Understanding and Coding MDS Item I8000D: Additional Active ICD Diagnosis 4

Understanding and Coding MDS Item I8000D: Additional Active ICD Diagnosis 4

Introduction

Purpose:
MDS Item I8000D, "Additional Active ICD Diagnosis 4," is used to document the fourth active ICD-10 diagnosis relevant to a resident’s care during the look-back period. Including all active diagnoses in the MDS assessment provides a full picture of the resident’s medical conditions, ensuring comprehensive care planning and accurate resource use.

What is MDS Item I8000D?

Explanation:
MDS Item I8000D is part of the I8000 series, which records active diagnoses using ICD-10 codes. This item allows for the documentation of the fourth active diagnosis affecting the resident’s care during the look-back period (typically 5-7 days). Active diagnoses are conditions that require ongoing treatment, monitoring, or assessment, such as chronic diseases (e.g., hypertension, diabetes) or acute conditions (e.g., infections, injuries).

Proper documentation of these diagnoses supports the development of a care plan tailored to the resident’s specific needs and ensures accurate Medicare or Medicaid reimbursement for care provided.

• Relevance: Capturing all active diagnoses is critical for understanding the resident’s overall health and ensuring that the care team addresses all relevant conditions. Listing these conditions ensures that appropriate treatments, monitoring, and interventions are part of the care plan.
• Importance: Correctly coding I8000D ensures that the fourth active diagnosis is accurately reflected in the MDS assessment. This leads to individualized care and better resource allocation for the resident’s medical needs.

Guidelines for Coding MDS Item I8000D

Coding Instructions:

1. Identify Active Diagnoses:
   Review the resident’s medical record to identify active diagnoses. These conditions should be actively managed during the look-back period, requiring treatment, monitoring, or regular assessment. Consider chronic diseases, infections, and recent injuries.

2. Select the Appropriate ICD-10 Code:
   Select the correct ICD-10 code for the fourth active diagnosis. Make sure the condition is actively affecting the resident’s care during the look-back period and is documented in the medical record by physicians or other healthcare providers.

3. Answering I8000D:

   • Enter the ICD-10 code for the fourth active diagnosis that is being treated, monitored, or assessed during the look-back period.
   • The diagnosis should directly influence the resident’s care, such as medication management, therapies, or other medical interventions.

4. Documentation Requirements:
   Ensure the diagnosis entered in I8000D is supported by the resident’s medical records, including progress notes, treatment plans, or physician orders. The documentation must show that the condition was actively addressed during the look-back period.

5. Verification:
   Cross-reference the ICD-10 code with the resident’s care plan and medical history to ensure accuracy. If the diagnosis is no longer active or does not impact the resident’s current care, it should not be included in the I8000 series.

Example Scenario:
Mr. Smith, a 74-year-old resident, has been receiving ongoing treatment for Type 2 diabetes mellitus, which includes blood sugar monitoring and medication management. His diagnosis, coded as E11.9 (Type 2 diabetes mellitus without complications), is entered as his fourth active diagnosis in I8000D.

Best Practices for Accurate Coding

Documentation:
Ensure that all active diagnoses in the I8000 series, including I8000D, are thoroughly documented in the resident’s medical record. Documentation should show how the condition was managed, monitored, or treated during the look-back period.

Communication:
Work closely with the interdisciplinary care team, including nurses, physicians, and therapists, to ensure that all relevant diagnoses are identified and properly coded. Accurate communication ensures that the resident’s health needs are fully reflected in the MDS assessment.

Training:
Provide training for staff on how to correctly identify and code active diagnoses using ICD-10 codes. Understanding the criteria for active diagnoses and proper coding practices ensures the resident’s conditions are accurately captured in the MDS.

Click here to see a detailed step-by-step on how to complete this item set 

Conclusion

MDS Item I8000D is essential for documenting the fourth active diagnosis that affects a resident’s care. Proper coding ensures that the resident’s health conditions are fully captured in the MDS assessment, leading to better care planning and resource allocation. Accurate documentation, communication, and staff training are critical to ensuring that all active diagnoses are reflected correctly.

Reference

For more detailed guidelines on coding MDS Item I8000D, 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 I8000D: Additional Active ICD Diagnosis 4 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.