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DiraChart MDS item reference
L0200ZSection Lv1.20.1Manual page L-1
Dental: none of the above
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick coding
Answer Codes
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Item-specific instructions
Coding Guidance
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Steps for Assessment
1. Ask the resident about the presence of chewing problems or
mouth or facial pain/discomfort.
2. Ask the resident, family, or significant other whether the
resident has or recently had dentures or partials. (If resident
or family/significant other reports that the resident recently
had dentures or partials, but they do not have them at the
facility, ask for a reason.)
3. If the resident has dentures or partials, examine for loose
fit. Ask them to remove, and examine for chips, cracks, and
cleanliness. Removal of dentures and/or partials is necessary for adequate assessment.
4. Conduct exam of the resident’s lips and oral cavity with dentures or partials removed, if
applicable. Use a light source that is adequate to visualize the back of the mouth. Visually
observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek
lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The
assessor should use their gloved fingers to adequately feel for masses or loose teeth.
5. If the resident is unable to self-report, then observe them while eating with dentures or
partials, if indicated, to determine if chewing problems or mouth pain are present.
6. Oral examination of residents who are uncooperative and do not allow for a thorough oral
exam may result in medical conditions being missed. Referral for dental evaluation should be
considered for these residents and any resident who exhibits dental or oral issues.
Coding Instructions
•
Check L0200A, broken or loosely fitting full or partial denture: if the
denture or partial is chipped, cracked, uncleanable, or loose. A denture is coded as loose
if the resident complains that it is loose, the denture visibly moves when the resident
opens their mouth, or the denture moves when the resident tries to talk.
•
Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the
resident is edentulous/lacks all natural teeth or parts of teeth.
•
Check L0200C, abnormal mouth tissue (ulcers, masses, oral lesions):
select if any ulcer, mass, or oral lesion is noted on any oral surface.
•
Check L0200D, obvious or likely cavity or broken natural teeth: if any
cavity or broken tooth is seen.
•
Check L0200E, inflamed or bleeding gums or loose natural teeth: if gums
appear irritated, red, swollen, or bleeding. Teeth are coded as loose if they readily move
when light pressure is applied with a fingertip.
•
Check L0200F, mouth or facial pain or discomfort with chewing: if the
resident reports any pain in the mouth or face, or discomfort with chewing.
•
Check L0200G, unable to examine: if the resident’s mouth cannot be examined.
•
Check L0200Z, none of the above: if none of conditions A through F is present.
DEFINITIONS
ORAL MASS
A swollen or raised lump,
bump, or nodule on any oral
surface. May be hard or soft,
and with or without pain.
ULCER
Mouth sore, blister or eroded
area of tissue on any oral
surface.
L0200: Dental (cont.)
Coding Tips
•
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.
•
The dental status for a resident who has some, but not all, of their natural teeth that do not
appear damaged (e.g., are not broken, loose, with obvious or likely cavity) and who does
not have any other conditions in L0200A–G, should be coded in L0200Z, none of the
above.
•
Many residents have dentures or partials that fit well and work properly. However, for
individualized care planning purposes, consideration should be taken for these residents
to make sure that they are in possession of their dentures or partials and that they are
being utilized properly for meals, snacks, medication pass, and social activities.
Additionally, the dentures or partials should be properly cared for with regular cleaning
and by assuring that they continue to fit properly throughout the resident’s stay.
SECTION M: SKIN CONDITIONS
Intent: The items in this section document the risk, presence, appearance, and change of
pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and
documents some treatment categories related to skin injury or avoiding injury. It is important to
recognize and evaluate each resident’s risk factors and to identify and evaluate all areas at risk of
constant pressure. A complete assessment of skin is essential to an effective pressure ulcer
prevention and skin treatment program. Be certain to include in the assessment process, a holistic
approach. It is imperative to determine the etiology of all wounds and lesions, as this will
determine and direct the proper treatment and management of the wound.
CMS is aware of the array of terms used to describe alterations in skin integrity due to pressure.
Some of these terms include: pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and
bed sore. Acknowledging that clinicians may use and documentation may reflect any of these
terms, it is acceptable to code pressure-related skin conditions in Section M if different
terminology is recorded in the clinical record, as long as the primary cause of the skin alteration
is related to pressure. For example, if the medical record reflects the presence of a Stage 2
pressure injury, it should be coded on the MDS as a Stage 2 pressure ulcer.
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