Step-by-Step Coding Guide for Item Set I5350: Tourette's Syndrome

1. Review of Medical Records

• Objective: Accurately determine and document the diagnosis of Tourette's syndrome in a resident.
• Steps:
  1. Collect Information: Gather comprehensive medical records, including physician notes, neurology assessments, psychological evaluations, and previous diagnoses.
  2. Identify Documentation of Tourette's Syndrome: Look for documented instances where Tourette's syndrome is diagnosed or mentioned in the resident's medical records.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Tourette's Syndrome: A neurological disorder characterized by repetitive, involuntary movements and vocalizations called tics.
• Key Points:
  • Motor Tics: Sudden, brief, repetitive movements, such as blinking or shoulder shrugging.
  • Vocal Tics: Involuntary sounds or words, such as grunting or repeating phrases.
  • Diagnosis: Typically involves clinical evaluation, patient history, and sometimes neuroimaging or other diagnostic tests.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the diagnosis of Tourette's syndrome, supported by physician notes and neurological evaluations.
  2. Verify Documentation: Ensure that the diagnosis is clearly noted in the records, including details of the symptoms and any diagnostic confirmations.
  3. Code Appropriately: Enter the appropriate code for item set I5350:
     • 0: No, the resident does not have Tourette's syndrome.
     • 1: Yes, the resident has Tourette's syndrome.

4. Coding Tips

• Accurate Identification: Ensure the diagnosis of Tourette's syndrome is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the diagnosis.
• Clarify with the Interdisciplinary Team: If there is any uncertainty, clarify with the interdisciplinary team to ensure accurate coding.

5. Documentation

• Required:
  • Physician Notes: Detailed notes from physicians documenting the diagnosis and treatment of Tourette's syndrome.
  • Neurology Assessments: Assessments from neurologists detailing the clinical evaluation of the resident.
  • Psychological Evaluations: Reports from psychologists or psychiatrists documenting the diagnosis and impact of Tourette's syndrome.
  • Previous Diagnoses: Any previous medical records that have documented the diagnosis of Tourette's syndrome.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the diagnosis through multiple records and notes.
• Incomplete Documentation: Make sure all relevant physician notes, neurology assessments, and psychological evaluations are included to support the documented diagnosis.
• Assumptions: Do not assume the diagnosis of Tourette's syndrome without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: John, a 25-year-old resident, has a history of motor and vocal tics and was previously diagnosed with Tourette's syndrome.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, noting the physician’s diagnosis and neurology assessment confirming Tourette's syndrome.
    2. Identify Diagnosis: It is confirmed through the documentation that John has Tourette's syndrome.
    3. Document and Code: The nurse documents the diagnosis in John’s records and codes I5350 as "1".
  • Outcome: John’s diagnosis of Tourette's syndrome 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 I5350 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.