Step-by-Step Coding Guide for Item Set I8000H: Additional Active ICD Diagnosis 8

1. Review of Medical Records

• Objective: Accurately determine and document the resident's additional active ICD-10 diagnosis.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including physician notes, diagnostic reports, laboratory results, and previous assessments.
  2. Identify Documentation of Diagnoses: Look for documented diagnoses that are active and relevant to the resident’s current care.
  3. Confirm Details: Verify the consistency and accuracy of the diagnosis documentation across various sources within the medical records.

2. Understanding Definitions

• Additional Active ICD Diagnosis: Refers to any additional active medical condition that the resident is currently being treated for or monitored.
• ICD-10 Code: The International Classification of Diseases, 10th Revision, is used to code and classify morbidity data from inpatient and outpatient records, physician offices, and most National Center for Health Statistics (NCHS) surveys.
• Key Points:
  • Active Diagnosis: A condition that is currently being treated or monitored during the assessment period.
  • ICD-10 Code: Specific alphanumeric codes used to represent diagnoses and health conditions.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the presence of additional active diagnoses.
  2. Verify Documentation: Ensure that the diagnosis is clearly noted in the records and is active during the assessment period.
  3. Code Appropriately: Enter the ICD-10 code for the additional active diagnosis in item set I8000H. Only active diagnoses should be coded in this section.

4. Coding Tips

• Accurate Identification: Ensure the additional active diagnosis is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and correct ICD-10 codes when documenting and coding the diagnosis.
• Consultation: If there is any uncertainty regarding the diagnosis, consult with the resident’s healthcare provider for clarification.

5. Documentation

• Required:
  • Physician Notes: Detailed notes from physicians documenting the diagnosis and the active treatment or monitoring.
  • Diagnostic Reports: Reports from diagnostic tests that confirm the diagnosis.
  • Laboratory Results: Lab reports that support the diagnosis.
  • Previous Assessments: Any previous assessments that have documented the resident’s additional active diagnosis.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the diagnosis details through multiple records and notes.
• Incomplete Documentation: Make sure all relevant physician notes, diagnostic reports, and laboratory results are included to support the diagnosis.
• Assumptions: Do not assume a diagnosis is active without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: John, a 75-year-old resident, has an additional active diagnosis of chronic obstructive pulmonary disease (COPD).
  • Steps:
    1. Review Records: The nurse reviews John’s medical records, noting the physician notes, diagnostic reports, and lab results documenting the COPD diagnosis.
    2. Identify Diagnosis: It is confirmed through the documentation that John’s COPD is an active diagnosis.
    3. Document and Code: The nurse documents the details of John’s COPD in his records and codes the ICD-10 code for COPD (J44.9) in I8000H.
  • Outcome: John’s additional active diagnosis of COPD 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 I8000H 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.