[music playing] dave nolley: welcome to the centers for medicare and medicaid services post-acute care provider training series. my name is dave nolley and i'm moderating today's training session on mds 3.0. specifically, today's training will focus on coding of section i: active diagnoses. before we begin discussing this section of the mds 3.0, i would like to offer an important reminder. while the 2013 mds 3.0 educational programs provide great information about select sections of the mds 3.0, it is critical to remember
that the rai user's manual, which is available at the cms website, must be used routinely by assessors to ensure accuracy in coding the mds 3.0. specifically, chapter 3 of the rai user's manual is where intent, rationale, and step-by-step coding instructions can be found for each section and item in the mds 3.0. the goal of chapter 3 is to facilitate the accurate coding of the mds 3.0 and to provide assessors with the rationale and resources to optimize resident care and outcomes. before going any further, i would like to introduce our panelist for today. joining me today are jennifer pettis and shelly ray. hello ladies and thank you
for joining us today. in addition to discussing the coding instructions for section i, jennifer and shelly will field some frequently asked questions from the provider community. so, let's start with you, jennifer. would you share with us the intent of section i? in other words, why is this an important part of the mds 3.0 assessment? jennifer pettis: sure, dave. i'd be happy to. according to the rai user's manual, the items coded in section i reflect diseases that have a direct relationship to the resident's
current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. one of the important functions of the mds assessment is to generate an updated accurate picture of the resident's current health status at regularly scheduled intervals. the phrase "direct relationship" is noted in the intent statement. what exactly does that mean? that's an excellent question, dave, and that concept is critical to understand in order to accurately code section i. a disease that drives the resident's plan of care is considered one that has a direct relationship to the resident's
status and therefore is considered to be an active diagnosis. in the rai user's manual, there are specific criteria used to determine and document resident diagnoses and then to determine if a documented diagnoses is active. there are several examples provided that demonstrate this concept. this is what we'll be discussing in today's program. disease processes can have a significant adverse effect on an individual's health status and quality of life. when coding section i, the assessor identifies active diseases and infections that drive the current plan of care and include them on the mds 3.0 in this section. shelly, please tell us about the steps that the assessor takes to accurately
code section i. shelly ray: there are two very distinct steps with specific look-back periods for coding section i. in the first step, the assessor must identify diagnoses. this will be accomplished by ensuring a physician-documented diagnosis in the last 60 days. it is important to note that the physician-documented diagnoses requirement can also be met by a nurse practitioner, a physician's assistant, or a clinical nurse specialist if allowable under state licensure laws. shelly, it seems that we have a question from a provider in new york about this
first step. they wrote we have a nurse practitioner that works with our physician. how do i know if the physician-documented diagnosis criterion is met with the nurse practitioner's notation of a diagnosis? that is a great question and it is definitely a state-specific one. your state nursing board, state nurse practice act, or state survey agency should provide you with information as to who can document diagnoses in the medical record. and it's the state rai coordinator who can further assist in understanding the criteria and coding instructions provided in section i. the state rai coordinator contact information can be found in appendix b of the rai user's
manual. sometimes providers ask about potential medical record sources of physician diagnoses. that's right. for example, a provider in wyoming asks if the care plan identifies a diagnosis of depression and the signed, physician orders indicate he or she has reviewed the plan of care, does this meet the criteria of a physician documented diagnosis provided the physician's orders were signed within sixty days of the assessment reference date or ard? a signature associated with a physician review of a care plan is not an acceptable substitute for a physician-documented diagnosis even if there are
physician orders signed within 60 days of the ard. the physician's orders that document a diagnosis, medication, or treatment are acceptable, as are the following sources within the medical record: progress notes, history and physicals, transfer documents, discharge summaries, diagnosis problem list, and other sources as available. if a diagnosis problem list is used, only diagnoses confirmed by the physician should be entered. the rai user's manual offers a couple of other key points about this section. although open communication regarding diagnostic information between the physician and other members of the interdisciplinary team is important, it is
also essential that diagnoses communicated verbally be documented in the medical record by the physician or other health care practitioner as allowable under state licensure laws to ensure follow-up. diagnostic information should be verified and documented in the medical record by the physician. past history obtained from family members and close contacts should also be documented in the medical record to ensure validity and follow-up by the physician. thanks, shelly. jennifer, can you provide an example of this? sure, dave. let's say a resident's daughter communicates to the facility social worker that the resident has a long history of depression. the daughter goes
onto report specific signs and symptoms that the staff should be aware of as these symptoms represent the need for additional measures to be taken to avoid a potential reoccurrence of the resident's depression. the social worker informs the physician of the discussion with the family. the physician then contacts the resident psychiatrist who provides the history. the physician then documents the diagnosis of depression in the resident's medical record. as long as the diagnosis is physician-documented in the last 60 days, the first qualifier has been met. ok. that was a great explanation of the first step of diagnoses identification.
can you describe the second step in determining if a diagnosis should be included in section i of the mds 3.0? sure. the second step of this two-step process is to determine whether diagnoses are active. active diagnoses are those that 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 seven-day look-back period. the assessor will not include conditions that have been resolved, do not affect the resident's current status, or do not drive the resident's plan of care during the seven-day look-back period as these would be considered active
diagnoses. we've heard examples of potential sources for physician diagnoses. shelly, do you have suggestions for where the assessor might find information that indicates the diagnosis is active in the last seven days? some potential sources include transfer documents, physician's progress notes, recent history and physicals, recent discharge summaries, nursing assessments, care plans, medication sheets, doctor's orders, consults, and diagnostic reports. this is not an all inclusive list but rather just some of the potential places in the medical record that the information might be located.
let's continue our early example in which the resident's daughter reported their depression. the team was successful in obtaining supporting information from the resident's mental health provider, which was added to the medical record. the care plan was updated to include the information from the daughter and the mental health provider including necessary monitoring and measures to take if the signs and symptoms of depression that were reported prior reoccur. taking all this information into account, it can be said that this diagnosis is active for the resident. shelly, we have a question from a provider in nebraska regarding determining if
a diagnosis is active. this is a resident specific question about ms. a. who is a new resident in the facility. she has diagnoses which include morbid obesity, stage 3 pressure ulcer, and hypoalbuminemia. ms. a is receiving protein supplements which were ordered by the physician after his consultation with the facility dietitian to aid in healing the stage 3 pressure ulcer. ms. a is also receiving a weight reduction diet per her request. after reviewing her most recent (30 days old) albumin level, the physician noted ms. a has protein malnutrition and requested the dietitian reevaluate ms. a's nutritional plan. adjustments to the dietary approaches to ms. a's plan were made and continue.
should i5600 malnutrition be coded? since we know she has been diagnosed with protein malnutrition by a physician during the last 60 days, the next step to take is to identify whether the diagnosis is active in the seven-day look-back period. ms. a is receiving additional protein to address newly diagnosed hypoalbuminemia and will continue with protein supplements to aid in healing her stage 3 pressure ulcer. nutritional plan adjustments were documented in ms. a's care plan to address the diagnosis of protein malnutrition. this is all evidence of an active diagnosis for protein malnutrition in the seven-day look-back period.
that is a great example, shelly, thanks. in the examples we have just heard, references have been made to specific diagnoses and their correlating item numbers that are included in section i of the mds 3.0. jennifer, will an assessor find a comprehensive list of diagnoses on the mds 3.0? there are many diagnoses listed by major disease category on the mds 3.0. and there are some diagnoses listed that have examples of diseases to be included in those diagnoses. it's important to note that these examples are not all inclusive. for example, i0200, anemia, includes anemia of any etiology including those listed, which are aplastic, iron deficiency, pernicious, or sickle cell.
the assessor will check off each active disease, being careful to check all that apply. in addition to all of the listed diagnoses, there is a none-of-the-above option as well as i8000, other additional active diagnoses, where the assessor can enter the international classification of disease or icd code of any disease or condition that is not specifically listed. if there is a physician-documented diagnosis of quadriplegia within the last 60 days and it is still an active diagnosis in the last seven days, it is to be coded on the mds. quadriplegia is the complete paralysis that affects all four limbs caused by injury to the spinal chord in the area of the neck. it is
usually identified by which vertebrae have been injured in the cervical spine and how complete the severing of the spinal chord may be. a diagnosis of quadriplegia unspecified may be used if an injury is old and there's no medical documentation related to how the spinal chord injury actually happened. facilities in general should work to clarify any nonspecific diagnoses as much as possible. for mds 3.0, item i-5100, quadriplegia, is not coded as a primary diagnosis in section i when it is not caused by spinal chord injury. let's consider a specific example that may help to clarify this point further. mrs. z has end stage alzheimer's disease and can no longer move any of her
limbs. mrs. z is dependent on facility staff to assist her with all of her activities of daily living. in this case, ms. z is an individual who has a severe debilitating diagnosis with a functional deficit that can render her functionally immobile. this functional immobility may seem comparable with what would be seen in a quadriplegic. however, it is the diagnosis of end stage alzheimer's that would be coded on the mds in i4200, alzheimer's disease, and not i5200, quadriplegia. it would be inappropriate to code the functional status or adl deficit associated with alzheimer's disease under i-5100, quadriplegia.
similarly, a resident with a diagnosis of cerebral palsy, spastic quad type, would be coded under i-4400, cerebral palsy, and not under i-5100, quadriplegia. a resident with severe rheumatoid arthritis would be coded under i-3700, arthritis, and not under i-5100, quadriplegia. if there is a physician-documented diagnosis of functional quadriplegia that is secondary to a debilitating disease, this diagnosis can be coded under i-800, other additional active diagnoses. regarding a resident with hemiplegia or hemiparesis secondary to cerebral vascular accident, cva, or a stroke, the cva is not considered the active
diagnosis if the cva itself has resolved. that is, the resident is receiving no treatment such as medications and or therapy to manage continued symptoms from the stroke. however, deficits, as in the case of mr. f, the hemiparesis are a result of the stroke that occurred two years. if the current plan of care is addressing deficits associated with hemiplegia or hemiparesis and all the requirements for coding the diagnosis as active are met, this should be captured in item i4900, hemiplegia or hemiparesis, and not under i4500, cerebral vascular accident. dave, there's one exception to these look-back periods: item i2300, urinary
tract infection or uti. not only does uti have a look-back period of 30 days for the active disease instead of seven or 60 days, it also has four elements that the assessor needs to identify in order to code this diagnosis. the first element is that the diagnosis of uti has to be present in the 30-day look-back period. like all diagnoses, this can be made by a physician or other authorized licensed staff as permitted by state law. next, the assessor needs to identify at least one sign or symptom attributed to uti. potential signs and symptoms are numerous and can certainly vary from one resident to another. a few common symptoms include fever, urinary symptoms such
as painful urination or urinary frequency, pain or tenderness, mental status changes including confusion, and changes in urine characteristics such as color or clarity. significant laboratory findings need to be determined by the attending physician as the level of these findings may vary amongst individuals. physicians should also determine whether or not a culture should be obtained. in other words, there may or may not be a need for a urine culture; it's the physician who determines the significance of any laboratory testing in conjunction with the individuals presenting signs and symptoms and whether the combination of these
findings are sufficient enough to constitute the diagnosis of uti. the fourth element is that a medication or treatment for a uti must be administered within the last 30 days. one thing that is really important to remember is that the rai user's manual does not provide definitions of diagnoses. this was an intentional omission as it's up to the physician that must make a determination and document the active diagnoses for all residents in the facility according to their assessment of the resident. determining if a diagnosis is active in the seven-day look-back period can be
challenging for some assessors. while the physician may specifically indicate that a diagnosis is active, it is very likely that the assessor will need to look for other sources of information that may document a particular diagnosis. there also may be documentation of a sign or symptom attributed to a diagnosis. it is important to remember, however, that sometimes signs and symptoms can be nonspecific and could be caused by a variety of diseases or conditions. for example, a productive cough would confirm a diagnosis of pneumonia if specifically noted as such by the physician and perhaps radiological reports. in other words, signs and symptoms alone do not stand on their own; they must be
specifically attributed to a particular disease or condition. all diagnoses documented in the medical record and subsequently reported on the mds must be those that have been confirmed by the physician. a medication indicates active disease if that medication is prescribed to manage an ongoing condition that requires monitoring or is prescribed to address symptoms associated with a particular condition. for example, if a medication is prescribed for a condition that requires regular staff monitoring of the drug's effect on that condition then the prescription of the medication would indicate active disease. yet the disease itself would still need to be confirmed and
documented in order to be coded on the mds. i see. it seems that there are a lot of potential sources where the information can be found to determine if there's an active diagnosis and the assessor needs to be aware of these sources in order to code section i correctly. we've covered a lot of information in today's training and answered some great questions from the provider community. we hope that you've found this training on section i to be helpful. ensuring mds 3.0 accuracy is critical to ensuring care plans, quality measures, and much more. if you have additional questions regarding section i, please refer to the rai user's manual. if you need further
clarification, please feel free to contact your state rai coordinator. the work that you do is important to ensure that the best possible care and quality of life is afforded to the residents in america's nursing homes. to all of you taking part in this educational activity, i would like to extend a final thank you on behalf of myself, jennifer, shelly, and cms. cms: section i 7 3/12/14 prepared by national capitol contracting 200 n. glebe rd. #1016 (703) 243-9696 arlington, va 22203
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