I3700: Arthritis, Step-by-Step

Step-by-Step Coding Guide for Item Set I3700: Arthritis

1. Review of Medical Records

• Objective: To verify the presence of a documented diagnosis of arthritis.
• Process:
  • Examine the resident's medical history and current diagnoses listed in the medical records.
  • Review physician's notes and orders for any mention of arthritis and related treatments.
  • Check medication administration records for medications commonly used to treat arthritis.

2. Understanding Definitions

• Arthritis: A condition causing inflammation of the joints, which may result in pain, swelling, stiffness, and limited movement. This encompasses various forms such as osteoarthritis, rheumatoid arthritis, and other inflammatory joint conditions.

3. Coding Instructions

• Code I3700:
  • 0: No — if there is no medical diagnosis of arthritis.
  • 1: Yes — if there is a medical diagnosis of arthritis.
• Example: If a resident has a documented diagnosis of rheumatoid arthritis in their medical record, code I3700 as '1'.

4. Coding Tips

• Ensure that the diagnosis is current and actively being managed.
• Distinguish arthritis from other musculoskeletal disorders based on diagnosis and treatment.

5. Documentation

• Required Documentation:
  • A clear medical diagnosis of arthritis, noted in the resident's health records.
  • Documentation of any clinical assessments that support the diagnosis.
  • Notes on the management or treatment plan for arthritis.
• Documentation should clearly confirm the arthritis diagnosis and ongoing management.

6. Common Errors to Avoid

• Coding arthritis without a formal diagnosis by a healthcare provider.
• Confusing symptoms or treatments of other conditions with those of arthritis.
• Overlooking updates in the medical record that might change the diagnosis status.

7. Practical Application

• Scenario: A resident who was previously diagnosed with osteoarthritis complains of increased joint pain and stiffness during her annual review. The healthcare provider reviews her symptoms and confirms the ongoing presence of osteoarthritis, adjusting her treatment plan to include a new anti-inflammatory medication. This diagnosis and treatment adjustment are documented clearly in her medical records. The MDS coordinator then accurately codes I3700 as '1' to reflect this diagnosed and treated condition.

Please note that the information provided in this guide for MDS 3.0 Item set I3700 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.