Understanding and Coding MDS Item I8000I: Additional Active ICD Diagnosis 9

Understanding and Coding MDS Item I8000I: Additional Active ICD Diagnosis 9

Introduction

Purpose:
MDS Item I8000I, "Additional Active ICD Diagnosis 9," is used to document the ninth active ICD-10 diagnosis relevant to a resident’s care during the look-back period. Proper coding of this item ensures that all significant diagnoses influencing the resident's care plan are captured, providing a comprehensive picture of their health and supporting effective care management.

What is MDS Item I8000I?

Explanation:
MDS Item I8000I is part of the I8000 series, where facilities can list active diagnoses using ICD-10 codes. This item allows for the recording of the ninth active diagnosis that impacts the resident’s care during the assessment period. Active diagnoses refer to conditions that require ongoing monitoring, treatment, or care, such as chronic diseases (e.g., hypertension, diabetes) or acute conditions (e.g., pneumonia, fractures).

The ICD-10 diagnoses listed in I8000 are essential for planning the resident’s care and ensuring that appropriate services and interventions are provided.

• Relevance: Active diagnoses provide valuable insight into the resident’s health status, highlighting conditions that need attention. Each diagnosis included in I8000 contributes to the creation of a tailored care plan, focusing on the resident’s specific medical needs.
• Importance: Proper coding of I8000I ensures that the resident’s ninth active diagnosis is accurately documented, which supports better care coordination, accurate resource use, and appropriate reimbursement for services under Medicare and Medicaid.

Guidelines for Coding MDS Item I8000I

Coding Instructions:

1. Identify Active Diagnoses:
   Review the resident’s medical record to identify active diagnoses that require treatment, monitoring, or assessment during the look-back period. Only active conditions that directly influence the resident’s care plan should be listed.

2. Select the Appropriate ICD-10 Code:
   Choose the correct ICD-10 code that corresponds to the ninth active diagnosis. Ensure the code is accurate and reflects the diagnosis being actively treated or monitored. This may involve consulting medical documentation, such as physician notes or hospital discharge summaries.

3. Answering I8000I:

   • Enter the ICD-10 code for the ninth active diagnosis that affects the resident’s care during the look-back period.
   • Verify that the diagnosis is relevant to the resident’s current health status and requires active monitoring or treatment.

4. Documentation Requirements:
   Ensure that the diagnosis entered in I8000I is supported by the resident’s medical record. Documentation should show that the diagnosis was actively monitored, treated, or required care during the look-back period. Examples of supporting documentation include physician notes, treatment records, and care plans.

5. Verification:
   Confirm that the ICD-10 code for the ninth diagnosis is correctly documented by cross-referencing the resident’s medical history and care plan. If the diagnosis is no longer active or does not influence the resident’s current care, it should not be included in I8000I.

Example Scenario:
Mr. Baker, a 76-year-old resident, is being monitored for his hypertensive heart disease (ICD-10 code I11.9), which has required daily blood pressure monitoring and adjustments to his medications during the look-back period. This condition is recorded as his ninth active diagnosis in I8000I.

Best Practices for Accurate Coding

Documentation:
Ensure that all active diagnoses in the I8000 series, including I8000I, are supported by proper documentation in the resident’s medical record. This includes evidence that the condition is being monitored, treated, or assessed, and that it is actively influencing the resident’s care.

Communication:
Coordinate with the interdisciplinary care team, including physicians, nurses, and therapists, to ensure all active diagnoses are identified and correctly coded. Open communication ensures that the resident’s medical needs are comprehensively addressed in their care plan.

Training:
Provide staff training on how to correctly code active diagnoses using ICD-10. Ensure that staff are familiar with the criteria for an active diagnosis and the importance of accurate coding for care planning and resource allocation.

Conclusion

MDS Item I8000I is essential for documenting the ninth active diagnosis that impacts a resident’s care. Accurate coding of this item helps ensure that the resident’s health status is fully represented in their MDS assessment and that appropriate care and interventions are provided. Proper documentation, communication, and staff training are vital to ensuring that all active diagnoses are coded correctly and comprehensively.

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 I8000I, 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 I8000I: Additional Active ICD Diagnosis 9 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.