05/07/2026

Questions of the Month: May ODH Guidance Addresses MDS Coding Issues

The Ohio Department of Health recently responded to provider inquiries related to coding standards. 

Question: I am seeking clarification on “active” diagnosis criteria. The diagnosis has been documented by the physician within the last 60 days. There are interventions in the plan of care and are offered daily. The problem is the resident frequently declines these offered interventions. Can we code the diagnosis as active on the MDS if there are no interventions performed in the lookback period due to resident refusal?

 Answer: There needs to be resident-specific interventions performed during the observation period, and the medical record must provide evidence that the intervention(s) was (or were) performed to code this item on the MDS. Interventions in the care plan that are not specific to the resident would not meet the criteria for coding the MDS, such as basic daily nursing observations. Interventions listed on a care plan without medical record documentation indicating the interventions were performed would also not meet the coding criteria.

Question: I am working on an admission assessment, and a weight was not obtained for the resident prior to the assessment reference date (ARD). If a facility could not weigh a resident upon admission prior to the ARD, can a weight before admission (e.g., hospital paperwork, family, resident reported) be used to code the weight item at K0200B?

Answer: According to page 3-3 of the MDS 3.0 RAI User's Manual, with the exception of certain items (e.g., some items in Sections J, K, and O), the look-back period does not extend into the preadmission period unless the item instructions state otherwise. In the case of reentry, the look-back period does not extend into time prior to the reentry, unless instructions state otherwise. As such, the resident’s weight should be obtained after entry or reentry into the facility.

Question: Can lymphedema wounds be coded at M1040D, Open lesions other than ulcers, rashes, cuts. 

Answer: The intent of M1040D is to capture wounds, sores, boils, cysts, blisters, etc., that are open (and cannot be coded elsewhere) and that develop as part of a disease or condition. If the resident has an open lesion(s) due to a disease or condition (including lymphedema), the provider can capture the lesion(s) in data item M1040D, Open lesion(s) other than ulcers, rashes, cuts (e.g., bullous pemphigoid).

If you have a Question of the Month to submit, please email Cheryl.Moya@odh.ohio.gov and place Question of the Month in the subject line.