Step-by-Step Coding Guide for Item Set I5000: Paraplegia

1. Review of Medical Records

• Objective: Collect comprehensive data regarding the resident’s diagnosis of paraplegia.
• Steps:
  1. Gather Medical Records: Collect all relevant medical records including physician notes, hospital discharge summaries, and diagnostic test results.
  2. Identify Diagnosis: Locate documentation that confirms the diagnosis of paraplegia.
  3. Verify Consistency: Ensure the diagnosis is consistently documented across all medical records.

2. Understanding Definitions

• Paraplegia: A condition characterized by paralysis affecting the lower half of the body, typically resulting from spinal cord injury or disease.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set I5000 on the MDS form.
  2. Confirm Diagnosis: Ensure the diagnosis of paraplegia is clearly documented in the medical records.
  3. Code the Item:
     • 1: Yes, if paraplegia is present and documented.
     • 0: No, if paraplegia is not present or not documented.
  4. Complete Entry: Double-check the entry for accuracy and completeness.

4. Coding Tips

• Detailed Documentation: Ensure that the diagnosis of paraplegia is clearly documented with supporting evidence such as diagnostic tests and physician notes.
• Consistency: Verify that the diagnosis is consistently mentioned in various sections of the medical records.
• Clarification: If the diagnosis is unclear, consult with the resident’s physician for confirmation.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set I5000 indicating the presence or absence of paraplegia.
  • Physician Notes: Detailed notes from the physician confirming the diagnosis of paraplegia.
  • Hospital Discharge Summaries: Summaries that include the diagnosis of paraplegia.
  • Diagnostic Test Results: Any relevant test results that support the diagnosis.

6. Common Errors to Avoid

• Incomplete Documentation: Avoid coding this item if there is no clear documentation of paraplegia in the medical records.
• Inconsistent Records: Ensure all sources of documentation consistently reflect the diagnosis.
• Assumptions: Do not code based on assumptions; always rely on documented evidence.

7. Practical Application

• Example:
  • Resident Background: Mrs. Jane Doe has a documented diagnosis of paraplegia due to a spinal cord injury, as noted in her hospital discharge summary and confirmed by her physician.
  • Review Process: Access Mrs. Doe’s medical records, including physician notes, hospital discharge summaries, and diagnostic test results.
  • Verification: Confirm the diagnosis of paraplegia through multiple documented sources.
  • Coding Process:
    • Step 1: Locate item set I5000 on the MDS form.
    • Step 2: Confirm the presence of documented paraplegia.
    • Step 3: Enter the code “1” for yes if paraplegia is documented.
    • Step 4: Verify the entry with the documentation.
  • Illustration:
    • Provide a sample MDS form showing item set I5000 with the correct code entered.
    • Include an example of a physician note documenting the diagnosis of paraplegia.

Please note that the information provided in this guide for MDS 3.0 Item set I5000 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.