MDS 3.0 Item I2000: Pneumonia

Introduction:

Pneumonia is a common but serious respiratory infection affecting elderly residents in long-term care facilities. Accurate coding for MDS Item I2000 ensures that care teams can initiate appropriate interventions, such as antibiotics or oxygen therapy, and monitor resident outcomes.

What is MDS Item I2000?

Item I2000 covers the diagnosis of pneumonia, an infection that inflames the air sacs in one or both lungs. These air sacs may fill with fluid or pus, leading to symptoms such as cough, fever, and difficulty breathing. This item helps identify residents with active or recently treated pneumonia to ensure adequate care planning.

Guidelines for Coding I2000:

To code for pneumonia under I2000, the following must be documented:

• A physician's diagnosis of pneumonia within the past 7 days.
• Documentation of active treatment or monitoring for pneumonia, such as antibiotics, oxygen therapy, or respiratory therapy.

Example: A resident with a cough and fever was diagnosed with pneumonia via a chest x-ray. The diagnosis was documented by the physician, and the resident was prescribed antibiotics. This resident would be coded for pneumonia under I2000.

Best Practices for Accurate Coding:

• Documentation: Ensure that all medical records clearly reflect the pneumonia diagnosis and the treatment provided.
• Communication: Collaborate with respiratory therapists and primary care providers to ensure accurate documentation and care planning.
• Training: Regularly train nursing staff to recognize the signs of pneumonia and ensure timely documentation.

Conclusion:

Coding pneumonia in MDS Item I2000 is essential for providing timely and appropriate respiratory care for residents, improving outcomes, and preventing complications.

Click here to see a detailed Step-by-Step on how to complete this item set.

Reference:

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Page I-10.

Disclaimer:

Please note that the information provided in this guide for MDS 3.0 Item I2000 was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024.