Step-by-Step Coding Guide for Item Set I2100: Septicemia

1. Review of Medical Records

• Objective: Accurately determine and document the presence of septicemia in a resident.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, hospital discharge summaries, laboratory results, and nursing notes.
  2. Identify Documentation of Septicemia: Look for documented instances of septicemia, including clinical diagnoses and laboratory confirmation.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Septicemia: A serious bloodstream infection that can rapidly become life-threatening. It arises when a bacterial infection elsewhere in the body, such as in the lungs or skin, enters the bloodstream.
• Key Points:
  • Symptoms: May include fever, chills, rapid breathing and heart rate, and confusion.
  • Diagnosis: Typically confirmed through blood cultures and clinical symptoms.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the diagnosis of septicemia, supported by physician notes and laboratory results.
  2. Verify Documentation: Ensure that the diagnosis is clearly noted in the records, including details of the infection and any laboratory confirmations.
  3. Code Appropriately: Enter the appropriate code for item set I2100:
     • 0: No, the resident does not have septicemia.
     • 1: Yes, the resident has septicemia.

4. Coding Tips

• Accurate Identification: Ensure the diagnosis of septicemia is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the diagnosis of septicemia.
• Clarify with the Interdisciplinary Team: If there is any uncertainty, clarify with the interdisciplinary team to ensure accurate coding.

5. Documentation

• Required:
  • Physician Notes: Detailed notes from physicians documenting the diagnosis and treatment of septicemia.
  • Hospital Discharge Summaries: Summaries that include the diagnosis of septicemia and any relevant treatment details.
  • Laboratory Results: Blood culture reports and other relevant laboratory findings confirming septicemia.
  • Nursing Notes: Detailed notes from nursing staff documenting symptoms, clinical signs, and responses to treatment.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the diagnosis of septicemia through multiple records and notes.
• Incomplete Documentation: Make sure all relevant physician notes, hospital discharge summaries, and laboratory results are included to support the documented diagnosis.
• Assumptions: Do not assume the presence of septicemia without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: James, a 78-year-old resident, was admitted with a diagnosis of septicemia following a urinary tract infection.
  • Steps:
    1. Review Records: The nurse reviews James’s medical records, noting the hospital discharge summary that includes a diagnosis of septicemia and the blood culture results confirming the infection.
    2. Identify Diagnosis: It is confirmed through the documentation that James was diagnosed with septicemia.
    3. Document and Code: The nurse documents the diagnosis in James’s records and codes I2100 as "1".
  • Outcome: James’s diagnosis of septicemia 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 I2100 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.