MDS Item I0020B – ICD Code 1-13

Introduction

Accurate ICD-10 coding is essential in long-term care facilities for proper documentation, care planning, and Medicare reimbursement. MDS Item I0020B requires the appropriate ICD-10 code to be entered based on the resident’s primary medical condition, which is coded in I0020.

What is MDS Item I0020B?

MDS Item I0020B records the ICD-10 code that corresponds to the resident’s primary medical condition. This condition must be the primary reason for the Medicare Part A stay. The ICD-10 code helps define the scope of the resident’s care and ensures that the diagnosis aligns with Medicare reimbursement guidelines.

Guidelines for Coding I0020B

• Identify the Primary Condition: Use the medical records to determine the primary medical condition documented in I0020.
• Use the ICD-10 Manual: Assign the correct ICD-10 code that matches the diagnosis entered in I0020.
• Consider Z Codes: Z codes may be used for aftercare following hospitalization. Ensure that another diagnosis for the related primary condition is also entered.

Instructions:

• Review the resident’s medical history, diagnoses, and physician notes to confirm the correct ICD-10 code.
• Enter the diagnosis code exactly as it appears, including the decimal point in the correct position.

Example Scenario:

Resident F was admitted after a hip fracture resulting in a total hip replacement. In I0020, the condition is coded as 10 (Fractures and Other Multiple Trauma). In I0020B, enter S72.062D (Displaced articular fracture of the head of the left femur) as the ICD-10 code.

Best Practices for Accurate Coding

• Documentation: Ensure that the primary medical condition is clearly documented with corresponding ICD-10 codes in the resident’s record.
• Training: Provide staff with up-to-date training on ICD-10 coding practices to ensure accuracy.
• Verification: Double-check that the ICD-10 code aligns with the condition documented in I0020.

Conclusion

Correctly coding MDS Item I0020B ensures proper documentation and compliance with Medicare requirements. It supports accurate reimbursement and care planning for the resident’s primary condition.

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, Chapter 3, Page I-4.

Disclaimer:

Please note that the information provided in this guide for MDS 3.0 Item I0020B 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. 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.