Understanding and coding MDS Item I1200: Gastroesophageal Reflux Disease (GERD) or Ulcer

MDS Item I1200 – Gastroesophageal Reflux Disease (GERD) or Ulcer

Introduction

Gastroesophageal reflux disease (GERD) and ulcers are common gastrointestinal conditions that require ongoing management to prevent complications like bleeding or esophageal damage. MDS Item I1200 captures whether a resident has a diagnosis of GERD or ulcer.

What is MDS Item I1200?

MDS Item I1200 identifies residents diagnosed with GERD or any type of ulcer, including esophageal, gastric, or peptic ulcers. Monitoring these conditions helps care teams manage symptoms and prevent complications like gastrointestinal bleeding or strictures.

Guidelines for Coding I1200

• Code 1: If the resident has a diagnosis of GERD or ulcer.
• Code 0: If the resident does not have GERD or ulcer.

Instructions:

• Review the resident’s medical records, including endoscopy results, imaging studies, and physician notes to confirm the diagnosis of GERD or ulcer.

Example Scenario:

Resident B has a history of GERD and is currently on a proton-pump inhibitor to manage symptoms. Code 1 for MDS Item I1200.

Best Practices for Accurate Coding

• Documentation: Ensure GERD or ulcer diagnoses are documented clearly, along with any treatments like medications or dietary modifications.
• Monitoring: Regularly monitor residents with GERD or ulcers for worsening symptoms like heartburn, pain, or bleeding.
• Training: Train staff to recognize symptoms of GERD and ulcers, ensuring these conditions are managed appropriately.

Conclusion

Properly coding MDS Item I1200 ensures residents with GERD or ulcers receive timely and effective care to prevent complications and improve gastrointestinal health.

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-10​.

Disclaimer:

Please note that the information provided in this guide for MDS 3.0 Item I1200 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.