MDS item M1200 (Skin and Ulcer/Injury Treatments) in section M (Skin Conditions) can impact payment under the Patient-Driven Payment Model (PDPM) in the Medicare Part A skilled nursing facility prospective payment system (SNF PPS), as well as affect reimbursement in some state Medicaid case-mix systems that use the RUG-III or RUG-IV case-mix models. However, it also plays a bigger role in both care planning and survey than many nurse assessment coordinators (NACs) and other interdisciplinary team members realize, points out Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH.
Here are the keys to understanding the item’s impacts and to improving coding accuracy:
Learn how M1200 can affect the PDPM nursing component
M1200 (Skin and Ulcer/Injury Treatments) has 10 sections or subitems, which include nine treatment options:
- M1200A (Pressure-Reducing Device for Chair);
- M1200B (Pressure-Reducing Device for Bed);
- M1200C (Turning/Repositioning Program);
- M1200D (Nutrition or Hydration Intervention to Manage Skin Problems);
- M1200E (Pressure Ulcer/Injury Care);
- M1200F (Surgical Wound Care);
- M1200G (Application of Nonsurgical Dressings (With or Without Topical Medications) Other Than to Feet);
- M1200H (Applications of Ointments/Medications Other Than to Feet);
- M1200I (Applications of Dressings to Feet (With or Without Topical Medications)); and
- M1200Z (None of the Above).
M1200 can contribute to the Special Care Low category in the nursing component of PDPM in either of the following ways, according to chapter 6 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual:
Special Care Low Option 1: If the Resident Has …
|M0300B1 (Number of Stage 2 Pressure Ulcers)
|Two or more stage 2 pressure ulcers with two or more selected skin treatments**
|M0300C1 (Number of Stage 3 Pressure Ulcers)
M0300D1 (Number of Stage 4 Pressure Ulcers)
M0300F1 (Number of Unstageable Pressure Ulcers due to Coverage of Wound Bed by Slough and/or Eschar)
|Any stage 3 or 4 pressure ulcer with two or more selected skin treatments**
|M1030 (Number of Venous and Arterial Ulcers)
|Two or more venous/arterial ulcers with two or more selected skin treatments**
|M0300B1 (Number of Stage 2 Pressure Ulcers)
M1030 (Number of Venous and Arterial Ulcers)
|One stage 2 pressure ulcer and one venous/arterial ulcer with two or more selected skin treatments**
|** Selected skin treatments may include:
Special Care Low Option 2: If the Resident Has …
|M1040A (Infection of the Foot)
M1040B (Diabetic Foot Ulcer(s))
M1040C (Other Open Lesion(s) on the Foot)
M1200I (Applications of Dressings to Feet (With or Without Topical Medications))
|Foot infection, diabetic foot ulcer or other open lesion of foot with application of dressings to the feet
Note: The only treatment item in M1200 that cannot affect Special Care Low is M1200F (Surgical Wound Care).
M1200 also can contribute to the Clinically Complex category in the nursing component of PDPM in the following way, according to chapter 6 of the RAI User’s Manual:
Clinically Complex: If the Resident Has …
|M1040D (Open Lesions (Other Than Ulcers, Rashes, and Cuts))
M1040E (Surgical Wounds)
|Open lesions (other than ulcers, rashes, and cuts) with any selected skin treatment* or surgical wounds
|* Selected skin treatments may include:
Use M1200 to guide individualized care plans
“With the continued focus on individualized, person-centered care planning, not paying attention to the Planning for Care section of the M1200 coding guidance on page M-33 of the RAI User’s Manual is one of the most common mistakes that NACs and other team members make,” says Hillier. This section states:
“Specifically, the care plans often do not reflect enough details to show why the chosen treatments or interventions are individualized for this resident, and there is no evidence that the treatments were reviewed and modified if the resident is not improving,” explains Hillier. “Providers tend to focus on residents who are worsening—but not on residents who are not worsening but also are not improving.”
Note: M1200 items also play a role in the Review of Indicators for some care area assessments (CAAs) in Appendix C of the RAI User’s Manual, including Behavioral Symptoms, Activities, Nutritional Status, Pain, Pressure Ulcer/Injury, and Physical Restraints.
Don’t skimp on the Steps for Assessment—or survey problems could result
“Another common issue throughout the entire MDS, not just with section M, is not following all Steps for Assessment as discussed in the coding guidance,” says Hillier. “Instead, assessors often simply do a quick medical record review.”
For this item, the Steps for Assessment section on page M-33 of the RAI User’s Manual includes more than a medical record review, stresses Hillier. Here are the excerpted steps:
|1. Review the medical record, including treatment records and health care provider orders for documented skin treatments during the past 7 days. Some skin treatments may be part of routine standard care for residents, so check the nursing facility’s policies and procedures and indicate here if administered during the look-back period.
2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review.
3. Some skin treatments can be determined by observation. For example, observation of the resident’s wheelchair and bed will reveal if the resident is using pressure-reducing devices for the bed or wheelchair.
“A common survey deficiency is related to skin treatments that are coded on the MDS, but when the surveyor talks to staff and observes care, treatments that were coded and/or in the care plan are not being used,” points out Hillier. “By talking with staff and doing their own observation, the assessor can validate that specific interventions are still being used, as well as identify any interventions that are in use, but might not have been properly documented in the medical record.”
Note: Surveyors use the Pressure Ulcer/Injury Critical Element Pathway in the Long-Term Care Survey Process (LTCSP) to assess for F686 (Treatment/Services to Prevent/Heal Pressure Ulcers) and related citations.
Know the coding definitions and tips for M1200C, M1200D
“Some assessors don’t understand the specific definitions for Turning/Repositioning Program (M1200C) and Nutrition or Hydration Intervention to Manage Skin Problems (M1200D) that are included in the RAI User’s Manual,” says Hillier. Excerpted from page M-35, these definitions are as follows:
Includes a consistent program for changing the resident’s position and realigning the body. “Program” is defined as a specific approach that is organized, planned, documented, monitored, and evaluated based on an assessment of the resident’s needs.
Nutrition or Hydration Intervention to Manage Skin Problems
Dietary measures received by the resident for the purpose of preventing or treating specific skin conditions, e.g., wheat-free diet to prevent allergic dermatitis, high calorie diet with added supplementation to prevent skin breakdown, high-protein supplementation for wound healing.
“For M1200C, the Coding Tips on page M-35 of the RAI User’s Manual state that ‘Progress notes, assessments, and other documentation (as dictated by facility policy) should support that the turning/repositioning program is monitored and reassessed to determine the effectiveness of the intervention,’” notes Hillier. “However, it is not uncommon to see turning and repositioning ‘programs’ coded on the MDS quarter after quarter, with no evidence that the program has been reassessed for effectiveness and modified if appropriate.”
For M1200D, there are two related issues involving the Coding Tips on pages M-35 – M-36, says Hillier. First, the Coding Tips state the following (bolding added):
|The determination as to whether or not one should receive nutritional or hydration interventions for skin problems should be based on an individualized nutritional assessment. … Vitamin and mineral supplementation should only be employed as an intervention for managing skin problems, including pressure ulcers/injuries, when nutritional deficiencies are confirmed or suspected through a thorough nutritional assessment.
“However, M1200D sometimes may be coded because the resident received a daily vitamin regimen—even though there is not a nutritional assessment relating the vitamin regimen to a resident-specific skin risk,” says Hillier.
The Coding Tips for M1200D also state the following:
|If it is determined that nutritional supplementation, that is, adding additional protein, calories, or nutrients is warranted, the facility should document the nutrition or hydration factors that are influencing skin problems and/or wound healing and tailor nutritional supplementation to the individual’s intake, degree of under-nutrition, and relative impact of nutrition as a factor overall; and obtain dietary consultation as needed.
“This detailed documentation is often missing, especially for long-stay residents who may have been receiving their vitamin regimen for quite some time,” points out Hillier.
Pay attention to common coding problems in M1200F
“Some assessors mistakenly code debridement of a pressure ulcer in M1200F (Surgical Wound Care). However, the RAI User’s Manual states that debridement of a pressure ulcer doesn’t create a surgical wound and therefore should not be coded in M1200F,” says Hillier.
Here is the relevant excerpt from page M-36:
|Surgical debridement of a pressure ulcer does not create a surgical wound. Surgical debridement is used to remove necrotic or infected tissue from the pressure ulcer in order to facilitate healing, and thus, any wound care associated with pressure ulcer debridement would be coded in M1200E (Pressure Ulcer Care). The only time a surgical wound would be created is if the pressure ulcer itself was excised and a flap and/or graft used to close the pressure ulcer.
“In addition, some assessors mistakenly do not code M1200F for residents with a surgical wound because a daily dressing change isn’t required,” says Hillier. “However, M1200F isn’t limited only to daily dressing changes.”
Here is the relevant excerpt from page M-36:
|Surgical wound care may include any intervention for treating or protecting any type of surgical wound. Examples may include topical cleansing, wound irrigation, application of antimicrobial ointments, application of dressings of any type, suture/staple removal, and warm soaks or heat application.
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