices to ensure that any assessments or significant observations related to skin integrity are accurately recorded.

5. Documentation

   • Document the coding decision accurately in the MDS. Additionally, in the resident’s care plan and medical record, explicitly note the absence of documented risk assessments or findings related to skin integrity, supporting the decision to code as "None of the Above."
   • Include a plan for future skin integrity assessments or monitoring, especially if the resident might be at risk based on clinical judgment or known risk factors despite the absence of formal documentation.

6. Common Errors to Avoid

   • Overlooking relevant documentation due to incomplete review of the resident’s medical records or not consulting with the interdisciplinary team.
   • Failing to recognize informal or undocumented assessments conducted by clinical staff, leading to inaccurate coding.

7. Practical Application

   • Example: Upon reviewing Mr. Brown’s medical records, no formal skin integrity risk assessments, clinical evaluations specifically assessing for skin integrity risks, or documentation of existing skin integrity issues were found. Despite this, the care team decides to initiate periodic skin inspections as a proactive measure due to his advancing age and mobility issues. For M0100Z, Mr. Brown is coded as "1" for Yes, indicating that none of the specified risk determination methods or findings have been documented. His care plan includes notes on this decision and outlines a schedule for future skin inspections and assessments to ensure early identification of any potential skin integrity issues.

The Step-by-Step Coding Guide for item M0100Z 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.