Understanding and Coding MDS 3.0 Item I4900: Hemiplegia or Hemiparesis

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Understanding and Coding MDS 3.0 Item I4900: Hemiplegia or Hemiparesis

MDS 3.0 Item I4900: Hemiplegia or Hemiparesis

Introduction

Purpose:
Hemiplegia (complete paralysis on one side of the body) or hemiparesis (weakness on one side) is often caused by a stroke or brain injury. MDS Item I4900 captures the presence of these conditions, ensuring residents receive appropriate rehabilitation and care plans tailored to their mobility and daily function needs.

What is MDS Item I4900?

Explanation:
MDS Item I4900 documents whether a resident has hemiplegia or hemiparesis. These conditions significantly impact a resident’s mobility and ability to perform activities of daily living (ADLs). Proper documentation allows care teams to implement rehabilitation strategies like physical therapy or the use of assistive devices to improve mobility and independence.

Guidelines for Coding MDS Item I4900

Coding Instructions:

  • Hemiplegia or hemiparesis must be diagnosed by a healthcare provider and actively treated or monitored.
  • Code this item as present if the resident exhibits paralysis or weakness on one side due to conditions like stroke.
    For example, if a resident has hemiplegia resulting from a stroke and requires assistance with daily activities, MDS Item I4900 should be coded as present.

Best Practices for Accurate Coding

Documentation:

  • The resident’s medical record should include clear documentation of hemiplegia or hemiparesis and any related rehabilitation therapies or assistive devices used.

Communication:

  • Ensure effective communication between the nursing team, physical therapists, and physicians to coordinate the resident’s care plan and monitor progress in physical therapy.

Training:

  • Train staff on proper techniques for assisting residents with mobility, preventing falls, and supporting independence through the use of mobility aids like walkers or wheelchairs.

Conclusion

Summary:
Correctly coding MDS Item I4900 ensures that residents with hemiplegia or hemiparesis receive the appropriate care and interventions to manage their condition, enhance mobility, and improve their 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 I4900 is 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 this guide as necessary

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