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Know the April 1 RAI Manual Instructions for Skin Tears, MASD, Weight Gain

Published on Thu Feb 23, 2012

The following verbiage has been excerpted verbatim from the April version of the RAI manual:

"M1040G Skin Tear(s)

  • Skin tears are a result of shearing, friction or trauma to the skin that causes a separation of the skin layers. They can be partial or full thickness. Code all skin tears in this item, even if already coded in Item J190.

"M1040H Moisture Associated Skin Damage (MASD)

  • Moisture associated skin damage is a result of skin damage caused by moisture rather than pressure. It is caused by sustained exposure to moisture which can be caused, for example, by incontinence, wound exudate and perspiration. MASD is also referred to as incontinence dermatitis."

"K0310: Weight Gain

Coding Instructions

Mathematically round weights as described in Section K0200B before completing the weight gain calculation.

Code 0, no or unknown: if the resident has not experienced weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available.

Code 1, yes on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight gain was planned and pursuant to a physician's order. In cases where a resident has a weight gain of 5% or more in 30 days or 10% or more in 180 days as a result of any physician ordered diet plan, K0310 can be coded as 1.

Code 2, yes, not on physician-prescribed weight-gain regimen: if the resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight gain was not planned and prescribed by a physician.

Coding Tips

A resident may experience weight variances in between the snapshot time periods. Although these require follow up at the time, they are not captured on the MDS.

If the resident is gaining a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status.

To code K0310 as 1, yes, the expressed goal of the weight gain diet must be documented."

Source: Excerpted verbatim from the April RAI manual.

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