MDS 3.0 Item I5500: Traumatic Brain Injury (TBI)

MDS 3.0 Item I5500: Traumatic Brain Injury (TBI)

Introduction

Purpose:
Traumatic brain injury (TBI) results from a blow or jolt to the head and can cause long-term cognitive, physical, and behavioral changes. MDS Item I5500 captures this diagnosis to ensure residents with TBIs receive appropriate rehabilitative care and monitoring for neurological symptoms.

What is MDS Item I5500?

Explanation:
MDS Item I5500 tracks residents with a diagnosis of TBI, ensuring that care plans address their cognitive and physical impairments. Documentation of TBI ensures the resident receives physical therapy, cognitive rehabilitation, and monitoring for secondary conditions like seizures.

Guidelines for Coding MDS Item I5500

Coding Instructions:

• TBI must be diagnosed by a healthcare provider and actively managed.
• Code this item as present if the resident is receiving ongoing therapy or monitoring for symptoms related to their TBI.
  For example, if a resident with TBI requires cognitive therapy and medication management for symptoms such as seizures or mood changes, MDS Item I5500 should be coded as present.

Best Practices for Accurate Coding

Documentation:

• Ensure that medical records include detailed documentation of the TBI, therapy sessions, and any cognitive or physical rehabilitation programs in place.

Communication:

• Engage with physical therapists, occupational therapists, and neurologists to create a coordinated care plan that addresses all aspects of the resident’s rehabilitation.

Training:

• Staff should be trained on how to manage TBI symptoms, including potential behavioral changes and cognitive impairments.

Conclusion

Summary:
Accurate coding of MDS Item I5500 ensures that residents with TBI receive the rehabilitative care they need, improving cognitive and physical function and quality of life.

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, Pages I-12 to I-14.

Disclaimer

This guide for MDS 3.0 Item I5500 is based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024.