Understanding and Coding MDS 3.0 Item M1040F: Other Skin Problems - Burns (Second or Third Degree)

Introduction

Purpose:
Burns, particularly second and third-degree burns, can be serious injuries that require specific care and attention in long-term care settings. These burns damage multiple layers of the skin, often leading to severe pain, infection risk, and prolonged healing times. MDS Item M1040F, Other Skin Problems: Burns (Second or Third Degree), is used to document the presence of second or third-degree burns during the assessment period. Proper coding ensures that these serious skin injuries are tracked and managed correctly. This article provides guidance on coding M1040F based on the latest MDS 3.0 standards.

What is MDS Item M1040F?

Explanation:
MDS Item M1040F, Other Skin Problems - Burns (Second or Third Degree), is used to document burns that affect multiple layers of the skin.

• Second-degree burns affect both the outer layer (epidermis) and the layer beneath (dermis), often causing blistering and severe pain.
• Third-degree burns extend into deeper tissues, destroying the entire thickness of the skin and sometimes affecting nerves, which can reduce pain sensation.

These burns may result from exposure to heat, chemicals, electricity, or friction. Documenting the presence of burns ensures that healthcare providers implement proper care and preventive measures to support healing and minimize complications such as infection.

Guidelines for Coding M1040F

Coding Instructions:
To correctly code Item M1040F, follow these steps:

1. Review the Resident’s Skin Assessment:

   • Assess the resident’s skin to confirm the presence of second or third-degree burns during the assessment period. These burns should be clearly documented, including their severity and location.

2. Determine if Second or Third-Degree Burns Are Present:

   • Code “0” if no second or third-degree burns are present during the assessment period.
   • Code “1” if second or third-degree burns are present during the assessment period.

3. Enter the Response in Item M1040F:

   • Record “1” if the resident has any second or third-degree burns during the assessment period. If no burns are present, enter “0.”

Example Scenario:
A resident sustains a second-degree burn on their arm after accidentally spilling hot tea. The wound blisters, and care is provided to manage the pain and prevent infection. In this case, 1 would be entered in Item M1040F to document the presence of a second-degree burn. If no burns are present during the assessment period, 0 would be entered.

Best Practices for Accurate Coding

Documentation:

• Ensure that all second or third-degree burns are thoroughly documented in the resident’s medical records, including the severity, size, location, and treatment provided (e.g., dressing changes, pain management, infection prevention).
• Regularly assess the burn site to track healing progress, and document any changes, including signs of infection or worsening of the burn.

Communication:

• Promote collaboration between nurses, wound care specialists, and physicians to ensure proper burn care and management.
• Discuss residents with burns during care planning meetings to ensure that appropriate wound care protocols are in place, such as regular dressing changes, infection control, and monitoring for complications.

Regular Audits:

• Conduct regular audits of care records to ensure that burns are documented accurately, and that proper care is being provided.
• Review the care plan frequently to ensure that residents with burns are receiving the necessary interventions to support healing and prevent complications.

Conclusion

Summary:
MDS Item M1040F is essential for documenting the presence of second or third-degree burns during the assessment period. Proper coding of this item ensures that burns are accurately tracked and managed, ensuring that residents receive the appropriate care to promote healing and prevent complications. By following the guidelines and best practices outlined in this article, healthcare professionals can provide optimal care for residents with serious burns in long-term care settings.

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. Refer to [Chapter 3, Page 3-167] for detailed guidelines on documenting second and third-degree burns as part of skin/ulcer treatments.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item M1040F: Other Skin Problems - Burns (Second or Third Degree) was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.