Step-by-Step Coding Guide for Item Set I7900: None of Above Active Diagnoses within Last 7 Days

1. Review of Medical Records

• Objective: Collect and review all relevant medical records to determine if any of the listed diagnoses have been active within the last 7 days.
• Steps:
  1. Obtain Records: Gather the resident's medical records, including recent assessments, physician notes, and progress notes.
  2. Identify Diagnoses: Check for any documentation of the listed diagnoses being active within the last 7 days.
  3. Verify Dates: Ensure that the diagnoses listed were not active within the specific 7-day period.

2. Understanding Definitions

• None of Above Active Diagnoses: This refers to the confirmation that none of the listed diagnoses were active for the resident within the last 7 days.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set I7900 on the MDS form.
  2. Confirm Absence: Verify that none of the listed diagnoses were active within the last 7 days through a thorough review of the medical records.
  3. Code the Item:
     • 0: No, if one or more of the listed diagnoses were active within the last 7 days.
     • 1: Yes, if none of the listed diagnoses were active within the last 7 days.
  4. Complete Entry: Double-check the entry for accuracy and completeness.

4. Coding Tips

• Thorough Review: Ensure that you have thoroughly reviewed all relevant medical records to confirm the absence of the listed diagnoses.
• Documentation Clarity: Make sure the documentation clearly indicates the activity status of the diagnoses within the last 7 days.
• Consult with Providers: If there is any uncertainty, consult with healthcare providers to confirm the status of the diagnoses.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set I7900 indicating whether none of the listed diagnoses were active within the last 7 days.
  • Medical Records: Detailed review of the resident’s medical records, including recent assessments and progress notes.
  • Provider Confirmation: Notes from consultations with healthcare providers if necessary.

6. Common Errors to Avoid

• Incomplete Review: Avoid coding this item without a thorough review of all relevant medical records.
• Inconsistent Documentation: Ensure that the documentation consistently reflects the absence of the listed diagnoses within the last 7 days.
• Incorrect Coding: Do not code based on assumptions; always rely on documented evidence.

7. Practical Application

• Example:
  • Resident Background: Mr. John Doe has no active diagnoses listed within the last 7 days.
  • Review Process: Access Mr. Doe’s medical records, including recent assessments and progress notes.
  • Verification: Confirm the absence of listed diagnoses through a detailed review of the documentation.
  • Coding Process:
    • Step 1: Locate item set I7900 on the MDS form.
    • Step 2: Verify that none of the listed diagnoses were active within the last 7 days.
    • Step 3: Enter the code “1” for yes, indicating that none of the listed diagnoses were active.
    • Step 4: Verify the entry with the documentation.
  • Illustration:
    • Provide a sample MDS form showing item set I7900 with the correct code entered.
    • Include an example of a medical record note indicating the absence of active diagnoses within the last 7 days.

Please note that the information provided in this guide for MDS 3.0 Item set I7900 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.