I1500: Renal insufficiency, renal failure, ESRD, Step-by-Step

Step-by-Step Coding Guide for Item Set I1500: Renal Insufficiency, Renal Failure, ESRD

1. Review of Medical Records

• Objective: To determine if the resident has a diagnosis of renal insufficiency, renal failure, or end-stage renal disease (ESRD).
• Process:
  • Diagnosis Records: Review the resident’s medical history for documented diagnoses of renal insufficiency, renal failure, or ESRD.
  • Physician Notes: Examine notes from nephrologists and other physicians detailing the diagnosis and treatment plans.
  • Laboratory Results: Check lab results for key indicators such as serum creatinine, glomerular filtration rate (GFR), and blood urea nitrogen (BUN).
  • Dialysis Records: If applicable, review dialysis treatment records and schedules.

2. Understanding Definitions

• Renal Insufficiency: Reduced kidney function not severe enough to be classified as renal failure.
• Renal Failure: Significant loss of kidney function that can be acute or chronic.
• End-Stage Renal Disease (ESRD): The final stage of chronic kidney disease where kidneys no longer function adequately, often requiring dialysis or transplantation.

3. Coding Instructions

• Code I1500:
  • 0: No, the resident does not have renal insufficiency, renal failure, or ESRD.
  • 1: Yes, the resident has renal insufficiency, renal failure, or ESRD.
• Example: If a resident has a documented diagnosis of ESRD and is undergoing dialysis, code I1500 as '1'.

4. Coding Tips

• Confirm Diagnosis: Ensure that the diagnosis is confirmed by a physician and supported by medical documentation, including lab results and treatment records.
• Current Status: Verify that the condition is currently affecting the resident’s health status, not just a historical diagnosis.

5. Documentation

• Required Documentation:
  • Physician Notes: Detailed notes confirming the diagnosis of renal insufficiency, renal failure, or ESRD.
  • Laboratory Results: Relevant lab results supporting the diagnosis.
  • Dialysis Records: Documentation of dialysis treatments if applicable.
• Example: "On 05/10/2024, the resident was diagnosed with chronic renal failure as confirmed by a nephrologist’s report. Lab results show a GFR of 15 mL/min, and the resident is receiving dialysis three times a week."

6. Common Errors to Avoid

• Misclassification: Coding for renal conditions without a confirmed diagnosis.
• Outdated Records: Using old medical records without confirming the current status of the condition.
• Incomplete Documentation: Failing to document all relevant details and supporting evidence of the diagnosis.

7. Practical Application

• Scenario: A resident with a history of diabetes and hypertension has been diagnosed with ESRD. The nephrologist’s notes confirm the diagnosis, and lab results show a significantly reduced GFR. The resident’s dialysis schedule is documented in their treatment records. Based on this comprehensive documentation, I1500 is coded as '1'.

Please note that the information provided in this guide for MDS 3.0 Item set I1500 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. 

  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.