Step-by-Step Coding Guide for Item Set I6500: "Cataracts, Glaucoma, or Macular Degeneration"

1. Review of Medical Records

• Objective: Ensure that there is documented evidence of cataracts, glaucoma, or macular degeneration as an active diagnosis in the last 7 days.
• Actions:
  • Access the resident’s most recent medical records and check for documented diagnoses related to cataracts, glaucoma, or macular degeneration.
  • Review physician notes, nursing records, and assessments that confirm the presence of these conditions within the 7-day look-back period.
  • Ensure that any treatments, medications, or interventions related to these diagnoses are clearly documented in the resident’s records.

2. Understanding Definitions

• I6500: Cataracts, Glaucoma, or Macular Degeneration: These are common eye conditions that affect vision, especially in elderly residents.
  • Cataracts: Clouding of the eye's lens, leading to decreased vision.
  • Glaucoma: A group of eye conditions that cause damage to the optic nerve, often due to high pressure in the eye.
  • Macular Degeneration: A disease that deteriorates the central part of the retina, leading to vision loss, especially in older adults​​.

3. Coding Instructions

• Step-by-Step:
  • Step 1: Identify if the resident has a diagnosis of cataracts, glaucoma, or macular degeneration within the last 7 days.
  • Step 2: Ensure that this diagnosis is active, meaning it directly affects the resident's current functional status, medical treatments, or requires monitoring.
  • Step 3: If the diagnosis is active and documented, check item I6500. If none of these conditions are present, leave the item unchecked.

4. Coding Tips

• Active Diagnoses: For I6500 to be marked, cataracts, glaucoma, or macular degeneration must have a direct relationship to the resident’s functional status, treatment, or require nursing monitoring during the look-back period.
• Documentation Sources: Look for evidence of the diagnosis in progress notes, physician orders, or care plans. Active management might include regular vision checks, eye medications, or interventions for visual impairment.

5. Documentation

• Objective: Provide detailed records of the diagnosis and management of cataracts, glaucoma, or macular degeneration.
• Actions:
  • Ensure that the diagnosis is documented by a physician or authorized clinician within the past 60 days and is noted as active within the last 7 days.
  • Keep records of any treatments (e.g., medications for glaucoma, recommendations for cataract surgery, or visual aids for macular degeneration).
  • Document any nursing or therapy interventions aimed at assisting the resident with visual impairments.

6. Common Errors to Avoid

• Coding Inactive Diagnoses: Do not code cataracts, glaucoma, or macular degeneration if the condition is no longer active or does not require current treatment or monitoring.
• Missing Documentation: Ensure the diagnosis is documented clearly in the medical record as active during the 7-day look-back period.

7. Practical Application

• Example 1: A resident with cataracts who experiences difficulty seeing clearly is under active management. Eye drops and regular vision checks are prescribed to manage the condition. I6500 would be coded because cataracts affect the resident’s daily function and require ongoing monitoring.
• Example 2: A resident diagnosed with glaucoma is prescribed medication to control eye pressure. Regular monitoring of the condition is necessary, so I6500 is coded as the glaucoma requires treatment and affects the resident’s health.

Please note that the information provided in this guide for MDS 3.0 Item set I6500 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.