Step-by-Step Coding Guide for Item Set I8000A: Additional Active ICD Diagnosis 1

1. Review of Medical Records

The initial step in coding for item I8000A, Additional Active ICD Diagnosis 1, involves a thorough review of the resident’s medical records. This includes:

• Physician’s Notes: Examine progress notes, the most recent history, and physical examination records.
• Diagnosis Lists: Verify the diagnosis/problem list for documented diagnoses confirmed by the physician.
• Discharge Summaries and Transfer Documents: Review summaries from hospital discharges or transfers to the current care setting.
• Interdisciplinary Notes: Check notes from nursing, dietary, rehabilitation, and other care team members.

2. Understanding Definitions

It is essential to understand the key definitions related to active diagnoses:

• Active Diagnosis: A condition that has a direct relationship to the resident’s current functional, cognitive, mood, or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.
• Inactive Diagnosis: Conditions that have been resolved, do not affect the resident’s current status, or do not drive the resident’s plan of care during the look-back period.

3. Coding Instructions

Follow these steps for accurate coding:

1. Identify Diagnoses: Confirm that the diagnoses have been documented by a physician or other authorized healthcare provider within the last 60 days.
2. Determine Activity: Establish whether the diagnoses are active, meaning they affect the resident's current care or require monitoring during the 7-day look-back period.
3. Enter ICD Codes: Document the ICD-10 code for each active diagnosis in the I8000 section, ensuring proper alignment and format in the MDS form.

4. Coding Tips

• Specific Documentation: Look for specific mentions in the medical record that indicate a condition is active. This includes recent treatment changes, symptoms, or monitoring requirements.
• Therapeutic Monitoring: Medications prescribed to manage conditions that require monitoring should be considered as indicative of active diagnoses.
• Avoid Ambiguities: Ensure that the diagnosis is not just listed in the problem list but is actively managed and documented within the look-back period.

5. Documentation

Accurate documentation is critical for compliance and effective care planning:

• Daily Records: Maintain thorough daily records of the resident’s condition and any changes.
• Care Plans: Update care plans to reflect active diagnoses and corresponding interventions.
• Interdisciplinary Communication: Ensure all team members are informed of and document any active diagnoses and their impact on care.

6. Common Errors to Avoid

• Inconsistent Documentation: Avoid discrepancies between the MDS data and other medical records.
• Outdated Diagnoses: Do not code diagnoses that are no longer active or relevant to the resident’s current care.
• Incorrect ICD Codes: Ensure ICD codes are accurate and properly aligned in the MDS form.

7. Practical Application

Use case studies and scenarios to apply your knowledge:

• Example 1: A resident with hypertension controlled by medication. Regular blood pressure monitoring is necessary, thus making hypertension an active diagnosis.
  • Coding: Enter the ICD-10 code for hypertension in the I8000A section.
• Example 2: A resident recovering from a recent stroke with ongoing physical therapy and medication management.
  • Coding: Enter the ICD-10 code for the specific type of stroke in the I8000A section.

Please note that the information provided in this guide for MDS 3.0 Item set I8000A   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.