Ask Diane: How do you code internal bleeding on the MDS?
Q: Can you code internal bleeding on the MDS if a resident’s hemoglobin was low during the assessment period?
Diane: The MDS definition and coding rules for internal bleeding (item J1j of the MDS 2.0), which can be found on page 3-139 of the RAI User’s Manual, Version 2.0, state the following:
“Bleeding may be frank (such as bright red blood) or occult (such as guaiac positive stools). Clinical indicators include black, tarry stools, vomiting “coffee grounds”, hematuria (blood in urine), hemoptysis (coughing up blood), and severe epistaxis (nosebleed) that requires packing. However, nose bleeds that are easily controlled should not be coded as internal bleeding.”
The instruction states that nose bleeds that either require packing or are not easily controlled are the only nosebleed items that may be coded on the MDS. Ultimately, CMS is not looking at causal factors, only at the end result. Therefore, you should not code internal bleeding on the MDS just because a resident’s hemoglobin was low during the assessment period.
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Diane Brown
Diane Brown is a long-term care regulatory specialist and lead educator for HCPro's MDS 3.0 Boot Camp and Medicare Boot Camp-Long-Term Care Version. She is also a long-term care consultant with over 25 years of operational experience in healthcare. For Diane's complete bio, visit the About page.
Diane has written 240 posts.
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