Step-by-Step Coding Guide for Item Set I6300: Respiratory Failure

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s diagnosis of respiratory failure.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, discharge summaries, and diagnostic test results.
  2. Identify Diagnoses: Look for documented instances of respiratory failure.
  3. Confirm Diagnosis: Verify the diagnosis of respiratory failure through consistent documentation and diagnostic evidence.

2. Understanding Definitions

• Respiratory Failure: A condition where the respiratory system fails in oxygenating the blood and/or removing carbon dioxide. It can be classified into acute or chronic.
• Key Points:
  • Acute Respiratory Failure: A sudden and severe onset of respiratory dysfunction.
  • Chronic Respiratory Failure: A long-term condition where the respiratory system gradually fails over time.

3. Coding Instructions

• Steps:
  1. Identify Respiratory Failure: Confirm that the resident has been diagnosed with respiratory failure from the medical records.
  2. Verify Documentation: Ensure the diagnosis is clearly documented by a physician and supported by diagnostic test results such as arterial blood gases (ABG) or pulse oximetry.
  3. Code Appropriately: Code I6300 as "1" if the resident has a documented diagnosis of respiratory failure, and "0" if they do not.

4. Coding Tips

• Accurate Identification: Ensure the diagnosis specifically mentions respiratory failure.
• Consistent Terminology: Use consistent terminology when documenting and coding respiratory failure.
• Consult Physicians: If there is any uncertainty, consult with the attending physician or specialist for clarification.

5. Documentation

• Required:
  • Physician Notes: Documented diagnosis of respiratory failure by a physician.
  • Diagnostic Test Results: Include results from tests such as ABG, chest X-rays, or pulse oximetry that support the diagnosis.
  • Medical History: Ensure the resident’s medical history includes any relevant information about respiratory conditions or treatments.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the diagnosis of respiratory failure.
• Incomplete Documentation: Make sure all relevant diagnostic tests and physician notes are included.
• Assumptions: Do not assume the presence of respiratory failure without proper documentation.

7. Practical Application

• Example:
  • Resident Profile: John, a 75-year-old resident, has a documented history of chronic obstructive pulmonary disease (COPD) and recent episodes of acute respiratory failure.
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, including physician notes and recent ABG results.
    2. Identify Diagnosis: It is confirmed that John has a documented diagnosis of acute respiratory failure.
    3. Document and Code: The nurse documents the diagnosis in John’s records and codes I6300 as "1".
  • Outcome: John’s diagnosis of respiratory failure 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 I6300 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.