Understanding and Coding MDS Item I8000A: Additional Active ICD Diagnosis 1

Understanding and Coding MDS Item I8000A: Additional Active ICD Diagnosis 1

Introduction

Purpose:
MDS Item I8000A, "Additional Active ICD Diagnosis 1," is used to document the first active ICD-10 diagnosis that affects the resident’s care during the look-back period. Accurately capturing all active diagnoses in the MDS assessment is essential for providing comprehensive care planning and ensuring proper resource allocation.

What is MDS Item I8000A?

Explanation:
MDS Item I8000A is part of the I8000 series, where facilities document active diagnoses using ICD-10 codes. This item specifically records the first active diagnosis affecting the resident’s care during the look-back period (typically 5-7 days). Active diagnoses are those conditions requiring ongoing treatment, monitoring, or assessment. These diagnoses can include chronic illnesses (e.g., hypertension, chronic obstructive pulmonary disease) or acute conditions (e.g., infections, injuries).

Accurate coding of these conditions ensures that the care plan reflects the resident’s medical needs and helps guide the interdisciplinary team in providing appropriate care.

• Relevance: Documenting all active diagnoses helps the care team address the resident’s overall health needs. This documentation is essential for developing an individualized care plan and ensuring the resident receives appropriate treatment.
• Importance: Correctly coding I8000A ensures that the first active diagnosis is accurately represented in the MDS assessment, leading to more accurate care interventions and resource use.

Guidelines for Coding MDS Item I8000A

Coding Instructions:

1. Identify Active Diagnoses:
   Review the resident’s medical records, including physician notes, care plans, and treatment records, to identify diagnoses that are actively treated or monitored during the look-back period.

2. Select the Appropriate ICD-10 Code:
   Choose the correct ICD-10 code for the first active diagnosis. Ensure the condition is actively impacting the resident’s care and is properly documented in their medical record.

3. Answering I8000A:

   • Enter the ICD-10 code for the first active diagnosis.
   • Make sure the diagnosis is actively managed and influences the resident’s treatment plan, medications, or interventions during the look-back period.

4. Documentation Requirements:
   Ensure that the diagnosis entered in I8000A is supported by the resident’s medical records. This includes clear documentation showing that the condition was treated or monitored during the look-back period.

5. Verification:
   Verify the ICD-10 code by cross-referencing the resident’s medical history and care plan. Only list conditions that are actively affecting care and require ongoing management during the look-back period.

Example Scenario:
Ms. Johnson, a 72-year-old resident, has a diagnosis of hypertension that requires regular blood pressure monitoring and medication adjustments. Her condition, coded as I10 (Essential (primary) hypertension), is entered as her first active diagnosis in I8000A because it significantly influences her care and medication regimen.

Best Practices for Accurate Coding

Documentation:
Ensure that all active diagnoses, including I8000A, are well-documented in the resident’s medical records. This should include evidence of how the condition was actively managed or monitored during the look-back period.

Communication:
Work with the interdisciplinary care team to ensure that all relevant diagnoses are identified and accurately coded. Collaboration between healthcare providers ensures that the resident’s care plan reflects all of their current medical conditions.

Training:
Provide training for staff on how to properly code active diagnoses using ICD-10 codes. Understanding how to identify active conditions and accurately document them in the MDS assessment ensures comprehensive care planning.

Conclusion

MDS Item I8000A is critical for documenting the first active diagnosis that impacts a resident’s care. Accurate coding of this item ensures that all relevant conditions are captured in the MDS assessment, leading to more individualized care and proper resource allocation. Proper documentation, communication, and staff training are key to ensuring that active diagnoses are coded 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 I8000A, 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 I8000A: Additional Active ICD Diagnosis 1 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.