Step-by-Step Coding Guide for Item Set M1030: Number of Venous and Arterial Ulcers

1. Review of Medical Records

• Objective: Ensure accurate coding by thoroughly reviewing the resident's medical history and current medical status.
• Steps:
  1. Gather Medical Records: Collect all relevant medical records, including wound care notes, physician orders, and previous assessments.
  2. Identify Ulcer Documentation: Look for detailed documentation regarding venous and arterial ulcers, including the location, size, and number of ulcers.
  3. Confirm Diagnoses: Verify that the ulcers are identified as venous or arterial based on medical assessments and physician documentation.

2. Understanding Definitions

• Venous Ulcers: Chronic wounds caused by improper functioning of venous valves, usually in the legs.
• Arterial Ulcers: Ulcers resulting from poor blood circulation due to arterial insufficiency, often found on the lower extremities.
• Performance Levels:
  • Number of Ulcers: Record the total number of venous and arterial ulcers present at the time of the assessment.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set M1030 on the MDS form.
  2. Determine Number of Ulcers: Count the total number of venous and arterial ulcers documented in the resident’s medical records.
  3. Select the Appropriate Code: Enter the total number of venous and arterial ulcers in the designated field on the MDS form.
  4. Record the Code: Enter the exact number of venous and arterial ulcers identified during the assessment period.

4. Coding Tips

• Accuracy: Ensure that each ulcer is accurately identified as either venous or arterial and correctly counted.
• Consistency: Verify that the number of ulcers documented is consistent across all medical records and assessments.
• Detail: Include detailed descriptions of each ulcer in the documentation, noting size, location, and type (venous or arterial).

5. Documentation

• Required:
  • Wound Care Notes: Detailed notes from wound care specialists documenting the number and type of ulcers.
  • Physician Orders: Orders confirming the treatment plan for venous and arterial ulcers.
  • Assessment Records: Formal assessments indicating the presence and number of venous and arterial ulcers.

6. Common Errors to Avoid

• Incorrect Count: Double-check the count to ensure all venous and arterial ulcers are included.
• Misclassification: Ensure that ulcers are correctly classified as venous or arterial based on clinical assessment.
• Incomplete Documentation: Ensure all ulcers are documented in detail, with specific notes on their type and count.

7. Practical Application

• Example: A resident has three venous ulcers and two arterial ulcers documented in their medical records.
  • Coding: The MDS form should reflect a total of 5 ulcers under item set M1030.
• Illustration:
  • Venous Ulcers: Ulcers located on the lower legs with characteristics such as irregular shape, and shallow, often associated with edema.
  • Arterial Ulcers: Ulcers on the feet or toes, typically with a punched-out appearance and well-defined edges, often painful.

Please note that the information provided in this guide for MDS 3.0 Item set M1030 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.