Step-by-Step Coding Guide for Item Set M1040G: Skin Tear(s)

1. Review of Medical Records

Objective: To accurately identify and code skin tears present on the resident.

• Key Points:
  • Thoroughly review the resident’s medical history, nursing notes, and wound care documentation for any mention of skin tears.
  • Pay special attention to body areas prone to skin tears, such as the extremities, due to friction or shearing.

2. Understanding Definitions

Objective: Define what constitutes a skin tear for MDS coding purposes.

• Key Points:
  • Skin Tear: A wound caused by shear, friction, or blunt force resulting in separation of skin layers. Can be categorized by severity into types or stages, with varying degrees of skin flap loss.

3. Coding Instructions

Objective: Provide guidelines for coding skin tears in the MDS.

• Key Points:
  • Code a wound as a "Skin Tear" if it fits the definition, regardless of the body location.
  • Include both new and healing skin tears observed during the assessment look-back period.

4. Coding Tips

Objective: Offer tips for accurate and precise coding of skin tears.

• Key Points:
  • Use consistent criteria to identify and categorize skin tears, considering the size, depth, and presence of a skin flap.
  • Differentiate skin tears from other types of skin injuries, such as abrasions or lacerations, based on the wound’s appearance and mechanism of injury.

5. Documentation

Objective: Ensure comprehensive documentation of skin tears for accurate coding.

• Key Points:
  • Document the location, size, severity (e.g., type or stage), and date of each skin tear.
  • Include detailed treatment protocols, such as cleaning, dressing type, and any preventive measures taken.
  • Regularly update the documentation to reflect the healing status and any changes in care or treatment.

6. Common Errors to Avoid

Objective: Highlight frequent mistakes in coding and documentation of skin tears.

• Key Points:
  • Misclassifying other types of wounds as skin tears.
  • Failing to document or code a skin tear because it appears minor.
  • Overlooking skin tears under dressings or in areas difficult to examine.

7. Practical Application

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

• Key Points:
  • Scenario: A resident brushes against a wheelchair, causing a skin tear on the forearm. The tear is 4 cm long, with a partially adhered skin flap.
  • Coding: This injury should be coded under M1040G as a skin tear. Document the cause (friction with wheelchair), location (forearm), size (4 cm), and treatment (cleaning, application of a non-adherent dressing).
  • Follow-Up: Note any improvement or complications in subsequent documentation, adjusting care as needed.

Please note that the information provided in this guide for MDS 3.0 Item set M1040G 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.