MDS Alert

Miscoding or omitting diagnosis codes here can hurt your facility.

So many diagnoses ... so little space to record them in I3. You have to make good use of those "five golden lines" in I3, advises Gail Robison, RN, RAC-C, a consultant with Boyer and Associates in Brookfield, WI.

The intent for I3 is to identify additional conditions not listed in I1 and I2 that affect the resident's current ADL status, mood and behavioral status, medical treatments, nursing monitoring, or risk of death, according to the RAI manual. If space permits, I3 may also be used to record more specific designations for general disease categories listed under I1 and I2, the manual adds.

You don't have to put a more specific ICD-9-CM code in I3, as long as the condition checked in I1 or I2 reflects what you're doing for the resident, advises Cindy MacQuarrie, RN, MSN, a consultant with BKD in Springfield, MO.

Use more specific codes related to a condition checked in I1 or I2 if it impacts the resident's care plan. One example would include diabetic neuropathy.

If the person's primary diagnosis for Medicare Part A is more specific or detailed than what's in I1 or I2, include that in I3, advises Cindy Fronning, RN, C, DNS, a consultant with Pathway Health Services in White Bear Lake, MN. "That diagnosis should also go on the claim as the primary diagnosis."

You don't have to rank order the diagnoses in I3, says Darlene Greenhill, RN, a consultant in Atlanta, but sequence codes for Medicare billing to support the daily skilled services. "These are generally submitted separately to the biller by the MDS coordinator."

Good idea: Robison recommends that both nursing and rehab sequence the codes that are the focus of skilled care. "Otherwise, the resident being treated for a fractured hip may have all medical diagnoses on the billing log and no V codes for his rehab therapy."

Remember: You can put V codes in I3, says Greenhill. Also, MDS coordinators must be sure to use the latest ICD-9-CM codes. If you rely on codes from the software, be sure they are the latest ones. "Ideally SNFs will have a trained coder," Greenhill adds.

Check the Lookback

Observe the correct lookback period for I3, which is seven days except for all quarterly assessments, which require a 90-day lookback, says Greenhill. The RAI manual states that the intent of I3 on the Quarterly Assessment Form is to update newly diagnosed diseases. However, include only those diseases diagnosed in the last 90 days that have a relationship to current ADL status, mood or behavior status, medical treatments, nursing monitoring, or risk of death.

Weed Out Outdated Diagnoses

"The MDS coordinator has to pay close attention to software programs that roll diagnoses forward from one assessment to the next," advises Fronning. For example, if you have coded an ICD-9-CM code for pressure ulcer or dehydration in I3 on a previous MDS, some software will roll it over so it's present on the next MDS, she cautions. And an ICD-9-CM code for pressure ulcer or dehydration in I3 can trigger the chronic-care pressure ulcer or dehydration QIs/QMs.

To review the ICD-9-CM diagnoses coded in I3 that affect the QIs/QMs, including pressure ulcers; dehydration; antipsychotic use in the absence of psychotic or related conditions; antianxiety/hypnotic use; and behavioral symptoms affecting others, go to http://www.qtso.com/download/mds/qiqm_rpt/Appendix_A_Technical_Specs_v1.1.pdf.