Step-by-Step Coding Guide for Item Set A1550B: ID/DD Status: Autism

1. Review of Medical Records

• Objective: To accurately document the resident’s status regarding Autism.
• Steps:
  1. Access Records: Retrieve the resident’s complete medical records, including any psychological evaluations, previous diagnoses, and educational or developmental reports.
  2. Verify Diagnoses: Look for any documented diagnoses of Autism Spectrum Disorder (ASD) by qualified healthcare professionals.
  3. Cross-Reference: Check for consistency of the Autism diagnosis across various records (e.g., physician notes, psychological evaluations).

2. Understanding Definitions

• ID/DD Status: Intellectual Disability/Developmental Disability status, which includes conditions like Autism.
• Autism: A developmental disorder characterized by challenges with social skills, repetitive behaviors, and communication.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Access item set A1550B on the MDS form.
  2. Verify Diagnosis: Confirm that the resident has a documented diagnosis of Autism.
  3. Code the Item: If Autism is confirmed, code the item as “Yes”. If there is no diagnosis of Autism, code the item as “No”.
  4. Complete Entry: Ensure all related information is accurately entered, including the date of diagnosis and the diagnosing professional if applicable.

4. Coding Tips

• Ensure Accuracy: Double-check the medical records to ensure the diagnosis of Autism is well-documented.
• Professional Diagnosis: The diagnosis should come from a licensed healthcare professional (e.g., psychologist, psychiatrist).
• Consistency: Ensure the Autism diagnosis is consistently documented in all relevant sections of the resident’s records.

5. Documentation

• Required:
  • Medical Records: Comprehensive records including psychological assessments, diagnostic reports, and physician notes confirming Autism.
  • MDS Form: Accurate completion of item set A1550B indicating the presence of Autism.
  • Supporting Documents: Include copies of the diagnostic report and the professional’s credentials.

6. Common Errors to Avoid

• Misdiagnosis: Incorrectly documenting Autism without a proper diagnosis from a qualified professional.
• Incomplete Records: Missing or incomplete documentation of the Autism diagnosis.
• Inconsistent Coding: Discrepancies between the MDS form and other medical records regarding the Autism diagnosis.

7. Practical Application

• Example:
  • Resident Background: Ms. Jane Smith has a documented diagnosis of Autism.
  • Review Process: Upon review, her medical records include a psychological evaluation from a licensed psychologist diagnosing her with Autism at age 5.
  • Coding Process:
    • Step 1: Access the MDS form and locate item set A1550B.
    • Step 2: Verify the Autism diagnosis in her records.
    • Step 3: Code the item as “Yes” to indicate the presence of Autism.
    • Step 4: Enter the date of diagnosis and the diagnosing professional’s name and credentials.
  • Documentation: Ensure that the MDS form is consistent with her medical records and includes the psychological evaluation as supporting documentation.
• Illustration:
  • Provide a sample MDS form showing item set A1550B coded as “Yes” with the corresponding supporting documentation.

Please note that the information provided in this guide for MDS 3.0 Item set A1550B was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.