Step-by-Step Coding Guide for Item Set I5400: Seizure Disorder or Epilepsy

1. Review of Medical Records

Start by thoroughly reviewing the resident's medical history, focusing on any records of neurological evaluations, diagnosis of seizure disorders, or prescriptions for antiepileptic drugs. Look for any documentation of witnessed seizures or episodes that might suggest undiagnosed seizure activity.

2. Understanding Definitions

Seizure Disorder/Epilepsy: A neurological condition characterized by recurrent, unprovoked seizures. Seizures are sudden surges of electrical activity in the brain that can affect how a person appears or acts for a short time.

3. Coding Instructions

For I5400:

• Code "1" if the resident has a documented diagnosis of seizure disorder or epilepsy.
• Code "0" if there is no such diagnosis or evidence of seizure activity in the medical record.

4. Coding Tips

• Ensure that the diagnosis is current and confirmed by appropriate medical personnel.
• Be aware of the difference between active seizure disorders and a history of seizures; code only active conditions.
• Review medications as some can be used for conditions other than epilepsy, such as mood stabilization.

5. Documentation

Record all relevant information in the resident’s medical record, including the date of diagnosis, details from the latest neurological evaluations, current treatments, and any recent seizure activity.

6. Common Errors to Avoid

• Failing to code for residents with an active diagnosis because no recent seizures have been witnessed.
• Misinterpreting psychogenic non-epileptic seizures (PNES) as epilepsy.
• Overlooking seizure activity that might be subtle or atypical, such as absence seizures.

7. Practical Application

Example: Mr. Johnson, a resident, has a documented history of epilepsy with the most recent seizure occurring two months ago. He is on a stable dose of levetiracetam (Keppra). During your coding assessment, you confirm his diagnosis and medication with his neurologist and code “1” for I5400, reflecting his active management for epilepsy.

Please note that the information provided in this guide for MDS 3.0 Item set I5400 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.