DiraChart MDS item reference

M1030Section Mv1.20.1Manual page M-30

Number of Venous and Arterial Ulcers

Item Rationale

Quick coding

Answer Codes

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Response format: Numeric entry

M1030 — Number of Venous and Arterial Ulcers
Enter the value requested for this item using the current CMS numeric entry format. Verify the entry against Manual page M-30 and the supporting facility documentation.

Item-specific instructions

Coding Guidance

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RAI Manual v1.20.1

Steps for Assessment

1. Review the medical record, including skin care flow sheet
or other skin tracking form.
2. Speak with direct care staff and the treatment nurse to
confirm conclusions from the medical record review.
3. Examine the resident and determine whether any venous or
arterial ulcers are present.

Key areas for venous ulcer development include the
area proximal to the lateral and medial malleolus (e.g.,
above the inner and outer ankle area).

Key areas for arterial ulcer development include the
distal part of the foot, dorsum or tops of the foot, or tips
and tops of the toes.

Venous ulcers may or may not be painful and are
typically shallow with irregular wound edges, a red
granular (e.g., bumpy) wound bed, minimal to moderate
amounts of yellow fibrinous material, and moderate to
large amounts of exudate. The surrounding tissues may
be erythematous or reddened, or appear brown-tinged
due to hemosiderin staining. Leg edema may also be
present.

Arterial ulcers are often painful and have a pale pink
wound bed, necrotic tissue, minimal exudate, and
minimal bleeding.
DEFINITIONS
VENOUS ULCERS
Ulcers caused by peripheral
venous disease, which most
commonly occur proximal to
the medial or lateral
malleolus, above the inner or
outer ankle, or on the lower
calf area of the leg.
ARTERIAL ULCERS
Ulcers caused by peripheral
arterial disease, which
commonly occur on the tips
and tops of the toes, tops of
the foot, or distal to the
medial malleolus.
DEFINITION
HEMOSIDERIN
An intracellular storage form
of iron; the granules consist
of an ill-defined complex of
ferric hydroxides,
polysaccharides, and
proteins having an iron
content of approximately
33% by weight. It appears as
a dark yellow-brown pigment.
M1030: Number of Venous and Arterial Ulcers (cont.)

Manual page M-30
RAI Manual v1.20.1

Coding Instructions

Pressure ulcers/injuries coded in M0210 through M0300 should not be coded here.

Enter the number of venous and arterial ulcers present.

Enter 0: if there were no venous or arterial ulcers present.

Manual page M-30
RAI Manual v1.20.1

Coding Tips

Arterial Ulcers

Trophic skin changes (e.g., dry skin, loss of hair growth, muscle atrophy, brittle nails)
may also be present. The wound may start with some kind of minor trauma, such as
hitting the leg on a wheelchair. The wound does not typically occur over a bony
prominence, however, can occur on the tops of the toes. Pressure forces play virtually no
role in the development of the ulcer, however, for some residents, pressure may play a
part. Ischemia is the major etiology of these ulcers. Lower extremity and foot pulses may
be diminished or absent.
Venous Ulcers

The wound may start with some kind of minor trauma, such as hitting the leg on a
wheelchair. The wound does not typically occur over a bony prominence, and pressure
forces play virtually no role in the development of the ulcer.
Example
1. A resident has three toes on their right foot that have black tips. They do not have diabetes,
but have been diagnosed with peripheral vascular disease.
Coding: Code M1030 as 3.
Rationale: Ischemic changes point to the ulcer being vascular.

Manual page M-30
MDS item matrix

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10 relationships6 groups
Official CMS source

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SourceCMS MDS 3.0 RAI Manual v1.20.1
Effective2025-10-01
Mapped locationManual page M-30
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