Step-by-Step Coding Guide for Item Set M1040H: Moisture Associated Skin Damage (MASD)

1. Review of Medical Records

Objective: Accurately identify any instances of Moisture Associated Skin Damage.

• Key Points:
  • Thoroughly review the resident's medical and nursing records for mentions of skin integrity issues related to moisture.
  • Look for dermatologist consultations, wound care team notes, and descriptions of skin conditions in areas prone to moisture accumulation.

2. Understanding Definitions

Objective: Define MASD and its subcategories for precise coding.

• Key Points:
  • Moisture Associated Skin Damage (MASD): Inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine, stool, perspiration, wound exudate, or mucus.
  • Subcategories include incontinence-associated dermatitis, intertriginous dermatitis, periwound moisture damage, and peristomal moisture damage.

3. Coding Instructions

Objective: Provide detailed guidance on how to code for MASD in the MDS.

• Key Points:
  • Code for MASD if the resident displays signs of skin damage attributed to moisture exposure during the assessment period.
  • Consider all subcategories of MASD and code accordingly based on clinical assessment and diagnosis.

4. Coding Tips

Objective: Offer advice to enhance the accuracy of MASD coding.

• Key Points:
  • Distinguish MASD from other skin conditions like pressure injuries, which are not primarily caused by moisture.
  • Assess all skin areas at risk, especially those commonly affected by moisture such as the groin, under breasts, axillae, and around medical devices.

5. Documentation

Objective: Ensure complete documentation of MASD for accurate coding and treatment.

• Key Points:
  • Document the specific type of MASD identified, the location(s) of the skin damage, the extent, and the condition's severity.
  • Include detailed treatment regimens initiated for MASD, such as barrier creams, frequent skin assessments, and changes in incontinence management practices.
  • Update documentation regularly to reflect the current status of the skin condition and responses to treatment.

6. Common Errors to Avoid

Objective: Identify and prevent typical errors in coding and documenting MASD.

• Key Points:
  • Failing to code MASD when skin damage is clearly related to moisture exposure.
  • Misclassifying other types of dermatitis or skin damage as MASD.
  • Overlooking mild cases of MASD that still require intervention and documentation.

7. Practical Application

Objective: Apply MASD coding principles to a practical example.

• Key Points:
  • Scenario: A resident with urinary incontinence develops red, inflamed skin in the groin area diagnosed as incontinence-associated dermatitis.
  • Coding: This condition should be coded under M1040H as MASD, specifically as incontinence-associated dermatitis. Document the diagnosis, affected area (groin), and interventions such as the use of a barrier cream and more frequent skin checks.
  • Follow-Up: Monitor and document the resident's response to the interventions, adjusting the care plan as necessary to promote healing and prevent recurrence.

Please note that the information provided in this guide for MDS 3.0 Item set M1040H 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.