Understanding and Coding MDS 3.0 Item I4000: Other Fracture

MDS 3.0 Item I4000: Other Fracture

Introduction

Purpose:
Fractures beyond the hip, such as fractures in the arms, legs, or ribs, can severely impact a resident’s mobility and overall health. MDS Item I4000 ensures that other fractures are appropriately documented, allowing care teams to plan effective treatments and monitoring.

What is MDS Item I4000?

Explanation:
MDS Item I4000 captures fractures other than hip fractures, such as fractures of the arms, legs, ribs, or other body parts. These fractures must be related to the resident’s current treatment or monitoring needs. Proper documentation of these fractures helps ensure that the resident’s care plan includes appropriate interventions, such as mobility support or pain management.

Guidelines for Coding MDS Item I4000

Coding Instructions:

• Code this item if a resident has a fracture that is being actively treated or monitored.
• The fracture may be due to trauma, a fall, or an underlying condition like osteoporosis.
  For example, if a resident fractured their arm in a fall and is receiving treatment, MDS Item I4000 should be coded as present.

Best Practices for Accurate Coding

Documentation:

• Include X-ray results, treatment notes, and care plans addressing the fracture. Document any rehabilitation or mobility aids provided.

Communication:

• Collaborate with physical therapists, physicians, and nursing staff to ensure coordinated care and support for the resident’s recovery.

Training:

• Train staff on safe handling and mobility techniques to prevent further injury and support residents recovering from fractures.

Conclusion

Summary:
Proper coding of MDS Item I4000 ensures that all fractures, aside from hip fractures, are documented and addressed in the care plan. This helps reduce the risk of complications and improves recovery outcomes.

Click here to see a detailed Step-by-Step on how to complete this item set.

Reference

• CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Pages I-11.

Disclaimer

This guide for MDS 3.0 Item I4000 is based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024.