Step-by-Step Coding Guide for Item Set A1550E: ID/DD Status - ID/DD with No Organic Condition

1. Review of Medical Records

• Objective: Accurately determine and document whether the resident has an intellectual disability/developmental disability (ID/DD) without an associated organic condition.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, psychological evaluations, diagnostic reports, and previous assessments.
  2. Identify Documentation of ID/DD: Look for documented instances of intellectual or developmental disabilities, specifying if there is no organic condition.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• ID/DD with No Organic Condition: Refers to intellectual and developmental disabilities that are not caused by identifiable organic conditions such as genetic disorders, brain injuries, or other physical health conditions.
• Key Points:
  • Intellectual Disability (ID): A disability characterized by significant limitations in intellectual functioning and adaptive behavior, which covers many everyday social and practical skills.
  • Developmental Disability (DD): A diverse group of chronic conditions that are due to mental or physical impairments, including conditions like autism spectrum disorders.
  • No Organic Condition: Indicates that the disability is not associated with a known organic cause such as genetic syndromes, brain injuries, or metabolic disorders.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records if the resident has been diagnosed with ID/DD and there is no associated organic condition.
  2. Verify Documentation: Ensure that the diagnosis and the absence of an organic condition are clearly noted in the records.
  3. Code Appropriately: Enter the code for ID/DD with no organic condition in item set A1550E:
     • 1: Yes, the resident has an ID/DD with no organic condition.
     • 0: No, the resident does not have an ID/DD with no organic condition.

4. Coding Tips

• Accurate Identification: Ensure the diagnosis of ID/DD with no organic condition is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s diagnosis of ID/DD.
• Clarify with the Resident: If there is any uncertainty, clarify with the resident or their legal representative to ensure accurate coding.

5. Documentation

• Required:
  • Physician Notes: Detailed notes from physicians documenting the diagnosis of ID/DD and specifying the absence of an organic condition.
  • Psychological Evaluations: Evaluations from psychologists or psychiatrists detailing the diagnosis of ID/DD.
  • Diagnostic Reports: Reports from diagnostic tests or assessments that support the diagnosis and absence of an organic condition.
  • Previous Assessments: Any previous assessments that have documented the resident’s diagnosis of ID/DD with no organic condition.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the diagnosis of ID/DD with no organic condition through multiple records and notes.
• Incomplete Documentation: Make sure all relevant physician notes, psychological evaluations, and diagnostic reports are included to support the diagnosis.
• Assumptions: Do not assume the resident has ID/DD with no organic condition without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: John, a 45-year-old resident, has been diagnosed with an intellectual disability without an associated organic condition.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, noting the psychological evaluations and physician notes documenting the diagnosis of ID/DD.
    2. Identify Diagnosis: It is confirmed through the documentation that John has been diagnosed with an intellectual disability and there is no associated organic condition.
    3. Document and Code: The nurse documents the diagnosis details in John’s records and codes A1550E as "1".
  • Outcome: John’s diagnosis of ID/DD with no organic condition is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set A1550E 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.