Step-by-Step Coding Guide for Item Set I8000E: Additional Active ICD Diagnosis 5

1. Review of Medical Records

• Objective: To identify and confirm an additional active ICD diagnosis for the resident.
• Steps:
  1. Collect Records: Gather all relevant medical records, including physician notes, diagnostic test results, hospital discharge summaries, and previous assessments.
  2. Identify Diagnoses: Look for any documented diagnoses that have been treated or are currently being managed.
  3. Verify Information: Cross-check the identified diagnoses across different sources to ensure accuracy and consistency.

2. Understanding Definitions

• Additional Active ICD Diagnosis: An active diagnosis is one that has a significant impact on the resident's health and well-being, requiring ongoing treatment or monitoring. ICD (International Classification of Diseases) codes are used to classify and code all diagnoses, symptoms, and procedures.

3. Coding Instructions

• Steps:
  1. Locate Item Set: Find item set I8000E on the MDS form.
  2. Confirm Diagnosis: Ensure the additional active diagnosis is documented and verified in the resident's medical records.
  3. Determine ICD Code: Identify the appropriate ICD-10 code for the confirmed diagnosis.
  4. Code the Item:
     • Enter ICD Code: Input the ICD-10 code in the field for I8000E.
  5. Complete Entry: Double-check the entry for accuracy and completeness.

4. Coding Tips

• Accurate ICD Codes: Use the most current ICD-10 codes for the diagnosis. Refer to the ICD-10-CM manual or an updated coding software.
• Consistency: Ensure the diagnosis and corresponding ICD code are consistently documented across all relevant medical records.
• Documentation: Make sure the diagnosis has been assessed and documented by a qualified healthcare professional.

5. Documentation

• Required:
  • MDS Form: Correctly filled entry for item set I8000E indicating the ICD-10 code for the additional active diagnosis.
  • Physician Notes: Documentation from physicians confirming the diagnosis.
  • Diagnostic Tests: Results of any tests or imaging studies that support the diagnosis.
  • Hospital Discharge Summaries: Records from any hospitalizations that mention the diagnosis.
  • Progress Notes: Ongoing documentation of the resident’s condition and management of the diagnosis.

6. Common Errors to Avoid

• Incorrect Coding: Avoid using outdated or incorrect ICD-10 codes.
• Inconsistent Records: Ensure all records consistently reflect the diagnosis and corresponding ICD code.
• Lack of Documentation: Do not code a diagnosis if it is not adequately documented in the medical records.

7. Practical Application

• Example:
  • Resident Background: Ms. Jane Doe has a documented diagnosis of chronic obstructive pulmonary disease (COPD) which requires ongoing treatment and monitoring.
  • Review Process: Access Ms. Doe’s medical records, including physician notes, diagnostic test results, and hospital discharge summaries.
  • Verification: Confirm the diagnosis of COPD through multiple sources.
  • Coding Process:
    • Step 1: Locate item set I8000E on the MDS form.
    • Step 2: Confirm the presence of COPD in the documentation.
    • Step 3: Identify the ICD-10 code for COPD (e.g., J44.9).
    • Step 4: Enter the code "J44.9" in the field for I8000E.
    • Step 5: Verify the entered code with the documentation.
  • Illustration:
    • Provide a sample MDS form showing item set I8000E with the correct ICD-10 code entered.
    • Include an example of a physician’s note confirming the diagnosis of COPD.

Please note that the information provided in this guide for MDS 3.0 Item set I8000E 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.