I0020: Indicate the Residents Primary Medical Condition Category, Step-by-Step

Step-by-Step Coding Guide for I0020: Indicate the Resident’s Primary Medical Condition Category

1. Review of Medical Records

Objective: Identify the primary medical condition category that best describes the resident’s main diagnosis or reason for admission to the facility.

Actions:

• Access the resident’s medical records, including admission documentation, hospital discharge summaries, physician progress notes, and care plans.
• Identify the condition that is primarily responsible for the resident’s need for nursing care or rehabilitation, as recorded by the attending physician.

2. Understanding Definitions

I0020: Resident’s Primary Medical Condition Category: This item captures the main reason for the resident’s admission to the long-term care facility. It should reflect the diagnosis or condition that most significantly affects the resident’s care and treatments.

Primary Medical Condition Categories:

• 01: Stroke (Cerebrovascular Accident [CVA], Transient Ischemic Attack [TIA], Hemiplegia)
• 02: Non-Traumatic Brain Dysfunction (e.g., Alzheimer's, Parkinson’s)
• 03: Traumatic Brain Dysfunction (e.g., Brain Injury)
• 04: Non-Traumatic Spinal Cord Dysfunction (e.g., Spinal Cord Lesion)
• 05: Traumatic Spinal Cord Dysfunction
• 06: Progressive Neurological Conditions (e.g., ALS, MS)
• 07: Other Neurological Conditions
• 08: Amputation
• 09: Hip and Other Fractures
• 10: Other Orthopedic Conditions
• 11: Cardiac Conditions and Circulatory Disorders
• 12: Pulmonary Disorders
• 13: Other Medical Conditions
• 14: Cancer (Active, newly diagnosed, or requiring treatment)

Illustration 1:

• Scenario: A resident is admitted following a hip fracture requiring rehabilitation.
• Result: I0020 is coded as 09: Hip and Other Fractures.

3. Coding Instructions

Step-by-Step:

• Step 1: Review the medical records to determine the main reason for the resident’s admission or the primary condition affecting their care.
• Step 2: Identify the medical condition that has the most significant impact on the resident’s current health status and care needs.
• Step 3: Select the appropriate primary medical condition category from the list (01–14) and code it accordingly in I0020.
• Step 4: If the resident has more than one condition, code the condition that requires the most care or represents the primary reason for admission.

Illustration 2:

• Scenario: A resident is admitted primarily for rehabilitation after a stroke that caused significant functional impairment.
• Result: I0020 is coded as 01: Stroke.

4. Coding Tips

• Focus on the Primary Condition: Ensure that the selected condition reflects the main reason the resident is in the facility, even if they have multiple diagnoses.
• Avoid Coding Acute, Resolved Conditions: Do not code conditions that were resolved prior to admission or those that are no longer actively affecting the resident’s care needs.

5. Documentation

Objective: Ensure the primary medical condition category is clearly documented and aligns with the resident’s care plan and diagnosis.

Actions:

• Document the primary condition in the resident’s care plan, physician orders, and assessments.
• Ensure that the condition selected in I0020 is consistent with the resident’s primary diagnosis as documented in their medical history.

Illustration 3:

• Scenario: A resident with Alzheimer's disease is primarily admitted for cognitive decline and care management.
• Documentation: The primary diagnosis of Alzheimer’s should be documented in the care plan, and I0020 is coded as 02: Non-Traumatic Brain Dysfunction.

6. Common Errors to Avoid

• Misclassifying Secondary Conditions: Ensure that the coded condition reflects the primary reason for admission, not a secondary condition that is being managed.
• Incomplete Documentation: Do not code I0020 without clear documentation of the primary condition in the resident’s medical record.

Illustration 4:

• Scenario: A resident is admitted for rehabilitation following a hip fracture but also has a history of diabetes. The primary reason for admission is the fracture, not diabetes.
• Error: Do not code diabetes as the primary condition. Instead, code 09: Hip and Other Fractures.

7. Practical Application

• Example 1: A resident with chronic obstructive pulmonary disease (COPD) is admitted due to respiratory decline. I0020 is coded as 12: Pulmonary Disorders.
• Example 2: A resident with Alzheimer's disease is admitted primarily for cognitive support. I0020 is coded as 02: Non-Traumatic Brain Dysfunction.

Please note that the information provided in this guide for MDS 3.0 Item set I0020 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.