MDS Alert

Is it really an active or an inactive diagnosis?

MDS 3.0 coding is frustrating enough even with just one look-back period to figure out per section — but Section I Active Diagnoses gives you two look-back periods for the price of one.

And because of these two look-back periods, coding diagnoses in Section I is a two-step process, according to the Texas Department of Aging and Disability Services (DADS). First, you must identify diagnoses in the 60-day look-back period, and then you need to determine the active/inactive status of diagnoses during the seven-day look-back period.

Check All These Spots to Find Diagnoses

So for the first step, you’re looking in the medical record for physician-documented diagnoses within the last 60 days. For these diagnoses, you can look in the:

·         Progress notes;

·         Most recent history and physical;

·         Transfer documents;

·         Discharge summaries;

·         Diagnosis/problem list (only if physician confirmed diagnoses);

·         Consolidated physician orders containing diagnoses;

·         Other similar resources.

“As staff are only looking for physician diagnoses written in the look-back period, there is no reason to look for original or previous copies of orders written more than 60 days prior to the ARD,” stated a recent DADS instructional article.

Understand Active Vs. Inactive for Correct Coding

For the second step, you must determine whether the diagnoses are active during the seven-day look-back period (except for Urinary Tract Infection, which has a 30-day look-back period — see story on page 51), DADS said. This isn’t always as easy as it may sound, however.

In the November 2012 update to the RAI Manual, the Centers for Medicare & Medicaid Services (CMS) continued to try to clarify what “active diagnosis” means, without actually making policy changes, according to Judy Wilhide Brandt, RN, BA, RAC-MT, in her synopsis of the changes for Washington, DC-based Leading Age, an association of non-profit organizations focused on aging.

Here’s how the MDS describes active and inactive diagnoses:

Active Diagnoses are diagnoses that, during the seven-day look-back period, have a direct relationship to the resident’s current:

·     Functional, cognitive or mood, or behavior status;

·     Medical treatments;

·     Nursing monitoring; or

·     Risk of death.

Inactive Diagnoses are conditions (during the seven-day look-back period) that:

·     Have been resolved;

·     Do not affect the resident’s current status; or

·     Do not drive the resident’s plan of care.

Mistake: “Physician consolidated orders or other tools that only list and/or confirm existing diagnoses, even if signed in the seven-day look-back period, do not make the listed diagnoses active,” DADS pointed out. “However, new orders written in the seven-day look-back period as the result of the onset of a new disease/diagnosis would qualify as active.”

What to Do When You Lack Direct Documentation

But in the absence of specific documentation that a disease or condition is active, how can you decide? How can you know that there was a recent onset or acute exacerbation that would qualify as an active diagnosis in the last seven days? Ann Spenard, MSN, RN, C, vice president for operations at Qualidigm, based in Rocky Hill, CT, offers the following suggestions in a CMS instructional session:

·         Test results: Did the resident present symptoms within the last seven days, followed by testing, such as an x-ray, blood work or an EKG? Did the test show changes in the resident’s health status that produced a new diagnosis or the sudden worsening of a past diagnosis?

·         Therapy: Is the resident receiving new or different therapies, based on a change in health status that could be connected to a now active diagnosis?

·         Signs and symptoms: Is the resident presenting with symptoms and abnormal signs indicating ongoing or decompensated disease in the last seven days? For example, is the resident experiencing increased pain or other problems that indicate an active disease or condition?

·         Medications: What medications is the resident currently taking, or has taken in the last seven days, and why? Is the medication for treating an active diagnosis? Does the medication require staff monitoring of the drug’s effect?