Step-by-Step Coding Guide for Item Set I8000B: Additional Active ICD Diagnosis 2

1. Review of Medical Records

• Objective: Accurately determine and document the resident's second additional active ICD diagnosis.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, diagnostic reports, previous assessments, and hospital discharge summaries.
  2. Identify Documentation of Diagnoses: Look for documented instances of active diagnoses, focusing on the second additional active ICD diagnosis.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• ICD Diagnosis: Refers to the diagnosis coded according to the International Classification of Diseases (ICD) standards.
• Additional Active Diagnosis: A diagnosis that is currently being treated or managed in addition to the primary diagnosis.
• Key Points:
  • Active Diagnosis: Conditions that require ongoing treatment or management.
  • ICD Codes: Standardized codes used for classifying diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the resident’s second additional active ICD diagnosis.
  2. Verify Documentation: Ensure that the diagnosis is clearly noted and consistent across all records.
  3. Code Appropriately: Enter the appropriate ICD code for item set I8000B:
     • Use the ICD-10 code that corresponds to the documented diagnosis.
     • Ensure the code is up-to-date and accurate according to the latest ICD-10 coding standards.

4. Coding Tips

• Accurate Identification: Ensure the second additional active diagnosis is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the diagnosis.
• Cross-Check: Double-check the ICD codes for accuracy and ensure they match the documented diagnosis in the medical records.

5. Documentation

• Required:
  • Physician Notes: Detailed notes from physicians documenting the diagnosis and treatment plans.
  • Diagnostic Reports: Reports from diagnostic tests that support the diagnosis.
  • Previous Assessments: Any previous assessments that have documented the additional active diagnosis.
  • Hospital Discharge Summaries: Summaries from hospital discharges that include the diagnosis.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the second additional active diagnosis through multiple records and notes.
• Incomplete Documentation: Make sure all relevant physician notes, diagnostic reports, and hospital discharge summaries are included to support the documented diagnosis.
• Incorrect ICD Codes: Do not use outdated or incorrect ICD codes; always verify the current ICD-10 code for the diagnosis.

7. Practical Application

• Example:
  • Resident Profile: Anna, a 68-year-old resident, has hypertension as her primary diagnosis and diabetes mellitus as her second additional active diagnosis.
  • Steps:
    1. Review Records: The nurse reviews Anna’s medical records, noting the physician’s notes and diagnostic reports documenting her diabetes.
    2. Identify Diagnosis: It is confirmed through the documentation that diabetes mellitus is an active diagnosis requiring ongoing management.
    3. Document and Code: The nurse documents the second additional active diagnosis in Anna’s records and codes I8000B with the appropriate ICD-10 code for diabetes mellitus (e.g., E11.9 for Type 2 diabetes mellitus without complications).
  • Outcome: Anna’s second additional active diagnosis 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 I8000B 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.