I5800: Depression (Other than Bipolar), Step-by-Step
Step-by-Step Coding Guide for Item Set I5800: Depression (Other than Bipolar)
Step-by-Step Coding Guide for Item Set I5800: Depression (Other than Bipolar)
1. Review of Medical Records
- Objective: Gather accurate information regarding the resident’s diagnosis of depression (other than bipolar).
- Steps:
- Collect Information: Review the resident’s comprehensive medical records, including physician notes, psychiatric evaluations, and previous assessments.
- Identify Diagnoses: Look for documented instances of depression, excluding bipolar disorder.
- Confirm Diagnosis: Verify the diagnosis of depression through consistent documentation and diagnostic evidence.
2. Understanding Definitions
- Depression (Other than Bipolar): A mood disorder characterized by persistent feelings of sadness, loss of interest, and other emotional and physical symptoms. This excludes any diagnosis of bipolar disorder.
- Key Points:
- Diagnostic Criteria: Typically diagnosed based on criteria outlined in the DSM-5, including symptoms such as depressed mood, loss of interest or pleasure, significant weight change, sleep disturbances, and others.
- Excludes Bipolar Disorder: Ensure the diagnosis is specifically depression and not related to bipolar disorder, which involves alternating periods of depression and mania/hypomania.
3. Coding Instructions
- Steps:
- Identify Depression: Confirm that the resident has been diagnosed with depression (other than bipolar) from the medical records.
- Verify Documentation: Ensure the diagnosis is clearly documented by a physician and supported by psychiatric evaluations or assessments.
- Code Appropriately: Code I5800 as "1" if the resident has a documented diagnosis of depression (other than bipolar), and "0" if they do not.
4. Coding Tips
- Accurate Identification: Ensure the diagnosis specifically mentions depression and excludes any form of bipolar disorder.
- Consistent Terminology: Use consistent terminology when documenting and coding depression.
- Consult Physicians: If there is any uncertainty, consult with the attending physician or psychiatrist for clarification.
5. Documentation
- Required:
- Physician Notes: Documented diagnosis of depression by a physician or psychiatrist.
- Psychiatric Evaluations: Include results from evaluations or assessments that support the diagnosis.
- Medical History: Ensure the resident’s medical history includes any relevant information about depression or related treatments.
6. Common Errors to Avoid
- Misclassification: Ensure accurate classification by verifying the diagnosis of depression and excluding bipolar disorder.
- Incomplete Documentation: Make sure all relevant psychiatric evaluations and physician notes are included.
- Assumptions: Do not assume the presence of depression without proper documentation.
7. Practical Application
- Example:
- Resident Profile: Sarah, a 70-year-old resident, has been diagnosed with major depressive disorder.
- Steps:
- Review Records: The nurse reviews Sarah’s medical records, including physician notes and psychiatric evaluations.
- Identify Diagnosis: It is confirmed that Sarah has a documented diagnosis of major depressive disorder, excluding any bipolar disorder.
- Document and Code: The nurse documents the diagnosis in Sarah’s records and codes I5800 as "1".
- Outcome: Sarah’s diagnosis of depression 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 I5800 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.
