MDS Alert

RAI manual clarification aims to prevent coding redundancy.

Question: What type of ulcers do you code in Section M1 come May 1?

Code pressure ulcers and circulatory-related ulcers in Section M1, according to the May 2005 RAI manual update. The update removes the term "open lesion" from instructions for coding this section and also removes the verbiage ulcers "due to any cause" from coding examples for M1. Circulatory-related ulcers include arterial and venous insufficiency ulcers. Rashes without open areas, burns, desensitized skin ulcers related to diseases such as syphilis and cancer and surgical wounds are NOT coded in M1 but included in M4 (other skin problems/lesions).

What About Diabetic Ulcers?

In deciding how to code diabetic ulcers, "look at the wound's etiology to determine if it's pressure or circulatory related," advised Ellen Gay, a health insurance specialist for the Centers for Medicare & Medicaid Services, in a presentation at the March 2005 American Association of Nurse Assessment Coordinators conference in Chicago.

"The term 'diabetic ulcer' is not descriptive enough to determine the precise etiology," comments Rena Shephard, MHA, RN, FACDONA, president of RRS Healthcare Consulting in San Diego. Thus, "the nurse, in consultation with the physician, should conduct a thorough assessment to determine the etiology of the ulcer" in order to code it on the MDS appropriately and develop a treatment plan.

More key instructions: Don't code a debrided ulcer as a surgical wound. But "if a skin ulcer is repaired with a flap graft, code it as a surgical wound and not a skin ulcer. If the graft fails, continue to code it as a surgical wound until healed," states the RAI manual update.

When a resident has an ulcer at different stages throughout the lookback (based on reverse staging required by the MDS), code the wound's stage as it appears nearest the assessment reference date or ARD, instructed Gay.

Example: If the ARD was March 25 and the wound was a Stage 3 on March 19 but a Stage 2 on March 24, code the wound as a Stage 2, said Gay.

CMS updated definitions for coding M5a and b (pressure-relieving devices for chair and bed), which technically appeared to exclude pressure-reduction devices before the update. The item allows facilities to code pressure-relieving or pressure-reducing devices.