Understanding and Coding MDS Item I6300: Respiratory Failure

Introduction

Purpose:
MDS Item I6300, "Respiratory Failure," is used to document whether a resident has been diagnosed with respiratory failure during the look-back period. Respiratory failure is a serious condition in which the lungs fail to adequately exchange oxygen and carbon dioxide, resulting in difficulty breathing, low oxygen levels, or elevated carbon dioxide levels. Accurate coding of this item ensures that the resident’s respiratory status is captured, allowing for the appropriate interventions and monitoring necessary to manage this life-threatening condition.

What is MDS Item I6300?

Explanation:
MDS Item I6300 is part of Section I, which captures active diagnoses that impact a resident’s care. This specific item is used to document respiratory failure as an active diagnosis during the look-back period (typically 5–7 days). Respiratory failure can be categorized into two types:

• Hypoxemic respiratory failure: Low oxygen levels in the blood (often caused by conditions like pneumonia, acute respiratory distress syndrome (ARDS), or pulmonary embolism).
• Hypercapnic respiratory failure: Elevated carbon dioxide levels in the blood (often due to conditions like chronic obstructive pulmonary disease (COPD) or drug overdose).

Respiratory failure requires immediate medical attention and often involves interventions such as mechanical ventilation, oxygen therapy, or medications to support breathing.

• Relevance: Respiratory failure is a critical condition that can have a profound impact on a resident’s overall health, requiring close monitoring, respiratory support, and frequent reassessment of care needs.
• Importance: Proper coding of I6300 ensures that respiratory failure is documented as part of the resident’s care plan, enabling the healthcare team to prioritize respiratory interventions and monitor the resident’s status closely.

Guidelines for Coding MDS Item I6300

Coding Instructions:

1. Identify the Presence of Respiratory Failure:
   Review the resident’s medical record to determine if respiratory failure has been diagnosed during the look-back period. This diagnosis must be actively affecting the resident’s care, requiring treatment, monitoring, or interventions like oxygen therapy or mechanical ventilation.

2. Answering I6300:

   • Code 1 (Yes) if the resident has been diagnosed with respiratory failure during the look-back period.
   • Code 0 (No) if the resident does not have respiratory failure or if it was not actively treated or monitored during the look-back period.

3. Documentation Requirements:
   Ensure that the resident’s medical record contains a clear diagnosis of respiratory failure, supported by clinical documentation such as respiratory assessments, arterial blood gas (ABG) results, or treatment records (e.g., the use of oxygen therapy, non-invasive ventilation, or intubation).

4. Verification:
   Verify the diagnosis of respiratory failure through physician notes, respiratory therapist documentation, and any relevant orders for respiratory support, including ventilators or oxygen. If respiratory failure was treated during the look-back period, it should be coded in I6300.

Example Scenario:
Mr. Baker, an 82-year-old resident with a history of COPD, was admitted with acute respiratory failure due to a severe exacerbation of his condition. He was placed on mechanical ventilation for 48 hours before being transitioned to oxygen therapy. In this case, code 1 (Yes) for I6300, as respiratory failure is an active diagnosis requiring significant respiratory support.

Best Practices for Accurate Coding

Documentation:
Ensure that all instances of respiratory failure are well-documented in the resident’s medical record. This includes physician documentation, ABG results, and records of respiratory interventions such as ventilation support, oxygen therapy, or medications.

Communication:
Work closely with the interdisciplinary care team, particularly respiratory therapists and physicians, to ensure that respiratory failure is identified and documented accurately. Timely communication helps ensure that the resident’s respiratory status is properly managed and reflected in the care plan.

Training:
Provide training for staff on how to recognize and document respiratory failure. Understanding the signs and interventions required for this condition is critical for ensuring accurate coding and appropriate care planning for residents experiencing respiratory distress.

Conclusion

MDS Item I6300 is crucial for documenting respiratory failure in residents. Accurate coding of this item ensures that this serious condition is included in the MDS assessment, leading to proper interventions and close monitoring of the resident’s respiratory status. Proper documentation, communication, and staff training are key to ensuring that respiratory failure is accurately coded and that residents receive timely and effective care.

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

Reference

For more detailed guidelines on coding MDS Item I6300, refer to the CMS’s Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Chapter 3, Section I, Page 3-97.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item I6300: "Respiratory Failure" 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.