Step-by-Step Coding Guide for Item Set M1200C: Skin/Ulcer Treatments - Turning/Repositioning

1. Review of Medical Records

Objective: Identify documentation supporting the implementation of a turning/repositioning schedule.

• Key Points:
  • Examine the resident's care plan and nursing notes for any mention of a prescribed turning or repositioning schedule.
  • Look for orders from healthcare providers that specify the frequency of turning/repositioning to prevent or treat pressure ulcers.

2. Understanding Definitions

Objective: Define the turning/repositioning process in the context of skin/ulcer treatments.

• Key Points:
  • Turning/Repositioning: A preventative and therapeutic measure to alter the pressure points on the body by changing the resident's position. This is crucial for residents at risk for or currently experiencing pressure ulcers.

3. Coding Instructions

Objective: Provide guidelines for accurately coding turning/repositioning activities in the MDS.

• Key Points:
  • Code "Yes" for M1200C if the resident is on a scheduled turning/repositioning regimen as part of their care plan to prevent or manage skin ulcers.
  • The schedule should be clearly documented and adhered to by the care team.

4. Coding Tips

Objective: Offer practical advice to ensure precise coding for turning/repositioning.

• Key Points:
  • Confirm the presence of a structured turning/repositioning plan, not just ad hoc adjustments.
  • Note that turning/repositioning schedules may vary based on the resident's condition and risk level for pressure ulcers.

5. Documentation

Objective: Highlight the importance of comprehensive documentation for turning/repositioning.

• Key Points:
  • Document each instance of turning/repositioning, including the time and the position to which the resident was moved.
  • Record any resident-specific adaptations to the turning/repositioning schedule (e.g., increased frequency for high-risk residents).
  • Include feedback or observations regarding the resident's response to the turning/repositioning schedule.

6. Common Errors to Avoid

Objective: Identify and prevent common mistakes in coding and documenting turning/repositioning.

• Key Points:
  • Overlooking the coding of turning/repositioning when it is part of the standard care for all residents.
  • Failing to document each turning/repositioning event, making it difficult to verify adherence to the prescribed schedule.
  • Assuming turning/repositioning is not necessary for residents who spend significant time out of bed.

7. Practical Application

Objective: Apply coding guidelines to a practical scenario involving turning/repositioning.

• Key Points:
  • Scenario: A resident with limited mobility due to paralysis is assessed as high risk for pressure ulcers. The care team implements a 2-hourly turning schedule during the day and a 4-hourly schedule at night.
  • Coding: This should be coded "Yes" for M1200C. Documentation should include the assessment of risk, the specifics of the turning/repositioning schedule, and any adjustments made based on the resident's needs or responses.
  • Follow-Up: Continuously monitor the resident's skin integrity and comfort level with the schedule, adjusting as necessary and documenting all changes and outcomes.

Please note that the information provided in this guide for MDS 3.0 Item set M1200C  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.