M1040B. Other skin problems: diabetic foot ulcer (s), Step-by-Step

Step-by-Step Coding Guide for Item Set M1040B: Other Skin Problems - Diabetic Foot Ulcer(s)

1. Review of Medical Records

Objective: Gather relevant resident information for accurate coding.

• Key Points:
  • Examine the resident’s medical records, focusing on dermatology, endocrinology, and podiatry consultations.
  • Identify diagnoses of diabetes and any mention of foot ulcers.
  • Review wound care reports, treatment orders, and progress notes for descriptions of foot ulcers, their locations, and treatments prescribed.

2. Understanding Definitions

Objective: Clarify the term "Diabetic Foot Ulcer."

• Key Points:
  • A diabetic foot ulcer is an open sore or wound found on the feet of individuals with diabetes, typically on the bottom of the foot.
  • Ulcers may be described by their depth, presence of infection, and whether there is arterial involvement.
  • Recognize the significance of neuropathy, poor circulation, and diabetes control in the development and healing of foot ulcers.

3. Coding Instructions

Objective: Guide accurate coding of diabetic foot ulcers.

• Key Points:
  • Code only active, observable diabetic foot ulcers within the assessment look-back period.
  • Consider ulcers covered by dressings; information should be obtained from recent wound care documentation.
  • Do not include healed ulcers, ulcers due to non-diabetic causes, or ulcers located above the ankle.

4. Coding Tips

Objective: Enhance coding accuracy and specificity.

• Key Points:
  • Pay close attention to ulcers with underlying osteomyelitis or those classified as ischemic due to peripheral arterial disease.
  • Include ulcers being treated with off-loading devices, negative pressure wound therapy, or bioengineered tissue.
  • Document the size, depth, and any signs of infection or ischemia.

5. Documentation

Objective: Ensure comprehensive and precise documentation.

• Key Points:
  • Record the location, size, depth, and stage of each diabetic foot ulcer.
  • Document treatments applied, including medications, dressings, and any surgical interventions.
  • Note the presence of neuropathy or peripheral artery disease impacting healing.

6. Common Errors to Avoid

Objective: Identify frequent mistakes in coding and documentation.

• Key Points:
  • Misclassifying ulcers caused by other etiologies as diabetic foot ulcers.
  • Failing to update the coding as ulcers heal or worsen.
  • Overlooking ulcers under dressings or in difficult-to-see locations.

7. Practical Application

Objective: Apply knowledge through a realistic scenario.

• Key Points:
  • Scenario: A resident with long-standing diabetes has a 2 cm x 2 cm ulcer on the plantar aspect of the left foot, noted to have a depth reaching the subcutaneous tissue but no bone involvement. The resident is on a regimen of strict glucose control, wound care with a silver-containing dressing, and off-loading with a diabetic shoe.
  • Coding: This ulcer should be coded as an active diabetic foot ulcer. Document the location, size, depth, and treatments being utilized.
  • Follow-Up: Plan for regular reassessment of the ulcer for changes in size, depth, or signs of infection.

Please note that the information provided in this guide for MDS 3.0 Item set M1040B 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.