Understanding and Coding MDS Item I8000B: Additional Active ICD Diagnosis 2

Understanding and Coding MDS Item I8000B: Additional Active ICD Diagnosis 2

Introduction

Purpose:
MDS Item I8000B, "Additional Active ICD Diagnosis 2," is used to document the second active ICD-10 diagnosis affecting a resident’s care during the look-back period. Accurately capturing all active diagnoses in the MDS assessment helps ensure that the resident’s health conditions are fully accounted for, leading to comprehensive care planning and proper resource allocation.

What is MDS Item I8000B?

Explanation:
MDS Item I8000B is part of the I8000 series, where facilities document active diagnoses using ICD-10 codes. This item specifically captures the second active diagnosis affecting the resident’s care. Active diagnoses are those conditions requiring ongoing treatment, monitoring, or assessment during the look-back period (typically 5-7 days). These diagnoses can include chronic diseases (e.g., diabetes, hypertension) or acute conditions (e.g., infections, fractures).

Accurate coding of these conditions is crucial for guiding the care plan, helping the interdisciplinary team provide appropriate interventions, and ensuring accurate Medicare and Medicaid reimbursement.

• Relevance: Listing all active diagnoses allows the care team to develop an individualized care plan that addresses all of the resident’s current medical needs.
• Importance: Correctly coding I8000B ensures that the second active diagnosis is properly reflected in the MDS assessment, which supports accurate care planning and resource allocation.

Guidelines for Coding MDS Item I8000B

Coding Instructions:

1. Identify Active Diagnoses:
   Review the resident’s medical record to identify all diagnoses that are being actively treated or monitored during the look-back period. These should include conditions that require ongoing management, such as chronic illnesses or recent acute events.

2. Select the Appropriate ICD-10 Code:
   Choose the correct ICD-10 code for the second active diagnosis. Make sure the diagnosis is actively impacting the resident’s care and is documented in the medical record, such as in physician notes, care plans, or nursing records.

3. Answering I8000B:

   • Enter the ICD-10 code for the second active diagnosis.
   • The condition should be one that is actively managed, monitored, or treated during the look-back period and is relevant to the resident’s current care plan.

4. Documentation Requirements:
   Ensure that the diagnosis entered in I8000B is supported by documentation in the resident’s medical record. This documentation should clearly show that the condition was actively managed during the look-back period.

5. Verification:
   Verify the accuracy of the ICD-10 code by cross-referencing the resident’s care plan and medical history. If the diagnosis is no longer active or does not impact the resident’s care, it should not be listed in I8000B.

Example Scenario:
Mr. Williams, a 75-year-old resident, is being treated for chronic kidney disease (CKD) stage 3, which requires ongoing monitoring of kidney function and medication adjustments. His diagnosis, coded as N18.30 (Chronic kidney disease, stage 3 unspecified), is entered as the second active diagnosis in I8000B because it significantly impacts his treatment plan.

Best Practices for Accurate Coding

Documentation:
Ensure that all active diagnoses in the I8000 series, including I8000B, are thoroughly documented in the resident’s medical record. The documentation should clearly demonstrate that the condition was actively managed, monitored, or treated during the look-back period.

Communication:
Collaborate with the interdisciplinary care team to ensure that all relevant diagnoses are identified and coded accurately. This helps ensure that the resident’s care needs are fully addressed and that the care plan reflects all current medical conditions.

Training:
Provide staff training on how to identify and code active diagnoses using ICD-10 codes. Staff should be familiar with identifying active conditions and accurately documenting them in the MDS assessment.

Conclusion

MDS Item I8000B is essential for documenting the second active diagnosis that impacts a resident’s care. Proper coding ensures that the resident’s health conditions are fully represented in the MDS assessment, leading to better care planning and resource allocation. Accurate documentation, communication, and staff training are crucial for ensuring that active diagnoses are coded correctly.

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 I8000B, 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 I8000B: Additional Active ICD Diagnosis 2 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.