I8000G: Additional Active ICD Diagnosis 7, Step-by-Step
Step-by-Step Coding Guide for Item Set I8000G: Additional Active ICD Diagnosis 7
Step-by-Step Coding Guide for Item Set I8000G
1. Review of Medical Records
- Objective: Ensure comprehensive review and accurate documentation of the resident’s additional active ICD diagnosis.
- Steps:
- Gather Information: Collect all relevant medical records, including physician notes, diagnostic reports, progress notes, and hospital discharge summaries.
- Identify Diagnoses: Look for documented evidence of active diagnoses that are currently being treated or managed.
- Confirm Details: Verify the specific diagnosis, ensuring it is clearly listed and documented as active.
2. Understanding Definitions
- Active Diagnosis: A condition that is currently being treated or managed, affecting the resident’s health status or care plan.
- ICD Code: International Classification of Diseases (ICD) code used to specify and classify diagnoses.
- Additional Active ICD Diagnosis 7: Refers to the seventh additional active diagnosis in the list of conditions being managed for the resident.
3. Coding Instructions
- Steps:
- Identify Relevant Documentation: Confirm through the medical records that the diagnosis is active and being managed.
- Verify Documentation: Ensure that the diagnosis is clearly documented and includes the ICD code.
- Code Appropriately: Enter the appropriate ICD code for item set I8000G, corresponding to the seventh additional active diagnosis.
- Example: If the diagnosis is diabetes mellitus type 2, the ICD code could be E11.9 (Type 2 diabetes mellitus without complications).
4. Coding Tips
- Accurate Identification: Ensure that the diagnosis is correctly identified and supported by relevant documentation.
- Consistent Terminology: Use consistent terminology and correct ICD codes when documenting and coding diagnoses.
- Clarify with the Interdisciplinary Team: If there is any uncertainty, clarify with the interdisciplinary team or the attending physician to ensure accurate coding.
5. Documentation
- Required:
- Physician Notes: Detailed notes from the physician indicating the diagnosis and its management.
- Diagnostic Reports: Reports from laboratory tests, imaging studies, or other diagnostics confirming the diagnosis.
- Progress Notes: Notes from staff documenting the resident’s condition, treatment, and response.
- Hospital Discharge Summaries: Summaries from any recent hospitalizations, including diagnoses and treatments.
6. Common Errors to Avoid
- Misclassification: Ensure accurate identification by verifying the diagnosis through multiple records and observations.
- Incomplete Documentation: Make sure all relevant physician notes, diagnostic reports, and progress notes are included to support the documented diagnosis.
- Assumptions: Do not assume the diagnosis status without proper documentation and verification; always check multiple sources.
7. Practical Application
- Example:
- Resident Profile: John, a resident, has multiple active diagnoses including hypertension, chronic kidney disease, and atrial fibrillation.
- Steps:
- Review Records: The nurse reviews John’s medical records, noting the physician notes and diagnostic reports documenting his diagnoses.
- Identify Diagnoses: It is confirmed through the documentation that John’s seventh additional active diagnosis is atrial fibrillation, with ICD code I48.91 (Unspecified atrial fibrillation).
- Document and Code: The nurse documents the diagnosis in John’s records and codes I8000G with ICD code I48.91.
- Outcome: John’s additional active diagnosis is accurately documented and coded, ensuring proper follow-up and management.
Please note that the information provided in this guide for MDS 3.0 Item set I8000G 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.
