Understanding and Coding MDS Item I8000C: Additional Active ICD Diagnosis 3

Understanding and Coding MDS Item I8000C: Additional Active ICD Diagnosis 3

Introduction

Purpose:
MDS Item I8000C, "Additional Active ICD Diagnosis 3," is used to document the third 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 critical to developing a comprehensive care plan and ensuring proper resource allocation for the resident’s care.

What is MDS Item I8000C?

Explanation:
MDS Item I8000C is part of the I8000 series, which allows for the documentation of active diagnoses using ICD-10 codes. This item specifically captures the third active diagnosis impacting the resident’s care. Active diagnoses are those that require ongoing treatment, monitoring, or assessment during the look-back period, such as chronic conditions (e.g., diabetes, arthritis) or acute illnesses (e.g., pneumonia, fractures).

These diagnoses inform the care plan and guide the care team in making decisions about treatments, medications, and therapies. Properly recording these conditions also supports Medicare and Medicaid reimbursement.

• Relevance: Accurately documenting active diagnoses helps the care team address the resident’s medical needs comprehensively, ensuring that all conditions requiring care are considered.
• Importance: Proper coding of I8000C ensures that the third active diagnosis is reflected in the MDS assessment, leading to appropriate care interventions and accurate reimbursement for the services provided.

Guidelines for Coding MDS Item I8000C

Coding Instructions:

1. Identify Active Diagnoses:
   Review the resident’s medical records to identify conditions that are actively being treated, monitored, or assessed during the look-back period. Active diagnoses can include both chronic and acute conditions.

2. Select the Appropriate ICD-10 Code:
   Choose the correct ICD-10 code for the third active diagnosis. Ensure that the condition is actively affecting the resident’s care during the look-back period and that it is documented in their medical record.

3. Answering I8000C:

   • Enter the ICD-10 code for the third active diagnosis that impacts the resident’s care.
   • Ensure that the diagnosis is being actively managed and influences the care plan, medications, or other interventions during the look-back period.

4. Documentation Requirements:
   The diagnosis entered in I8000C must be supported by documentation in the resident’s medical record. This includes progress notes, treatment plans, physician orders, and other healthcare provider documentation that shows how the diagnosis was managed during the look-back period.

5. Verification:
   Verify the accuracy of the ICD-10 code by cross-referencing the diagnosis with the resident’s care plan and medical history. Ensure that the diagnosis is still relevant and active, requiring care during the look-back period.

Example Scenario:
Ms. Thompson, a 78-year-old resident, is being treated for osteoporosis with regular bone density monitoring and medications to prevent fractures. Her diagnosis, coded as M81.0 (Age-related osteoporosis without current pathological fracture), is entered as her third active diagnosis in I8000C because it significantly affects her treatment plan.

Best Practices for Accurate Coding

Documentation:
Ensure that all active diagnoses, including I8000C, are thoroughly documented in the resident’s medical record. Documentation should show that the condition was actively treated, monitored, or assessed during the look-back period.

Communication:
Collaborate with the interdisciplinary care team to ensure that all relevant diagnoses are identified and coded correctly. Open communication between physicians, nurses, and therapists ensures that the resident’s care plan accurately reflects their medical needs.

Training:
Provide staff training on how to correctly code active diagnoses using ICD-10. Staff should be familiar with identifying active conditions and accurately documenting them in the MDS assessment.

Conclusion

MDS Item I8000C is crucial for documenting the third active diagnosis that impacts a resident’s care. Accurate coding ensures that all relevant conditions are reflected in the MDS assessment, which supports effective care planning and resource allocation. Proper documentation, communication, and staff training are key to ensuring that active diagnoses are correctly coded.

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 I8000C, 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 I8000C: Additional Active ICD Diagnosis 3 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.