Understanding and Coding MDS Item I6500: Cataracts, Glaucoma, or Macular Degeneration

Introduction

Purpose:
MDS Item I6500, "Cataracts, Glaucoma, or Macular Degeneration," is used to document whether a resident has been diagnosed with one or more of these common eye conditions during the look-back period. These conditions are significant for elderly residents, as they can cause vision impairment, leading to safety risks and reduced quality of life. Accurate coding ensures that vision-related diagnoses are addressed in the care plan, allowing for proper interventions to maintain the resident’s visual function and overall safety.

What is MDS Item I6500?

Explanation:
MDS Item I6500 is part of Section I, which captures active diagnoses that impact a resident’s care. This item specifically addresses the presence of cataracts, glaucoma, or macular degeneration during the look-back period (typically 5-7 days).

• Cataracts: A condition where the lens of the eye becomes clouded, leading to blurred vision. Cataracts are common in older adults and can lead to progressive vision loss if not treated.
• Glaucoma: A group of eye conditions that damage the optic nerve, often due to high eye pressure, leading to vision loss if untreated.
• Macular Degeneration: A disease that affects the central part of the retina (macula), causing central vision loss. It is a leading cause of blindness in older adults.

These conditions can affect the resident’s ability to perform daily activities, and documenting them helps ensure that appropriate interventions, such as assistive devices, therapy, or surgery, are included in the resident’s care plan.

• Relevance: Diagnosing and documenting these eye conditions is crucial because untreated vision loss can increase fall risk and impair a resident’s independence. Identifying and managing these conditions allows the care team to provide interventions that support the resident’s safety and quality of life.
• Importance: Proper coding of I6500 ensures that these significant eye conditions are noted in the MDS assessment, leading to individualized care planning that includes visual aids, therapy, and monitoring to maintain the resident’s functional vision.

Guidelines for Coding MDS Item I6500

Coding Instructions:

1. Identify the Presence of Diagnoses:
   Review the resident’s medical record to determine if they have been diagnosed with cataracts, glaucoma, or macular degeneration during the look-back period. These conditions must be actively affecting the resident’s care, requiring treatment, monitoring, or intervention.

2. Answering I6500:

   • Code 1 (Yes) if the resident has been diagnosed with cataracts, glaucoma, or macular degeneration during the look-back period.
   • Code 0 (No) if none of these conditions were present or actively treated during the look-back period.

3. Documentation Requirements:
   Ensure that the resident’s diagnosis of cataracts, glaucoma, or macular degeneration is clearly documented in the medical record, including treatment plans, eye exams, or ongoing monitoring.

4. Verification:
   Verify the presence of these eye conditions through physician notes, ophthalmology reports, or any ongoing treatments related to eye health. If the resident is receiving care (such as medication for glaucoma or plans for cataract surgery), these diagnoses should be coded in I6500.

Example Scenario:
Ms. Thompson, a 79-year-old resident, has been diagnosed with glaucoma and is currently receiving daily eye drops to manage her eye pressure. Additionally, she has early-stage cataracts, which are being monitored by her ophthalmologist. In this case, code 1 (Yes) for I6500, as both conditions are present and actively affecting her care.

Best Practices for Accurate Coding

Documentation:
Ensure that all diagnoses of cataracts, glaucoma, or macular degeneration are well-documented in the resident’s medical record. This should include details about the resident’s vision status, treatments, and any monitoring required.

Communication:
Work with the resident’s care team, including physicians, nurses, and eye specialists, to ensure that these diagnoses are captured accurately in the MDS assessment. Regular communication ensures that visual impairments are recognized and addressed in the care plan.

Training:
Train staff on the importance of identifying and documenting vision-related diagnoses, as these conditions can significantly impact the resident’s quality of life. Ensuring that staff are aware of vision changes and the need for regular eye exams can prevent further complications.

Conclusion

MDS Item I6500 is essential for documenting cataracts, glaucoma, or macular degeneration in residents. Proper coding ensures that these common eye conditions are accounted for in the MDS assessment, leading to appropriate interventions and care planning to address vision loss. Accurate documentation, effective communication, and staff training are vital to ensuring that residents receive the necessary care to maintain their visual function and safety.

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 I6500, 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 I6500: "Cataracts, Glaucoma, or Macular Degeneration" 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.