Step-by-Step Coding Guide for Item Set I0020B: ICD Code 1 - 13

1. Review of Medical Records

• Objective: Accurately determine and document up to 13 ICD-10 diagnosis codes relevant to the resident’s current health status.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, discharge summaries, diagnostic reports, laboratory results, and previous assessments.
  2. Identify Documentation of Diagnoses: Look for documented instances of diagnoses that are currently active and relevant to the resident’s care.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• ICD-10 Code: The International Classification of Diseases, 10th Revision, used to code and classify morbidity data from inpatient and outpatient records, physician offices, and most National Center for Health Statistics (NCHS) surveys.
• Key Points:
  • Active Diagnosis: A condition that is currently being treated or monitored during the assessment period.
  • Primary Diagnosis: The main condition being treated or monitored.
  • Secondary Diagnoses: Additional conditions that are being treated or monitored.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the resident’s active diagnoses.
  2. Verify Documentation: Ensure that the diagnoses are clearly noted in the records and are active during the assessment period.
  3. Code Appropriately: Enter up to 13 ICD-10 codes for the active diagnoses in item set I0020B. Prioritize the primary diagnosis first, followed by secondary diagnoses in order of clinical significance.
  4. Enter the ICD Codes:
     • Primary Diagnosis (Code 1): The main condition being treated or monitored.
     • Secondary Diagnoses (Codes 2 - 13): Additional active conditions.

4. Coding Tips

• Accurate Identification: Ensure the active diagnoses are correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and correct ICD-10 codes when documenting and coding the diagnoses.
• Consultation: If there is any uncertainty regarding the diagnosis, consult with the resident’s healthcare provider for clarification.

5. Documentation

• Required:
  • Physician Notes: Detailed notes from physicians documenting the diagnoses and the active treatment or monitoring.
  • Diagnostic Reports: Reports from diagnostic tests that confirm the diagnoses.
  • Laboratory Results: Lab reports that support the diagnoses.
  • Previous Assessments: Any previous assessments that have documented the resident’s active diagnoses.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the diagnosis details through multiple records and notes.
• Incomplete Documentation: Make sure all relevant physician notes, diagnostic reports, and laboratory results are included to support the diagnoses documented.
• Assumptions: Do not assume a diagnosis is active without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: James, a 70-year-old resident, has multiple active diagnoses including hypertension, diabetes, and chronic kidney disease.
  • Steps:
    1. Review Records: The nurse reviews James’s medical records, noting the physician notes, diagnostic reports, and lab results documenting James’s active diagnoses.
    2. Identify Diagnoses: It is confirmed through the documentation that James has the following active diagnoses: hypertension (I10), diabetes (E11.9), and chronic kidney disease (N18.9).
    3. Document and Code: The nurse documents the details of James’s active diagnoses in his records and codes I0020B as follows:
       • Code 1: I10 (Hypertension)
       • Code 2: E11.9 (Diabetes)
       • Code 3: N18.9 (Chronic Kidney Disease)
    4. Complete the Form: If there are additional active diagnoses, they would be listed in Codes 4 through 13.
  • Outcome: James’s active diagnoses are 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 I0020B 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.