Step-by-Step Coding Guide for Item Set I0100: Cancer (With or Without Metastasis)

1. Review of Medical Records

• Objective: Accurately determine and document whether the resident has a diagnosis of cancer, either with or without metastasis.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, oncology reports, diagnostic imaging, laboratory results, and previous assessments.
  2. Identify Documentation of Cancer: Look for documented instances of cancer diagnosis, specifying the type of cancer and whether metastasis is present.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Cancer: A broad group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body.
• Metastasis: The spread of cancer cells from the place where they first formed to another part of the body.
• Key Points:
  • Cancer can affect any part of the body and may be localized or metastatic.
  • Diagnosis of cancer should be confirmed by a physician and documented in the medical records.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records if the resident has been diagnosed with cancer.
  2. Verify Documentation: Ensure that the diagnosis of cancer, along with any information about metastasis, is clearly noted in the records.
  3. Code Appropriately: Enter the code for cancer in item set I0100:
     • 1: Yes, the resident has a diagnosis of cancer (with or without metastasis).
     • 0: No, the resident does not have a diagnosis of cancer.

4. Coding Tips

• Accurate Identification: Ensure the diagnosis of cancer is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s diagnosis of cancer.
• 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 cancer, including type and stage.
  • Oncology Reports: Reports from oncologists detailing the diagnosis, treatment plan, and any metastasis.
  • Diagnostic Imaging: Imaging reports that confirm the presence and extent of cancer.
  • Laboratory Results: Lab reports that support the diagnosis, such as biopsy results or tumor markers.
  • Previous Assessments: Any previous assessments that have documented the resident’s diagnosis of cancer.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the diagnosis of cancer through multiple records and notes.
• Incomplete Documentation: Make sure all relevant physician notes, oncology reports, and diagnostic imaging are included to support the diagnosis.
• Assumptions: Do not assume the resident has cancer without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Mary, a 70-year-old resident, has been diagnosed with breast cancer with metastasis to the bone.
  • Steps:
    1. Review Records: The nurse reviews Mary’s medical records, noting the physician notes, oncology reports, and diagnostic imaging documenting the cancer diagnosis.
    2. Identify Diagnosis: It is confirmed through the documentation that Mary has breast cancer with metastasis to the bone.
    3. Document and Code: The nurse documents the diagnosis details in Mary’s records and codes I0100 as "1".
  • Outcome: Mary’s diagnosis of cancer 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 I0100 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.