Understanding and Coding MDS Item I8000G: Additional Active ICD Diagnosis 7

Understanding and Coding MDS Item I8000G: Additional Active ICD Diagnosis 7

Introduction

Purpose:
MDS Item I8000G, "Additional Active ICD Diagnosis 7," is used to document the seventh active ICD-10 diagnosis relevant to a resident’s care during the look-back period. Capturing all relevant diagnoses, including this seventh entry, ensures that the MDS assessment accurately reflects the resident's current medical status and care needs.

What is MDS Item I8000G?

Explanation:
MDS Item I8000G is part of the I8000 series, where active diagnoses are recorded using ICD-10 codes. This specific item allows for documenting the seventh active diagnosis impacting the resident’s care. An active diagnosis is one that requires ongoing treatment, monitoring, or assessment, whether it's a chronic condition (e.g., diabetes, hypertension) or an acute health issue (e.g., infection, injury).

The diagnoses entered in I8000, including I8000G, influence the resident’s care plan, guiding clinical decisions and interventions. Properly identifying and documenting these active diagnoses ensures that all relevant health conditions are considered.

• Relevance: Active diagnoses provide insight into the resident’s medical status and guide the development of their care plan. Listing all relevant conditions ensures the care team can adequately address the resident's health needs.
• Importance: Accurate coding of I8000G helps ensure that the seventh active diagnosis is fully represented in the resident’s MDS assessment, which supports personalized care planning and facilitates appropriate resource allocation for Medicare and Medicaid reimbursement.

Guidelines for Coding MDS Item I8000G

Coding Instructions:

1. Identify Active Diagnoses:
   Review the resident’s medical record to identify the diagnoses actively influencing their care during the look-back period. These diagnoses may require ongoing medication management, therapy, or monitoring.

2. Select the Appropriate ICD-10 Code:
   Choose the correct ICD-10 code for the seventh active diagnosis. Ensure the diagnosis is active and relevant to the resident’s care during the look-back period and is documented appropriately in the resident’s medical records.

3. Answering I8000G:

   • Enter the ICD-10 code for the seventh active diagnosis.
   • Ensure the diagnosis is one that requires treatment, monitoring, or assessment during the look-back period.

4. Documentation Requirements:
   The ICD-10 diagnosis listed in I8000G must be supported by documentation in the resident’s medical record. Documentation should clearly indicate that the condition was actively managed or monitored during the look-back period. This may include notes from physicians, nursing staff, or therapists.

5. Verification:
   Confirm the accuracy of the ICD-10 code for the seventh diagnosis by cross-referencing the resident’s medical record, care plan, and physician documentation. If the diagnosis is no longer active or relevant, it should not be included.

Example Scenario:
Ms. Turner, an 81-year-old resident, is being treated for chronic kidney disease (CKD) stage 3. During the look-back period, her kidney function has been closely monitored, and adjustments to her diet and medication have been made. This condition, with the ICD-10 code N18.30 (Chronic kidney disease, stage 3 unspecified), is entered as her seventh active diagnosis in I8000G.

Best Practices for Accurate Coding

Documentation:
Ensure that all active diagnoses listed in the I8000 series, including I8000G, are thoroughly documented in the resident’s medical record. Documentation should clearly show that the condition was managed, monitored, or treated during the look-back period.

Communication:
Collaborate with the interdisciplinary care team, including nurses, physicians, and therapists, to ensure that all relevant diagnoses are accurately coded. This ensures the resident’s health needs are fully addressed in the care plan.

Training:
Train staff on how to accurately identify and code active diagnoses using ICD-10 codes. Understanding the criteria for an active diagnosis and correctly coding these diagnoses ensures that the resident’s MDS assessment reflects their current health status.

Conclusion

MDS Item I8000G is crucial for documenting the seventh active diagnosis that impacts a resident’s care. Accurate coding of this item ensures that the resident’s health conditions are fully reflected in their MDS assessment, which supports the development of an individualized care plan. Proper documentation, communication, and staff training are key to ensuring that all active diagnoses are captured accurately.

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 I8000G, 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 I8000G: Additional Active ICD Diagnosis 7 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.