Understanding and Coding MDS Item I8000H: Additional Active ICD Diagnosis 8

Understanding and Coding MDS Item I8000H: Additional Active ICD Diagnosis 8

Introduction

Purpose:
MDS Item I8000H, "Additional Active ICD Diagnosis 8," is used to document the eighth active ICD-10 diagnosis relevant to a resident’s care during the look-back period. This item ensures that all significant diagnoses are captured in the MDS assessment, providing a complete picture of the resident’s medical conditions and their impact on care.

What is MDS Item I8000H?

Explanation:
MDS Item I8000H is part of the I8000 series, where facilities can list active diagnoses using ICD-10 codes. This specific item allows for the documentation of the eighth active diagnosis that is relevant to the resident’s care. These active diagnoses refer to medical conditions that require treatment, monitoring, or care during the look-back period, such as chronic illnesses or acute health issues.

Including the resident’s active diagnoses helps ensure the care team understands the scope of their medical needs and adjusts the care plan accordingly. The diagnoses listed in I8000, including I8000H, contribute to determining resource utilization and appropriate interventions.

• Relevance: Active diagnoses are crucial for understanding the resident’s current medical needs. By documenting these conditions, the care team can provide individualized care and ensure that the resident’s conditions are appropriately managed.
• Importance: Proper coding of I8000H ensures that the eighth active diagnosis is accurately reflected in the resident’s MDS assessment. This aids in the creation of a tailored care plan and ensures proper reimbursement for services under Medicare and Medicaid.

Guidelines for Coding MDS Item I8000H

Coding Instructions:

1. Identify Active Diagnoses:
   Review the resident’s medical record to identify conditions that are actively treated or monitored during the look-back period. An active diagnosis requires ongoing care, such as medication management, therapy, or monitoring.

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

3. Answering I8000H:

   • Enter the ICD-10 code for the eighth active diagnosis that is relevant to the resident’s care during the look-back period.
   • The selected diagnosis should reflect a condition that directly impacts the resident’s current treatment plan, whether chronic or acute.

4. Documentation Requirements:
   Ensure that the active diagnosis entered in I8000H is supported by documentation in the resident’s medical record, such as physician notes, nursing assessments, or treatment plans. The diagnosis should be clearly linked to care or monitoring provided during the look-back period.

5. Verification:
   Verify the ICD-10 code and diagnosis by cross-referencing the resident’s care plan, medical history, and documentation. If the diagnosis is no longer relevant or is not actively affecting care, it should not be included in I8000H.

Example Scenario:
Mr. Roberts, a 78-year-old resident, is being treated for benign prostatic hyperplasia (BPH), which is managed with medications and regular assessments. This diagnosis, documented as N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms), is entered as his eighth active diagnosis in I8000H.

Best Practices for Accurate Coding

Documentation:
Ensure that each active diagnosis listed in the I8000 series, including I8000H, is well-documented in the resident’s medical record. The documentation should show that the condition is being monitored, treated, or affecting care during the look-back period.

Communication:
Collaborate with the entire care team, including physicians, nurses, and therapists, to ensure all active diagnoses are identified and accurately coded. This ensures that the resident’s complete medical picture is reflected in their care plan.

Training:
Provide staff training on how to accurately identify and code active diagnoses using ICD-10 codes. This helps ensure that all relevant conditions are captured and that the coding process is consistent with the resident’s care needs.

Conclusion

MDS Item I8000H is essential for documenting the eighth active diagnosis that impacts a resident’s care. Accurate coding of this item ensures that the resident’s medical conditions are fully represented in their MDS assessment, allowing for the development of an individualized care plan. Proper documentation, communication, and staff training are key to 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 I8000H, 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 I8000H: Additional Active ICD Diagnosis 8 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.