MDS Alert
Wound Coding
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Question: How would you code this resident's wounds on Section M of the MDS?
Mr. C has diabetes and poor circulation to his lower extremities. Last month Mr. C spent two weeks in the hospital where he had a left below the knee amputation (BKA) for treatment of a gangrenous foot. His hospital course was complicated by delirium (acute confusion) and he spent most of his time on bed rest. Nurses remarked that he would only stay lying on his back. He had only an egg crate mattress on his bed to relieve pressure. Staff tried a water mattress and air mattress, which aggravated his agitation. He was readmitted to the nursing facility three days ago with a stage 2 pressure ulcer over his sacrum and a stage 1 pressure ulcer over his right heel and both elbows. No other ulcers were present.
Answer: Items M1, Ulcers (due to any cause) Code (# at stage)
a. Stage 1: 3
b. Stage 2: 1
c. Stage 3: 0
d. Stage 4: 0
Items M2, Type of Ulcer Code (highest stage)
a. Pressure Ulcer: 2
b. Stasis Ulcer: 0
Rationale for coding: Mr. C has 4 pressure ulcers, the highest stage of which is Stage 2.
Source: Revised December 2003 Resident Assessment Instrument User's manual, chapter 3.
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