Step-by-Step Coding Guide for Item Set I0800: Orthostatic Hypotension

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s diagnosis of orthostatic hypotension.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, diagnostic test results, nursing notes, and previous assessments.
  2. Identify Documentation of Orthostatic Hypotension: Look for documented instances of orthostatic hypotension, including diagnostic criteria and treatment plans.
  3. Confirm Details: Verify the consistency and accuracy of the documentation through various sources within the medical records.

2. Understanding Definitions

• Orthostatic Hypotension: A form of low blood pressure that happens when standing up from sitting or lying down, defined by a drop in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg within three minutes of standing.
• Key Points:
  • Symptoms can include dizziness, lightheadedness, fainting, and blurred vision.
  • It is essential to differentiate orthostatic hypotension from other types of hypotension.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm the resident’s diagnosis of orthostatic hypotension based on medical records and diagnostic tests.
  2. Verify Documentation: Ensure the diagnosis of orthostatic hypotension is clearly documented, including specific details about the blood pressure readings and symptoms observed upon standing.
  3. Code Appropriately: Enter the code for orthostatic hypotension in item set I0800. If the resident has a documented diagnosis, code as "1"; if not, code as "0".

4. Coding Tips

• Accurate Identification: Ensure the diagnosis is supported by relevant medical documentation, including blood pressure readings taken in different positions.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s orthostatic hypotension.
• Consult Records: Cross-check with other records and assessments to verify the diagnosis of orthostatic hypotension.

5. Documentation

• Required:
  • Physician Notes: Detailed notes from physicians documenting the diagnosis of orthostatic hypotension, including the criteria used.
  • Nursing Notes: Records of blood pressure readings and symptoms observed upon the resident standing.
  • Diagnostic Test Results: Include results from tests used to diagnose orthostatic hypotension, such as blood pressure measurements.
  • Treatment Plans: Document any interventions or treatments implemented to manage the resident’s orthostatic hypotension.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the diagnosis through multiple records and diagnostic tests.
• Incomplete Documentation: Make sure all relevant diagnostic test results, physician notes, and assessments are included.
• Assumptions: Do not assume the diagnosis of orthostatic hypotension without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Emma, a 78-year-old resident, frequently experiences dizziness and lightheadedness when standing up.
  • Steps:
    1. Review Records: The nurse reviews Emma’s medical records, noting that she has a documented diagnosis of orthostatic hypotension based on blood pressure readings taken while lying down and standing up.
    2. Identify Diagnosis: It is confirmed that Emma has orthostatic hypotension, with recorded drops in blood pressure meeting the diagnostic criteria.
    3. Document and Code: The nurse documents the diagnosis details in Emma’s records and codes I0800 as "1".
  • Outcome: Emma’s orthostatic hypotension 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 I0800 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.