C1310D: Signs of Delirium: Altered Level of Consciousness, Step-by-Step

Step-by-Step Coding Guide for Item Set C1310D: Signs of Delirium: Altered Level of Consciousness

1. Review of Medical Records

• Objective: To verify if there are documented signs of altered level of consciousness, indicative of delirium.
• Process:
  • Examine the nursing notes, psychological assessments, and daily monitoring logs for any mentions of changes in the resident’s level of consciousness.
  • Review physician and neurology consultation notes that might detail episodes of altered consciousness.
  • Consult with nursing staff and other care providers who interact daily with the resident for their observations and notes regarding the resident’s alertness and responsiveness.

2. Understanding Definitions

• Altered Level of Consciousness: Refers to a state where there is a deviation from normal alertness, including increased confusion, reduced awareness, hyperalertness, or stupor. It is a key indicator of delirium and can fluctuate throughout the day.

3. Coding Instructions

• Code C1310D:
  • 0: No, the resident does not show signs of an altered level of consciousness.
  • 1: Yes, signs of an altered level of consciousness are observed.
• Example: If a resident exhibits periods of unresponsiveness interspersed with hyperalertness, inconsistent with their usual behavior, code C1310D as '1'.

4. Coding Tips

• Observe and record behaviors across different times of the day to capture any fluctuations in consciousness levels.
• Collaborate with the care team to gather comprehensive observational data before coding.

5. Documentation

• Required Documentation:
  • Detailed and specific instances when altered levels of consciousness were observed, including time of day and preceding activities or treatments.
  • Notes from interdisciplinary team discussions about the resident’s cognitive status and potential causes of observed symptoms.
  • Documentation of any medical interventions or evaluations related to the resident’s altered consciousness.
• Accurate and timely documentation is crucial for supporting the diagnosis of delirium and subsequent coding.

6. Common Errors to Avoid

• Misinterpreting normal sleepiness or fatigue as altered consciousness.
• Overlooking the documentation of transient episodes of altered consciousness.
• Failing to consider and document the impact of medications or environmental factors on the resident’s level of consciousness.

7. Practical Application

• Scenario: A resident recovering from surgery unexpectedly begins to exhibit periods of drowsiness and disorientation, alternating with moments of unusual hyperactivity. These changes are noted by the nursing staff over a 24-hour period and discussed in a care meeting with the resident’s physician, who suggests monitoring for postoperative delirium. The observations are thoroughly documented in the resident’s medical record, including specific descriptions of each episode, and C1310D is coded as '1' to indicate the presence of altered consciousness as part of potential delirium symptoms.

Please note that the information provided in this guide for MDS 3.0 Item set C1310D 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.