I2900: Diabetes Mellitus (DM), Step-by-Step
Step-by-Step Coding Guide for I2900: Diabetes Mellitus (DM)
1. Review of Medical Records
Objective: Identify if the resident has an active diagnosis of diabetes mellitus (DM) within the assessment period.
Actions:
- Access the resident’s medical records, including physician notes, care plans, lab results, and medication records.
- Confirm that diabetes mellitus is actively being managed, treated, or monitored during the 7-day look-back period. This includes any records of insulin administration, oral diabetic medications, or diet modifications.
2. Understanding Definitions
I2900: Diabetes Mellitus (DM): This category refers to residents diagnosed with diabetes mellitus, a chronic condition that affects blood sugar regulation.
Examples of Active Diabetes Mellitus:
- Type 1 diabetes (insulin-dependent)
- Type 2 diabetes (managed with oral medications, insulin, or diet)
Illustration 1:
- Scenario: A resident has a diagnosis of Type 2 diabetes and receives oral medication for blood sugar control.
- Result: I2900 is coded "Yes" to reflect the active management of diabetes.
3. Coding Instructions
Step-by-Step:
- Step 1: Review the medical records to verify the diagnosis of diabetes mellitus.
- Step 2: Confirm that diabetes mellitus has been actively managed, treated, or monitored in the past 7 days (e.g., through medication or blood glucose monitoring).
- Step 3: If diabetes mellitus is active, check I2900 as "Yes".
- Step 4: If diabetes mellitus is not active or there is no history of the diagnosis, check I2900 as "No".
Illustration 2:
- Scenario: A resident is being treated with insulin injections daily for Type 1 diabetes.
- Result: I2900 is coded "Yes" to document the ongoing management of diabetes.
4. Coding Tips
- Exclude Temporary Hyperglycemia: Ensure that temporary hyperglycemia is not misclassified as diabetes. Short-term high blood sugar from other conditions should not be coded under I2900.
- Check for Diabetic Complications: If the resident has complications from diabetes (e.g., neuropathy, retinopathy), ensure these are documented appropriately in other relevant sections of the MDS.
5. Documentation
Objective: Ensure the presence of diabetes mellitus is properly documented in the care plan.
Actions:
- Record the type of diabetes (e.g., Type 1 or Type 2) and how it is being managed (e.g., insulin, oral medications).
- Document any relevant treatments, blood glucose monitoring, or diet adjustments related to diabetes.
Illustration 3:
- Scenario: A resident is on a controlled diabetic diet and receives insulin therapy. Their care plan outlines the need for regular blood glucose monitoring.
- Documentation: Ensure that the care plan notes the resident’s diabetes management and I2900 is coded "Yes".
6. Common Errors to Avoid
- Misclassifying Blood Sugar Issues: Do not code temporary or stress-related hyperglycemia under I2900 unless diabetes mellitus is officially diagnosed.
- Incomplete Documentation: Avoid coding I2900 unless there is clear documentation in the medical record confirming active diabetes management.
Illustration 4:
- Scenario: A resident has elevated blood glucose levels due to an infection but does not have a diagnosis of diabetes.
- Error: Do not code I2900 for hyperglycemia without an official diagnosis of diabetes mellitus.
7. Practical Application
- Example 1: A resident with Type 2 diabetes managed with oral hypoglycemics has active monitoring and medication during the look-back period. I2900 is coded "Yes".
- Example 2: A resident does not have a diagnosis of diabetes but has temporary hyperglycemia during a hospital stay. I2900 is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set I2900 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.
