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I: Active Diagnoses in the Last 7 Days, Step-by-Step

Section I. Active Diagnoses

Step-by-step Coding Guide For I: Active Diagnoses in the Last 7 Days.

1. Review of Medical Records

  • Purpose: To identify and code all active diagnoses that affect the resident's functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the last 7 days.
  • Process: Thoroughly review the resident's medical record, including physician's notes, nursing notes, and other relevant documentation to identify all diagnoses meeting these criteria.

2. Understanding Definitions

  • Active Diagnoses: Conditions that are actively being treated, monitored, or affect the resident's functional or cognitive status. This includes conditions that impact mood or behavior, require therapeutic interventions, or necessitate nursing monitoring or risk of death.

3. Coding Instructions

  • For each condition listed in Section I, determine if it has been present and received active intervention, monitoring, or treatment in the last 7 days.
  • Code "1" if the condition is active as defined.
  • Code "0" if the condition is not active according to the definitions provided.

4. Coding Tips

  • Review interdisciplinary notes for comprehensive understanding.
  • Verify active status by confirming recent treatments or interventions.
  • Clarify ambiguous or unclear documentation with relevant healthcare professionals.

5. Documentation

  • Clearly document in the medical record the rationale for coding a diagnosis as active.
  • Include evidence of treatment, monitoring, or the condition's impact on the resident's status.

6. Common Errors to Avoid

  • Overlooking diagnoses that may not have prominent interventions but significantly affect the resident's care (e.g., a controlled condition that influences dietary or activity recommendations).
  • Failing to review the entire 7-day look-back period.
  • Misinterpreting "active" status by not considering conditions that impact functional or cognitive status.

7. Practical Application

  • Example 1: A resident with Type II Diabetes Mellitus receiving daily insulin injections and dietary monitoring should have this condition coded as "1" for active.
  • Example 2: A resident with a history of stroke affecting left-side mobility, requiring physical therapy, and special equipment for daily activities should also be coded as "1" for active, given its impact on functional status.

 

 

The Step-by-Step Coding Guide for item I in MDS 3.0 Section I is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Please note that healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field. 

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MDS 3.0 Manual Version 1.18.11
Step-by-Step Coding Guide & SECTION I ACTIVE DIAGNOSIS
October 2023
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Section I. Active Diagnoses

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