Step-by-Step Coding Guide for Item Set M1040F: Other Skin Problems - Burns (Second or Third Degree)

1. Review of Medical Records

Objective: Identify and accurately code second or third-degree burns.

• Key Points:
  • Thoroughly review the resident’s medical records for any documentation of burns, including emergency department reports, physician notes, and treatment records.
  • Look for descriptions of burn injuries, including the cause, extent, and degree of burns, as well as any hospitalization or specialist care received.

2. Understanding Definitions

Objective: Define what constitutes second and third-degree burns.

• Key Points:
  • Second-Degree Burns (Partial Thickness Burns): These burns affect both the epidermis and part of the dermis layer of skin. They are characterized by redness, blistering, and severe pain and may swell significantly.
  • Third-Degree Burns (Full Thickness Burns): These burns destroy the epidermis and dermis, possibly affecting underlying tissues. They may appear charred, white, or translucent and often do not hurt initially due to nerve damage.

3. Coding Instructions

Objective: Provide clear instructions for coding burns in the MDS.

• Key Points:
  • Code a resident’s condition as M1040F if they have a current second or third-degree burn, regardless of the burn’s location on the body.
  • Include burns that are being actively treated during the assessment period.

4. Coding Tips

Objective: Offer tips to enhance the accuracy of coding burns.

• Key Points:
  • Distinguish between burn degrees based on medical assessments and documentation. Only code second and third-degree burns under M1040F.
  • Pay attention to the progression or healing of burns, as the degree of a burn may change over time.

5. Documentation

Objective: Ensure detailed documentation of burns for accurate coding.

• Key Points:
  • Document the location, size (percentage of body surface area), and degree of burns.
  • Include detailed treatment regimens, such as wound care protocols, pain management, and any surgical interventions.
  • Regularly update the resident’s file with progress notes reflecting the healing status or any complications.

6. Common Errors to Avoid

Objective: Identify and prevent common mistakes in coding burns.

• Key Points:
  • Misclassifying the degree of burns due to a lack of understanding of burn depth and characteristics.
  • Overlooking burns that are covered by dressings or located in less visible areas.
  • Failing to code burns that are in the process of healing but still require active treatment.

7. Practical Application

Objective: Apply coding guidelines to a realistic scenario involving burns.

• Key Points:
  • Scenario: A resident accidentally spilled boiling water on their arm, resulting in a second-degree burn covering 5% of their body surface area. The burn site shows blistering and redness and is being treated with antibiotic cream and sterile dressings.
  • Coding: This injury should be coded under M1040F as a second-degree burn. Document the cause (scalding water), location (arm), size (5% body surface area), degree (second-degree), and treatment (antibiotic cream, sterile dressings).

Please note that the information provided in this guide for MDS 3.0 Item set M1040F 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.