I2400: Viral Hepatitis (Includes Type A, B, C, D, and E), Step-by-Step

Step-by-Step Coding Guide for Item Set I2400: Viral Hepatitis

1. Review of Medical Records

• Objective: Accurately determine and document whether the resident has a diagnosis of viral hepatitis, including types A, B, C, D, and E.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, laboratory results, diagnostic reports, and previous assessments.
  2. Identify Documentation of Viral Hepatitis: Look for documented instances of viral hepatitis, specifying the type (A, B, C, D, or E) if available.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Viral Hepatitis: A group of infectious diseases that affect the liver, caused by different viruses, namely hepatitis A, B, C, D, and E.
• Key Points:
  • Hepatitis A: Typically spread through ingestion of contaminated food or water.
  • Hepatitis B: Transmitted through contact with infectious body fluids, such as blood.
  • Hepatitis C: Spread primarily through blood-to-blood contact.
  • Hepatitis D: Only occurs in those infected with hepatitis B.
  • Hepatitis E: Usually spread through consumption of contaminated water.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records if the resident has been diagnosed with viral hepatitis.
  2. Verify Documentation: Ensure that the type of viral hepatitis is clearly noted in the records.
  3. Code Appropriately: Enter the code for viral hepatitis in item set I2400:
     • 1: Yes, the resident has a diagnosis of viral hepatitis (type A, B, C, D, or E).
     • 0: No, the resident does not have a diagnosis of viral hepatitis.

4. Coding Tips

• Accurate Identification: Ensure the diagnosis of viral hepatitis is correctly identified and supported by relevant documentation, including lab results and physician notes.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s diagnosis of viral hepatitis.
• Clarify with the Resident: If there is any uncertainty, clarify with the resident or their legal representative to ensure accurate coding.

5. Documentation

• Required:
  • Physician Notes: Detailed notes from physicians documenting the diagnosis of viral hepatitis, including the type.
  • Laboratory Results: Lab reports confirming the presence of hepatitis virus, including tests such as liver function tests, viral load tests, and serology.
  • Diagnostic Reports: Reports from imaging studies or liver biopsies that support the diagnosis.
  • Previous Assessments: Any previous assessments that have documented the resident’s diagnosis of viral hepatitis.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the diagnosis of viral hepatitis through multiple records and notes.
• Incomplete Documentation: Make sure all relevant physician notes, lab results, and diagnostic reports are included to support the diagnosis.
• Assumptions: Do not assume the resident has viral hepatitis without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Jane, a 60-year-old resident, has been diagnosed with hepatitis C.
  • Steps:
    1. Review Records: The nurse reviews Jane’s medical records, noting the laboratory results and physician notes documenting the diagnosis of hepatitis C.
    2. Identify Diagnosis: It is confirmed through the documentation that Jane has been diagnosed with hepatitis C.
    3. Document and Code: The nurse documents the diagnosis details in Jane’s records and codes I2400 as "1".
  • Outcome: Jane’s diagnosis of hepatitis C 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 I2400 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.