Understanding and Coding MDS Item I8000F: Additional Active ICD Diagnosis 6

Introduction

Purpose:
MDS Item I8000F, "Additional Active ICD Diagnosis 6," is used to document the sixth active ICD-10 diagnosis that affects the resident’s care during the look-back period. Accurate coding of this item ensures that all relevant diagnoses influencing the resident’s care plan are captured, providing a comprehensive view of their health status.

What is MDS Item I8000F?

Explanation:
MDS Item I8000F is part of the I8000 series, where facilities can list active diagnoses using ICD-10 codes. This item allows for the documentation of the sixth active diagnosis that directly affects the resident’s care during the look-back period (typically 5–7 days). Active diagnoses include any medical condition that requires ongoing care, monitoring, or treatment, such as chronic conditions (e.g., heart disease, diabetes) or acute issues (e.g., infections, injuries).

Capturing these diagnoses in the MDS assessment is essential for creating an individualized care plan and ensuring that appropriate resources are used in the resident’s treatment.

• Relevance: Active diagnoses provide insight into the resident’s health needs, guiding care decisions and interventions. Documenting all relevant conditions ensures that the care team can address the resident’s comprehensive medical needs.
• Importance: Proper coding of I8000F ensures that the sixth active diagnosis is recorded in the MDS assessment, helping to tailor the resident’s care plan and facilitate accurate Medicare or Medicaid reimbursement.

Guidelines for Coding MDS Item I8000F

Coding Instructions:

1. Identify Active Diagnoses:
   Review the resident’s medical record to identify all diagnoses that are actively affecting their care. An active diagnosis requires ongoing treatment, monitoring, or assessment and impacts the resident’s day-to-day management.

2. Select the Appropriate ICD-10 Code:
   Choose the correct ICD-10 code for the sixth active diagnosis. Ensure that the diagnosis is actively influencing the resident’s care and is accurately documented in the medical record, such as in physician notes, treatment plans, or therapy records.

3. Answering I8000F:

   • Enter the ICD-10 code for the sixth active diagnosis that affects the resident’s care.
   • Ensure the diagnosis is active during the look-back period and directly impacts the resident’s treatment, monitoring, or care decisions.

4. Documentation Requirements:
   The diagnosis entered in I8000F must be supported by the resident’s medical record. Documentation should demonstrate that the condition required active management during the look-back period. Examples include changes in medication, therapy adjustments, or ongoing monitoring.

5. Verification:
   Verify the accuracy of the ICD-10 code by cross-referencing it with the resident’s care plan and medical history. Ensure that only active and relevant diagnoses are included in the MDS assessment.

Example Scenario:
Ms. Bennett, a 79-year-old resident, has been managing chronic obstructive pulmonary disease (COPD), which requires daily inhaler use and oxygen therapy. This condition, coded as J44.9 (Chronic obstructive pulmonary disease, unspecified), is listed as her sixth active diagnosis in I8000F, as it significantly affects her daily care and treatment plan.

Best Practices for Accurate Coding

Documentation:
Ensure that all active diagnoses in the I8000 series, including I8000F, are well-documented in the resident’s medical record. The documentation should clearly show that the condition was actively managed, treated, or monitored during the look-back period.

Communication:
Coordinate with the interdisciplinary care team, including physicians, nurses, and therapists, to ensure all relevant diagnoses are accurately coded. Open communication ensures that the resident’s health needs are fully represented in their care plan and that all diagnoses are correctly listed in the MDS.

Training:
Provide staff training on how to identify and code active diagnoses using ICD-10 codes. Proper training ensures that the MDS assessment accurately reflects the resident’s current health status and that diagnoses are coded consistently and correctly.

Conclusion

MDS Item I8000F is essential for documenting the sixth active diagnosis that affects a resident’s care. Accurate coding of this item helps ensure that the resident’s full medical profile is captured in the MDS assessment, allowing for individualized care planning. Proper documentation, communication, and staff training are crucial for ensuring that active diagnoses are correctly coded and that the resident receives the care they need.

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 I8000F, 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 I8000F: Additional Active ICD Diagnosis 6 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.