I0500: Deep Venous Thrombosis (DVT), Pulmonary Embolism (PE), or Pulmonary Thromboembolism (PTE), Step-by-Step
Step-by-Step Coding Guide for Item Set I0500: Deep Venous Thrombosis (DVT), Pulmonary Embolism (PE), or Pulmonary Thromboembolism (PTE)
1. Review of Medical Records
- Objective: Gather accurate information regarding the resident’s diagnosis of DVT, PE, or PTE.
- Steps:
- Collect Information: Review the resident’s comprehensive medical records, including physician notes, radiology reports, lab results, and previous assessments.
- Identify Relevant Diagnoses: Look for documented instances of DVT, PE, or PTE.
- Confirm Diagnosis: Verify the diagnosis through consistent documentation and diagnostic evidence such as imaging studies (e.g., ultrasound, CT scans) and lab results (e.g., D-dimer).
2. Understanding Definitions
- Deep Venous Thrombosis (DVT): A condition where a blood clot forms in a deep vein, typically in the legs.
- Pulmonary Embolism (PE): A condition where one or more arteries in the lungs become blocked by a blood clot.
- Pulmonary Thromboembolism (PTE): Similar to PE, it refers to the blockage of the lung arteries due to a clot that traveled from the deep veins.
3. Coding Instructions
- Steps:
- Identify Relevant Diagnoses: Confirm that the resident has been diagnosed with DVT, PE, or PTE from the medical records.
- Verify Documentation: Ensure the diagnosis is clearly documented by a physician and supported by diagnostic tests.
- Code Appropriately: Code I0500 as "1" if the resident has a documented diagnosis of DVT, PE, or PTE, and "0" if they do not.
4. Coding Tips
- Accurate Identification: Ensure the diagnosis specifically mentions DVT, PE, or PTE and is supported by diagnostic tests.
- Consistent Terminology: Use consistent terminology when documenting and coding these conditions.
- Consult Physicians: If there is any uncertainty, consult with the attending physician or specialist for clarification.
5. Documentation
- Required:
- Physician Notes: Documented diagnosis of DVT, PE, or PTE by a physician.
- Diagnostic Tests: Include results from imaging studies (e.g., ultrasound, CT scans) and lab results (e.g., D-dimer).
- Medical History: Ensure the resident’s medical history includes any relevant information about DVT, PE, or PTE and treatments.
6. Common Errors to Avoid
- Misclassification: Ensure accurate classification by verifying the diagnosis of DVT, PE, or PTE.
- Incomplete Documentation: Make sure all relevant diagnostic tests and physician notes are included.
- Assumptions: Do not assume the presence of these conditions without proper documentation.
7. Practical Application
- Example:
- Resident Profile: John, a 78-year-old resident, has been diagnosed with a pulmonary embolism.
- Steps:
- Review Records: The nurse reviews John’s medical records, including physician notes and diagnostic test results confirming the pulmonary embolism.
- Identify Diagnosis: It is confirmed that John has a documented diagnosis of pulmonary embolism.
- Document and Code: The nurse documents the diagnosis in John’s records and codes I0500 as "1".
- Outcome: John’s diagnosis of pulmonary embolism 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 I0500 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.
