Step-by-Step Coding Guide for Item Set I3900: Hip Fracture

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s diagnosis of a hip fracture.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, nursing notes, radiology reports, discharge summaries, and previous assessments.
  2. Identify Hip Fracture Documentation: Look for documented instances of a hip fracture, such as physician diagnoses, imaging reports, and surgical notes.
  3. Confirm Details: Verify the consistency and accuracy of the hip fracture documentation through various sources within the medical records.

2. Understanding Definitions

• Hip Fracture: A break in the upper quarter of the femur (thigh) bone. Hip fractures can occur at different locations on the femur, including the femoral neck, intertrochanteric region, and subtrochanteric region.
• Key Points:
  • Hip fractures are typically confirmed through radiological imaging, such as X-rays or MRI.
  • Symptoms can include severe pain in the hip or groin, inability to move immediately after a fall, and swelling or bruising around the hip area.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm that the resident has been diagnosed with a hip fracture based on medical records.
  2. Verify Documentation: Ensure the diagnosis of hip fracture is clearly documented in the resident’s records, including imaging reports and physician notes.
  3. Code Appropriately: Code I3900 as "1" if the resident has documented evidence of a hip fracture, and "0" if they do not.

4. Coding Tips

• Accurate Identification: Ensure the diagnosis specifically mentions a hip fracture and is supported by radiological imaging.
• Consistent Terminology: Use consistent terminology when documenting and coding the resident’s hip fracture.
• Consult Physicians: If there is any uncertainty, consult with the attending physician or radiologist for clarification.

5. Documentation

• Required:
  • Physician Notes: Documented diagnosis of hip fracture by a physician.
  • Radiology Reports: Include imaging reports confirming the presence of a hip fracture.
  • Nursing Notes: Include observations from nursing staff detailing signs and symptoms of the hip fracture and the resident’s condition.
  • Surgical Notes: If applicable, document any surgical interventions related to the hip fracture.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the diagnosis of hip fracture through multiple records and imaging reports.
• Incomplete Documentation: Make sure all relevant imaging reports, physician notes, and nursing observations are included.
• Assumptions: Do not assume the presence of a hip fracture without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: John, a 75-year-old resident, fell and was subsequently diagnosed with a hip fracture.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, including the physician notes and radiology reports that confirm the hip fracture.
    2. Identify Fracture: It is confirmed that John’s hip fracture is documented in the records with supporting imaging reports.
    3. Document and Code: The nurse documents the diagnosis in John’s records and codes I3900 as "1".
  • Outcome: John’s hip fracture 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 I3900 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.