Step-by-Step Coding Guide for Item Set I1700: Multidrug-Resistant Organism (MDRO)

1. Review of Medical Records

• Objective: Ensure thorough and accurate documentation of the resident's status regarding Multidrug-Resistant Organism (MDRO) infection.
• Steps:
  1. Access Records: Retrieve the resident’s comprehensive medical records, including lab reports, physician notes, and infection control logs.
  2. Verify Information: Confirm the presence of MDRO based on microbiological reports and documented clinical assessments.
  3. Cross-Reference: Ensure consistency of this information across different sections of the medical records (e.g., nursing notes, care plans).

2. Understanding Definitions

• Multidrug-Resistant Organism (MDRO): Pathogens resistant to multiple classes of antimicrobial agents, making infections difficult to treat. Examples include MRSA (Methicillin-Resistant Staphylococcus aureus), VRE (Vancomycin-Resistant Enterococci), and certain strains of Gram-negative bacteria.
• Coding Presence: Indicates whether the resident has a documented MDRO infection during the assessment period.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Access item set I1700 on the MDS form.
  2. Assess Presence: Determine if the resident has a documented MDRO infection based on medical records and clinical assessments.
  3. Code the Item:
  • If the resident has a documented MDRO infection, code the item as “1” (Yes).
  • If the resident does not have a documented MDRO infection, code the item as “0” (No).
  4. Complete Entry: Ensure accurate documentation in the MDS form reflecting the resident’s MDRO status.

4. Coding Tips

• Accuracy: Double-check records to ensure the presence or absence of MDRO is correctly documented.
• Consistency: Ensure that the information is consistent across all relevant sections of the medical records.
• Detail: Include any specific details regarding the type of MDRO and relevant treatment protocols.

5. Documentation

• Required:
  • Medical Records: Detailed records including lab reports, infection control logs, and physician notes documenting the presence or absence of MDRO.
  • MDS Form: Accurate completion of item set I1700 indicating the resident’s MDRO status.
  • Supporting Documents: Include any additional documentation supporting the assessment (e.g., microbiological culture reports).

6. Common Errors to Avoid

• Misdocumentation: Incorrectly documenting the presence or absence of MDRO without proper verification.
• Incomplete Records: Missing or incomplete documentation regarding the resident’s MDRO status.
• Inconsistent Coding: Discrepancies between the MDS form and other sections of the resident’s medical records.

7. Practical Application

• Example:

  • Resident Background: Mr. John Doe has a documented MRSA infection noted in his medical records.
  • Review Process: Upon review, his medical records include lab reports confirming the MRSA infection.
  • Coding Process:
    • Step 1: Access the MDS form and locate item set I1700.
    • Step 2: Assess lab reports and clinical documentation confirming the presence of MRSA.
    • Step 3: Code the item as “1” (Yes) to indicate that Mr. Doe has a documented MDRO infection.
    • Step 4: Document the assessment and any relevant details in the MDS form.
  • Documentation: Ensure that the MDS form is consistent with his medical records and includes all supporting documentation.

• Illustration:

  • Provide a sample MDS form showing item set I1700 coded as “1” (Yes) with the corresponding supporting documentation.

Please note that the information provided in this guide for MDS 3.0 Item set I1700 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.