Disorganized Diagnoses in Section I
Section I is often a source of inaccurate coding. Inaccurate coding may cause loss of reimbursement, poor quality ranking, and poor resident care.
The RAI Manual describes active diagnoses as:
“Physician-documented diagnoses in the last 60 days that have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death (emphasis added) during the 7-day look-back period.”
The manual goes on to specify:
“There are two look-back periods for this section: Diagnosis identification (Step 1) is a 60-day look-back period. Diagnosis status: Active or Inactive (Step 2) is a 7-day look-back period (except for Item I2300 UTI, which does not use the active 7-day look-back period).”
So, what should this mean to MDS Coordinators? If the criteria for the first step is not met, we stop there and do not code the diagnosis. Is the diagnosis documented by a provider within the required 60-day window?
Here is what to look for:
- Physician documentation in progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/ problem list, and other resources as available.
- Do not rely only on diagnosis lists.
- Even if the diagnosis was spoken about during IDT (interdisciplinary team) communication, it is still essential that diagnoses be documented in the medical record by the physician.
- Reported diagnoses from family members or representatives, must also be documented in the medical record by the physician to ensure validity and follow-up.
If the discussed diagnosis is not documented by a provider but is pertinent, the MDS Coordinator should query the medical provider to find out why it was not listed in the provider’s documentation.
Providers who can document a diagnosis include:
- Physician
- Nurse Practitioner
- Physician Assistant
- Clinical nurse specialist as allowed by state
Do not include conditions that have been resolved, do not affect the resident’s status, or do not drive the resident’s plan of care during the 7-day look-back period- these are inactive diagnoses.
Once you identify physician documentation, go on to step 2. Do these diagnoses have a direct relationship to the resident’s current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period? In other words, are the diagnoses active?
The RAI states:
“There may be specific documentation in the medical record by a physician, nurse practitioner, physician assistant, or clinical nurse specialist of active diagnosis (emphasis added). In the absence of specific documentation that a disease is active, the following indicators may be used to confirm active disease: Recent onset or acute exacerbation of the disease or condition indicated by a positive study, test or procedure, hospitalization for acute symptoms and/or recent change in therapy in the last 7 days.”
Here is where to look for clues:
- transfer documents
- physician progress notes
- recent history and physical
- recent discharge summaries
- nursing assessments
- nursing care plans
- medication sheets
- doctor’s orders
- consults and official diagnostic reports
- other sources as available
Lastly, remember three other pointers:
- Examples listed in section I are not all inclusive. For item I0200, Anemia- this item includes anemia of any etiology, including those listed (e.g., aplastic, iron deficiency, pernicious, sickle cell). One should also include vitamin B12 anemia, even if it is not listed.
- Item I2300 (UTI) has specific coding criteria and does not use the active 7-day look-back. Please refer to Page I-12 in the RAI Manual (or our blog specifically on this topic) for specific coding instructions for Item I2300 UTI.
- Quadriplegia is when there is paralysis of all four limbs caused by a spinal cord injury. Check item I5100 for quadriplegia only when the condition is a result of spinal cord injury and not the result of another condition, such as dementia or cerebral palsy.
Good look weeding out inaccurate coding in Section I!