MDS Manual update brings welcome clarity

Attendees of last month’s American Association of Nurse Assessment Coordination (AANAC) 2013 annual conference in San Antonio, Texas, received a number of welcome clarifications. They were able to preview changes in the May 2013 update of the RAI User’s Manual for MDS 3.0, released May 20.

With updates made to chapter 2 of the manual, providers finally have their answer about what to do with the prospective payment (PPS) schedule when a resident transitions from managed care, Medicare C, to traditional Medicare Part A. The update states that “if a resident goes from Medicare Advantage to Medicare Part A, the Medicare PPS schedule must start over with a 5-day PPS assessment, as the resident is now beginning a Medicare Part A stay” (p. 2-45).

Some of the important updates to chapter 3 of the RAI User’s Manual are as follows:


When interviewing a resident for pain in section J, consider pain of the mouth as well as other types of specific or systemic pain. Item L0200 has an added coding tip that states, “Mouth or facial pain coded for this item should also be coded in Section J, items J0100 through J0850, in any items in which the coding requirements of Section J are met.”

Section L has a 7-day look-back, while coding for pain in section J requires a 5-day look-back, so the clinician who interviews the resident for pain needs to keep that in mind when reconciling scoring in these two sections.


In response to recent expert-endorsed recommendations by the National Pressure Ulcer Advisory Panel (NPUAP), CMS has added some new information to section M, most notably regarding planning for care when there is a pressure ulcer. For Stage 2–4 pressure ulcers, the revised manual has additional instructions regarding monitoring the progress toward healing, stating, “If the pressure ulcer fails to show some evidence toward healing within 14 days, the pressure ulcer (including potential complications) and the patient’s overall clinical condition should be reassessed” (pp. M-9, M-11, M-14).

A new clarification was posted for item M0210, regarding oral pressure ulcers:

Oral mucosal ulcers caused by pressure should not be coded in Section M. These ulcers are captured in item L0200C, Abnormal mouth tissue. Mucosal ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made (p. M-5).

Stage 4 pressure ulcers include exposed cartilage, which is most often seen, for example, on the ears. The manual adds (p. M-15), “Cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage 4.”

A clarification for coders emphasizes that they are not to consider development of slough or eschar on a staged wound as “worsening”:

If a pressure ulcer was numerically staged and becomes unstageable due to slough or eschar, do not consider this pressure ulcer as worsened. The only way to determine if this pressure ulcer has worsened is to remove enough slough or eschar so that the wound bed becomes visible. Once enough of the wound bed can be visualized and/or palpated such that the tissues can be identified and the wound restaged, the determination of worsening can be made (p. M-26).

When two pressure ulcers merge into one pressure ulcer, the ulcer is not necessarily considered to have worsened.The M0800 clarification states:

If two pressure ulcers merge, do not code as worsened. Although two merged pressure ulcers might increase the overall surface area of the ulcer, there would need to be an increase in numerical stage in order for it to be considered as worsened.

The measurement of the wound will have increased when the pressure ulcers merged, but unless the numerical stage has increased, the ulcer is not considered to have worsened.

CMS has added a clarification to the Planning for Care section of M0900, Healed Pressure Ulcers. The clarification follows the NPUAP guidelines and states:

Clinical standards do not support reverse staging or back staging as a way to document healing as it does not accurately characterize what is physiologically occurring as the ulcer heals. For example, over time, even though a Stage 4 pressure ulcer has been healing and contracting such that it is less deep, wide, and long, the tissues that were lost (muscle, fat, dermis) will never be replaced with the same type of tissue…. Nursing homes can document the healing of pressure ulcers using descriptive characteristics of the wound (i.e., depth, width, presence or absence of granulation tissue, etc.) or by using a validated pressure ulcer healing tool. Once a pressure ulcer has healed, it is documented as a healed pressure ulcer at its highest numerical stage—in this example, a healed Stage 4 pressure ulcer. (p. M-29)

The difference between a surgical wound and a surgically debrided pressure ulcer is spelled out in item M1040E (pp. M-34–M-35). CMS’s updated tip includes this:

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. A pressure ulcer that has been surgically debrided should continue to be coded as a pressure ulcer.

CMS further states:

Do code pressure ulcers that require intervention for closure with grafts and/or flap procedures in this item (e.g., excision of pressure ulcer with myocutaneous flap). Once a pressure ulcer is excised and a graft and/or flap is applied, it is no longer considered a pressure ulcer, but a surgical wound.

Moisture associated skin damage (MASD) was a new item added to the MDS item sets in April 2012. At the recent AANAC conference, the CMS representative noted that errors occur with this item when a skin area that has MASD is incorrectly coded as a pressure ulcer. To increase clarity for coders, CMS made some changes to the description for this item (M1040H). It now reads:

Moisture associated skin damage (MASD) 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. It is characterized by inflammation of the skin, and occurs with or without skin erosion and/or infection. MASD is also referred to as incontinence-associated dermatitis and can cause other conditions such as intertriginous dermatitis, periwound moisture-associated dermatitis and peristomal moisture-associated dermatitis. Provision of optimal skin care and early identification and treatment of minor cases of MASD can help avoid progression and skin breakdown.

To ensure proper management of skin condition, particularly pressure ulcers. CMS now instructs providers that, “The interdisciplinary care plan should be reevaluated to ensure that appropriate preventative measures and pressure ulcer management principles are being adhered to when new pressure ulcers develop or when pressure ulcers worsen.” (p. M-25)

ITEM X0300

After May 19, 2013, the technical specifications for coding gender (A0800) on the MDS 3.0 item sets no longer allow a dash (-). The update states:

Although a dash (indicating unable to determine) is no longer an acceptable value in A0800, a dash must be used in X0300 on a modification or inactivation request to locate a record if a dash was previously entered in A0800 on the original record (p. X-3).

At the AANAC conference, attendees received a preview of this change. CMS instructed listeners to determine whether the resident is male or female by matching coding with the gender listed in the Social Security system.


The revised manual posted in May 2013 includes changes or additions to 315 pages and involves nearly every chapter. Nursing home and swing bed providers are strongly encouraged to update their facility manuals with the revised pages and to schedule training for interdisciplinary team members responsible for MDS coding as well as for nurses engaged in skin condition management.

One way to process the changes quickly is to review the change tables, which are available in the Downloads section of the CMS MDS 3.0 manual site.

For additional assistance with the RAI User’s Manual update, Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE, can be reached at


Davis C. (2013, May 9). Current ADL coding policy, RAI manual revisions highlight CMS keynote. AANAC LTC Leader2013;May9:1–4. Retrieved May 19, 2013, from

Spenard A. Centers for Medicare & Medicaid Services. CMS topics and MDS updates. PowerPoint at: the AANAC Annual Conference; May 2013; San Antonio, Texas.

Long-term care facility resident assessment instrument user’s manual (version 3.0). Centers for Medicare & Medicaid Services, Baltimore, October 2012. Available at:

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