Step-by-Step Coding Guide for Item Set M1040E: Other Skin Problems - Surgical Wound(s)

1. Review of Medical Records

Objective: To identify and accurately code any surgical wounds present.

• Key Points:
  • Examine the resident’s medical records for any history of recent surgeries or procedures that resulted in surgical wounds.
  • Pay special attention to operation reports, post-operative notes, and wound care documentation for detailed information about the wound(s).

2. Understanding Definitions

Objective: Define what constitutes a surgical wound for MDS coding purposes.

• Key Points:
  • Surgical Wound: Any incision or excision made during a surgical procedure that penetrates the dermis and requires suturing or another form of closure.
  • Includes wounds from major surgeries (e.g., abdominal surgery) and minor procedures (e.g., skin biopsy).

3. Coding Instructions

Objective: Provide guidelines for coding surgical wounds in the MDS.

• Key Points:
  • Code a wound as "Surgical" if it results directly from a surgical procedure.
  • Include wounds that are healing by primary intention (closed surgical wounds) and those healing by secondary intention (wounds left open to heal).

4. Coding Tips

Objective: Offer tips for accurate and precise coding of surgical wounds.

• Key Points:
  • Verify the wound origin through medical record review to differentiate surgical wounds from other types of skin integrity issues.
  • Be aware of the timing of the surgery and the current status of wound healing to accurately reflect it in the MDS assessment.

5. Documentation

Objective: Ensure comprehensive documentation of surgical wounds.

• Key Points:
  • Document the location, size, and depth of the wound, as well as the date of the surgery and the type of surgical procedure performed.
  • Include current status of the wound (e.g., open, closed, signs of infection, healing progress).

6. Common Errors to Avoid

Objective: Highlight frequent mistakes in coding and documentation of surgical wounds.

• Key Points:
  • Failing to code a wound as "Surgical" when it directly results from a procedure.
  • Misclassifying surgical wounds as other types of wounds or skin integrity issues.
  • Not updating the wound status as it heals or if complications arise.

7. Practical Application

Objective: Apply the coding instructions to a real-life scenario.

• Key Points:
  • Scenario: A resident recently had a hip replacement surgery. During the current MDS assessment period, the surgical incision is noted to be healing well, with sutures in place and no signs of infection.
  • Coding: This wound should be coded under M1040E as a surgical wound. Document the location (hip area), size (length of incision), and healing status (healing well, sutures in place, no signs of infection).

Please note that the information provided in this guide for MDS 3.0 Item set M1040E 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.