MDS Alert

Identify and address these hard-to-heal wounds.

Just because Section M doesn't have a checkbox for diabetic neuropathic ulcer doesn't mean you can't identify these wounds on the MDS and care plan them. That way, you can show surveyors you're on top of a wound that falls into its own unique category.

For someone to have a diabetic neuropathic ulcer, he must have a documented diagnosis of both diabetes mellitus and peripheral neuropathy, according to the F314/F309 survey guidance, notes Elizabeth Ayello, PhD, RN, APRN, BC, CWOCN, FAAN, a nursing professor at Excelsior College in Albany, NY.

The problem: "The label of diabetic ulcer isn't descriptive enough to tell you where to code the ulcer on the MDS," says Rena Shephard, RN, MHA, FACDONA, president of RRS Healthcare Consulting in San Diego.

Solution: The physician needs to define the underlying etiology of the ulcer, which allows you to code it on the MDS, advises Shephard.

"For example, is it ischemic and then affected by pressure and diabetes-related factors such as decreased sensation?" Shephard notes that "any time a person has an ulcer, you need to carefully assess what role pressure may have played in causing the wound or in affecting how it heals."

If you suspect an arterial ulcer in a resident with diabetes, suggest the prescribing clinician order a transcutaneous oximetry to assess the person's microcirculation, advises Michael Miller, DO, a wound care expert in Terre Haute, IN.

When the shoe doesn't fit: If the resident with diabetes and peripheral neuropathy has an ulcer on the foot caused by tight shoes, "the ulcer may be both a pressure and diabetic ulcer," advises Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL. In that case, code the ulcer on the foot at M6 as well as at M1 and M2.

Code the Diabetic Ulcer in I3

You can use ICD-9-CM codes in I3 to identify a foot ulcer diagnosed as a diabetic ulcer in a person with diabetes and diabetic peripheral neuropathy. When the cause of the ulcer is due to a diabetic neuropathy, assign the diabetic code 250.6X (Diabetes with neurological manifestations) followed by the code for the ulcer of the lower extremity (707.10-707.19), advises Ann Zeisset, RHIT, CCS, CCS-P, practice manager, American Health Information Management Association. Thus, you'd code the foot ulcer diagnosed as a diabetic ulcer in a person with diabetes and diabetic peripheral  neuropathy as:

• 250.6X

• 707.14 (Ulcer of heel and midfoot) or 707.15 (Ulcer of other part of foot).

Code 707.14 would include  the heel and midfoot, while  707.15 would be of the toes, says Zeisset. "The medical record documentation should specify the site of the ulcer." 

Care plan it: The care plan for a person with a diabetic neuropathic ulcer should first and foremost focus on glycemic control and nutrition, including monitoring A1c levels and timing the Accuchecks appropriately, says Kathleen Thimsen, RN, ET, MSN, president of RARE Consulting Group Inc. in Belleville, IL.