Step-by-Step Coding Guide for Item Set I8000C: Additional Active ICD Diagnosis 3

1. Review of Medical Records

• Objective: To identify and verify the third additional active ICD diagnosis for the resident.
• Process:
  • Review the resident’s complete medical history for any chronic and acute conditions that have been diagnosed.
  • Examine recent physician's notes, hospital discharge summaries, and consultation reports for any updated diagnoses.
  • Check the current medication list and treatment plans that might correlate with active ICD diagnoses.

2. Understanding Definitions

• Additional Active ICD Diagnosis: Refers to any diagnosable health condition that is currently affecting the resident and is not listed as one of the primary or secondary diagnoses. This should be a condition that requires active management, monitoring, or treatment.

3. Coding Instructions

• Code I8000C:
  • Enter the appropriate ICD-10 code for the third most significant condition that is actively being treated or monitored.
• Example: If the resident has a primary diagnosis of diabetes (E11.9) and secondary hypertension (I10), but also suffers from chronic obstructive pulmonary disease (COPD) which is actively managed, enter the ICD-10 code for COPD (e.g., J44.9) in I8000C.

4. Coding Tips

• Ensure accuracy by cross-referencing the ICD-10 code with the latest ICD-10 updates to avoid using outdated or incorrect codes.
• Prioritize conditions based on their impact on the resident’s current health and care plan.

5. Documentation

• Required Documentation:
  • Documented diagnosis from a qualified healthcare provider, found in the medical records.
  • Evidence of ongoing treatment or management of the condition, such as medication administration records or therapy notes.
  • Recent clinical assessments or lab results supporting the active status of the condition.
• Documentation should be clear, current, and specific to the diagnosis and its management.

6. Common Errors to Avoid

• Coding a condition that is no longer active or significantly impacting the resident’s current health.
• Failing to update the ICD codes and resident’s health status in the MDS as changes occur.
• Misplacing the priority of conditions, thus misrepresenting the resident's health status and care needs.

7. Practical Application

• Scenario: During an annual review of a resident's health status, it is noted that aside from the primary management of diabetes and hypertension, the resident’s COPD has exacerbated and required additional interventions, including increased medication and regular nebulizer treatments. These changes are thoroughly documented, including the adjustment in therapy and the direct orders from the resident's pulmonologist. For the MDS update, I8000C is accurately coded with J44.9, reflecting COPD as an additional active diagnosis that significantly impacts the resident's care.

Please note that the information provided in this guide for MDS 3.0 Item set I8000C 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.