I0900: Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD), Step-by-Step
Step-by-Step Coding Guide for Item Set I0900: Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)
Step-by-Step Coding Guide for Item Set I0900: Peripheral Vascular Disease (PVD) or PAD
1. Review of Medical Records
- Objective: Gather accurate information regarding the diagnosis of Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD).
- Steps:
- Collect Information: Review the resident's comprehensive medical records, including physician notes, diagnostic test results, and previous assessments.
- Identify Diagnoses: Look for documented diagnoses of PVD or PAD by healthcare providers.
- Confirm Diagnostic Tests: Check for supporting diagnostic tests such as Doppler ultrasounds, angiograms, or ABI (Ankle-Brachial Index) measurements that confirm PVD or PAD.
2. Understanding Definitions
- Peripheral Vascular Disease (PVD): A circulation disorder that causes blood vessels outside of the heart and brain to narrow, block, or spasm.
- Peripheral Arterial Disease (PAD): A common type of PVD that involves the arteries, specifically causing reduced blood flow to the limbs.
- Key Points:
- Symptoms: Includes leg pain when walking (claudication), numbness, coldness in lower legs or feet, and sores that won't heal.
- Risk Factors: Smoking, diabetes, obesity, high blood pressure, high cholesterol, and age.
3. Coding Instructions
- Steps:
- Identify PVD/PAD: Confirm the diagnosis of PVD or PAD from the resident’s medical records.
- Verify Documentation: Ensure the diagnosis is well-documented by a physician and supported by diagnostic test results.
- Code Appropriately: Code I0900 as "1" if there is a documented diagnosis of PVD or PAD, and "0" if there is no such diagnosis.
4. Coding Tips
- Accurate Identification: Ensure the diagnosis specifically mentions PVD or PAD.
- Consistent Terminology: Use consistent terminology when documenting and coding PVD or PAD.
- Consult Providers: If there is any uncertainty, consult with healthcare providers for clarification.
5. Documentation
- Required:
- Physician Notes: Documented diagnosis of PVD or PAD by a physician.
- Diagnostic Test Results: Include results from tests such as Doppler ultrasounds, angiograms, or ABI measurements.
- Medical History: Ensure the resident’s medical history includes any relevant information about PVD or PAD.
6. Common Errors to Avoid
- Misclassification: Ensure that only confirmed cases of PVD or PAD are coded.
- Incomplete Documentation: Make sure all relevant diagnostic tests and physician notes are included.
- Assumptions: Do not assume the presence of PVD or PAD without proper documentation.
7. Practical Application
- Example:
- Resident Profile: Jane, a 70-year-old resident, has been experiencing leg pain and has a documented diagnosis of PAD.
- Steps:
- Review Records: The nurse reviews Jane’s medical records, including her physician’s notes and Doppler ultrasound results confirming PAD.
- Identify Diagnosis: It is confirmed that Jane has a documented diagnosis of PAD.
- Document and Code: The nurse documents the diagnosis and codes I0900 as "1".
- Outcome: Jane’s diagnosis of PAD is accurately documented and coded, ensuring appropriate care planning and management.
Please note that the information provided in this guide for MDS 3.0 Item set I0900 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.
