I6000: Schizophrenia, Step-by-Step
Step-by-Step Coding Guide for I6000: Schizophrenia
1. Review of Medical Records
Objective: Verify if the resident has a diagnosis of schizophrenia or related conditions such as schizoaffective or schizophreniform disorders in their medical records.
Actions:
- Access the resident’s medical records, including progress notes, psychiatric evaluations, hospital discharge summaries, and physician orders.
- Ensure that the schizophrenia diagnosis has been clearly documented by a qualified healthcare professional such as a psychiatrist.
2. Understanding Definitions
I6000: Schizophrenia: This item captures a documented diagnosis of schizophrenia or closely related disorders like schizoaffective disorder and schizophreniform disorder.
- Schizophrenia: A mental disorder characterized by delusions, hallucinations, disorganized speech, and impairment in functioning.
- Schizoaffective disorder: A combination of schizophrenia symptoms and mood disorder symptoms like depression or mania.
Illustration:
Scenario: A resident is diagnosed with schizophrenia by their psychiatrist and is being treated with antipsychotic medications for persistent hallucinations.
Result: I6000 is coded "Yes" as the diagnosis is documented.
3. Coding Instructions
Step-by-Step:
- Step 1: Review the resident’s medical records to confirm a diagnosis of schizophrenia or a related disorder (schizoaffective or schizophreniform disorder).
- Step 2: Ensure that the diagnosis is active (i.e., it impacts the resident’s current functioning, treatment, or monitoring).
- Step 3: If schizophrenia or a related disorder is documented, check I6000 as "Yes".
- Step 4: If no diagnosis is present or if the condition does not meet the criteria, check I6000 as "No".
Illustration:
Scenario: A resident was previously diagnosed with schizophrenia, but the condition is no longer impacting their current care or treatment plan.
Result: I6000 is coded "No" as the diagnosis is no longer active.
4. Coding Tips
- Ensure Active Status: Only code schizophrenia if the condition is currently active and impacts the resident’s care, treatment, or monitoring during the assessment period.
- Consider Related Disorders: Schizoaffective and schizophreniform disorders should also be coded under I6000 if present and active.
5. Documentation
Objective: Ensure that the diagnosis of schizophrenia is clearly documented in the resident’s medical records and is reflected in their care plan.
Actions:
- Record the diagnosis, date, and the healthcare provider who made the diagnosis.
- Document any medications or therapies used to manage the symptoms, such as antipsychotic medications.
Illustration:
Scenario: A resident’s medical record shows a diagnosis of schizoaffective disorder, treated with antipsychotic medications and counseling. The diagnosis is documented by a psychiatrist.
Documentation: Ensure the diagnosis and treatments are clearly noted in the medical records, and I6000 is coded "Yes".
6. Common Errors to Avoid
- Lack of Documentation: Do not code schizophrenia without clear, documented evidence from the resident’s medical records.
- Misclassifying Mood Disorders: Ensure that mood disorders such as bipolar disorder are not coded under I6000 unless they are part of a schizoaffective disorder diagnosis.
Illustration:
Scenario: A resident is diagnosed with bipolar disorder, but there is no mention of schizophrenia or schizoaffective disorder.
Error: Do not code I6000 as "Yes" in this case.
7. Practical Application
- Example 1: A resident has a diagnosis of schizophrenia and is receiving antipsychotic treatment. I6000 is coded "Yes".
- Example 2: A resident was previously diagnosed with schizophrenia, but the condition is now in remission, and they are not receiving any active treatment. I6000 is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set I6000 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.
