I2200: Tuberculosis, Step-by-Step

Step-by-Step Coding Guide for Item Set I2200: Tuberculosis

1. Review of Medical Records

• Objective: To identify whether the resident has a diagnosis of tuberculosis.
• Process:
  • Medical History: Review the resident’s comprehensive medical history for any past diagnosis of tuberculosis.
  • Lab Results: Examine laboratory and diagnostic test results, including tuberculin skin tests (TST), interferon-gamma release assays (IGRAs), and chest X-rays.
  • Physician Notes: Review notes and diagnosis records from physicians and specialists.
  • Treatment Records: Check for any history of anti-tuberculosis treatment or ongoing treatment plans.

2. Understanding Definitions

• Tuberculosis (TB): A contagious bacterial infection caused by Mycobacterium tuberculosis, typically affecting the lungs, but it can also affect other parts of the body. TB can be latent or active; active TB is contagious and requires immediate treatment.

3. Coding Instructions

• Code I2200:
  • 0: No, the resident does not have tuberculosis.
  • 1: Yes, the resident has tuberculosis.
• Example: If a resident’s medical records indicate a positive TST or IGRA, supported by clinical symptoms and a confirmed diagnosis by a physician, code I2200 as '1'.

4. Coding Tips

• Confirm the diagnosis through multiple sources of documentation to ensure accuracy.
• Pay attention to the distinction between latent TB infection (LTBI) and active TB disease, as coding typically reflects active disease.
• Consider historical diagnoses if the resident is currently undergoing treatment or has a history of TB.

5. Documentation

• Required Documentation:
  • Diagnosis Records: Physician’s notes confirming the diagnosis of tuberculosis.
  • Lab Results: Positive results from TB tests (TST, IGRA, chest X-rays).
  • Treatment Records: Documentation of anti-tuberculosis treatment, including medication regimens.
  • Public Health Records: Any records from public health departments indicating TB diagnosis or contact tracing.
• Example: "On 05/10/2024, the resident was diagnosed with active pulmonary tuberculosis based on a positive IGRA test and chest X-ray showing infiltrates. Anti-tuberculosis treatment initiated on 05/12/2024."

6. Common Errors to Avoid

• Misclassification: Coding for TB based on historical LTBI without current active disease.
• Incomplete Documentation: Failing to document the basis of the diagnosis thoroughly.
• Outdated Records: Using old medical records without confirming the current TB status of the resident.

7. Practical Application

• Scenario: A resident is admitted to the facility with a history of coughing and weight loss. Upon review, their medical records show a recent positive IGRA test and a chest X-ray consistent with TB. The attending physician confirms the diagnosis and starts the resident on a standard TB treatment regimen. The interdisciplinary team discusses the case, updates the care plan to include infection control measures, and documents these steps. For MDS coding, I2200 is marked as '1', indicating the presence of tuberculosis.

Please note that the information provided in this guide for MDS 3.0 Item set I2200 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.