Understanding and Coding MDS Item I8000E: Additional Active ICD Diagnosis 5

Introduction

Purpose:
MDS Item I8000E, "Additional Active ICD Diagnosis 5," is used to document the fifth active ICD-10 diagnosis that is relevant to the resident’s care during the look-back period. Capturing all relevant active diagnoses in the MDS assessment ensures that the resident’s health status is fully represented, allowing for appropriate care planning and resource allocation.

What is MDS Item I8000E?

Explanation:
MDS Item I8000E is part of the I8000 series, which records active diagnoses using ICD-10 codes. This item specifically allows for the documentation of the fifth active diagnosis that affects the resident’s care. An active diagnosis is defined as a condition requiring ongoing treatment, monitoring, or assessment during the look-back period (typically 5–7 days). Diagnoses could include chronic conditions (e.g., congestive heart failure, chronic kidney disease) or acute health issues (e.g., infections, fractures).

These diagnoses guide the care team in providing appropriate interventions, and they play a role in determining reimbursement rates under Medicare and Medicaid.

• Relevance: Active diagnoses provide critical information about the resident’s medical needs and directly influence care planning. Documenting these conditions ensures that the care team addresses the resident’s health comprehensively.
• Importance: Proper coding of I8000E ensures that the fifth active diagnosis is accurately reflected in the MDS assessment. This leads to better care coordination and supports accurate billing for services related to the resident’s treatment.

Guidelines for Coding MDS Item I8000E

Coding Instructions:

1. Identify Active Diagnoses:
   Review the resident’s medical records, including physician notes, treatment plans, and assessments, to identify active diagnoses. These are conditions that require ongoing care, monitoring, or treatment during the look-back period.

2. Select the Appropriate ICD-10 Code:
   Select the correct ICD-10 code for the fifth active diagnosis. Ensure that the diagnosis is currently affecting the resident’s care and that it is properly documented in their medical record.

3. Answering I8000E:

   • Enter the ICD-10 code for the fifth active diagnosis that affects the resident’s care during the look-back period.
   • Ensure that the condition is actively managed and has an impact on the resident’s care plan, medications, or interventions.

4. Documentation Requirements:
   The diagnosis entered in I8000E must be supported by medical documentation showing that the condition was actively monitored, treated, or assessed during the look-back period. This may include notes from physicians, nursing staff, or other healthcare providers.

5. Verification:
   Verify that the diagnosis and ICD-10 code are correct by cross-referencing the resident’s care plan and medical history. If the diagnosis is no longer active or does not affect the resident’s current care, it should not be listed.

Example Scenario:
Mr. Johnson, an 82-year-old resident, is being monitored for congestive heart failure (CHF), which requires daily weight checks and medication adjustments. His diagnosis, coded as I50.9 (Heart failure, unspecified), is entered as his fifth active diagnosis in I8000E, as it significantly influences his care plan and medication regimen.

Best Practices for Accurate Coding

Documentation:
Ensure that all active diagnoses listed in the I8000 series, including I8000E, are well-documented in the resident’s medical record. Documentation should clearly show that the condition required monitoring, treatment, or assessment 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 coded accurately. This helps ensure that the resident’s care needs are fully addressed in their MDS assessment.

Training:
Provide staff training on how to correctly identify and code active diagnoses using ICD-10 codes. Proper training ensures that diagnoses are accurately captured, leading to improved care planning and more appropriate reimbursement.

Conclusion

MDS Item I8000E is essential for documenting the fifth active diagnosis affecting a resident’s care. Accurate coding of this item ensures that the resident’s medical conditions are fully represented in the MDS assessment, leading to better care planning and appropriate reimbursement. Proper documentation, communication, and staff training are critical for ensuring that active diagnoses are coded correctly.

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 I8000E, 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 I8000E: Additional Active ICD Diagnosis 5 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.