Q:
We are caring for a resident who recently admitted with a new G-tube. Can I code the G-tube site as a surgical wound in Section M?
A:
The RAI describes surgical wounds as any healing and non-healing, open or closed surgical incisions, skin grafts, or drainage sites. The coding tips go on to say that this category does not include healed surgical sites and healed stomas. Knowing this, it is possible to code a new G-tube site as a surgical wound, but only until the wound edges heal, which typically takes around a week.
In addition to accurate MDS coding, it’s important to monitor the G-tube site closely for signs of infection, delayed healing, or other complications that could indicate a change in condition. Any signs of redness, drainage, pain, or deterioration at the site should be promptly evaluated and reported, as they may require intervention and could affect the resident’s overall status and care plan. Always ensure documentation reflects ongoing assessment and clinical decision-making related to the wound status.
Next Steps:
Register to join Proactive on June 17, 2025 for the webinar Managing Changes in Resident Condition as part of the Reducing Litigation Risk for SNF & AL series!
Written By:
Eleisha Wilkes, RN, GERO-BC, RAC-CT, DNS-CT
Senior Consultant
Proactive LTC Consulting
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