M1040C: Other Skin Problems: Other Open Lesion(s) on the Foot, Step-by-Step

Step-by-Step Coding Guide for Item Set M1040C: Other Skin Problems: Other Open Lesion(s) on the Foot

1. Review of Medical Records

• Objective: Gather accurate information about any open lesions on the resident’s foot.
• Steps:
  1. Collect Information: Review the resident's medical records, including physician notes, wound care assessments, and previous MDS assessments.
  2. Wound Documentation: Identify any documented open lesions on the foot, including descriptions, treatment plans, and progress notes.
  3. History and Physical: Review the resident’s medical history and physical examination records for any mention of foot lesions.

2. Understanding Definitions

• Other Open Lesion(s) on the Foot: Includes any open skin lesions on the foot that are not classified as pressure ulcers, diabetic foot ulcers, or arterial/venous ulcers. These can include cuts, abrasions, blisters, or other open wounds.
• Key Points:
  • Lesion Types: Be familiar with different types of open lesions such as cuts, blisters, and abrasions.
  • Exclusions: Do not include lesions classified under other specific categories like pressure ulcers or diabetic foot ulcers.

3. Coding Instructions

• Steps:
  1. Identify Lesions: Confirm the presence of open lesions on the foot from medical records.
  2. Check Documentation: Ensure lesions are documented as open wounds in the resident’s records.
  3. Code Appropriately: Code M1040C for any open lesions on the foot that are not otherwise specified.

4. Coding Tips

• Accurate Identification: Ensure the lesion is on the foot and not another part of the body.
• Clarify Lesion Type: If uncertain about the type of lesion, consult with a healthcare provider for clarification.
• Consistent Terminology: Use consistent terminology in documentation to avoid confusion.

5. Documentation

• Required:
  • Wound Assessments: Include detailed descriptions of the lesions, location, size, and type.
  • Progress Notes: Document any changes or treatments provided for the lesions.
  • Photographs: If possible, include photographs of the lesions for visual reference.

6. Common Errors to Avoid

• Misclassification: Do not code lesions that fall under other specific categories (e.g., pressure ulcers, diabetic foot ulcers).
• Incomplete Documentation: Ensure all relevant details about the lesions are documented.
• Overlooking Small Lesions: Even small or minor open lesions should be documented and coded if present.

7. Practical Application

• Example:
  • Resident Profile: Sarah, a 70-year-old resident, has an open blister on her left foot.
  • Steps:
    1. Review Records: The nurse reviews Sarah’s medical records and wound care assessments.
    2. Identify Lesion: The blister on Sarah’s foot is documented as an open lesion.
    3. Confirm Details: The nurse confirms the lesion is not a pressure ulcer or diabetic ulcer.
    4. Document and Code: The nurse codes M1040C for Sarah’s open blister on the foot.
  • Outcome: Sarah’s open lesion is accurately documented and coded, ensuring proper treatment and follow-up.

Please note that the information provided in this guide for MDS 3.0 Item set M1040C 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.