- In this session,
I will present the definition of active diagnosis,
the intent of Section I,
explain the new items and changes,
discuss coding instructions, and walk through
a few coding scenarios using the new items.
I have reviewed some of the questions
that were submitted this morning,
And, hopefully, my presentation will answer some of them.
I0050 and I0500A are new items on the admission assessment.
Changes include an expanded list of comorbidities
and co-existing conditions.
I will be going over the new items
in more detail in subsequent slides.
The items in Section I are intended to indicate
the presence of select diagnosis
that influence a patient's functional outcomes,
or increase a patient's risk
for the development or worsening of pressure ulcers.
As we all know, a patient's disease processes and conditions
can significantly affect a patient's health status
and quality of life.
This section serves to identify
the active diseases or conditions
that are associated with the patient's LTCH stay.
An important component of completing Section I
is identifying the patient's primary medical diagnosis,
and determining if they are active.
Active diagnosis are those diagnoses
that have a direct relationship to the patient's current
functional, cognitive, mood or behavior status,
medical treatments, nurse monitoring,
or risk of death at the time of the assessment.
Diseases or conditions
that have been resolved at the time of the assessment,
or do not affect any of the patient factors
I just mentioned, should not be included.
Item I0050 describes the major medical conditions
for which the patient was admitted to the LTCH,
and applies to the admission assessment only.
The four condition categories are:
Acute onset respiratory condition,
such as aspiration and specified bacterial pneumonia;
chronic respiratory conditions,
such as chronic obstructive pulmonary disease;
acute onset and chronic respiratory conditions;
and chronic cardiac conditions, such as heart failure.
What you would do in this section
is enter the code of the primary medical condition,
for example, 1 for acute onset respiratory condition,
2 for COPD, etcetera.
If your patient has a diagnosis
that's not indicated in one of these four categories,
then you would enter the number 5, as the code,
and then in I005A, you would enter the ICD code
for that particular diagnosis.
So for example, if your patient's primary diagnosis
was complete tetraplegia also known as quadriplegia,
you would enter the ICD code for complete tetraplegia.
The first step for the assessment
is to identify the primary medical condition
as shown on the list in the previous slide.
The diseases and conditions in this section
require a physician, or nurse practitioner,
physician assistant, clinical nurse specialist,
or other authorized licensed staff,
if allowable under state licensure laws,
documented diagnoses at the time of the assessment.
The second step in the assessment process
is to determine the patient's active diagnosis.
As previously stated, active diagnoses
are diagnoses that have a direct relationship
to the patient's current functional, cognitive,
mood or behavior status, medical treatments,
nurse monitoring, or risk of death
at the time of the assessment.
The patient's diagnosis may be found in any of,
or a combination of, the medical records resources
listed on this slide--
patient problem list, physician orders,
history and physical, etcetera.
Although open communication regarding diagnostic information
between the physician and other clinical staff is important,
it is also essential that diagnosis communicated verbally
be documented in the medical record, by the physician,
or another authorized licensed staff person
as I've previously described,
to ensure follow-up and coordination of care.
Diagnostic information,
including past medical and surgical history
obtained from family members and close contacts,
must also be documented in the medical record
by the physician, or designee
to ensure validity, follow-up and coordination of care.
A key point in identifying the primary medical condition
is determining whether or not,
as I've said already, the diagnoses are active.
Once the diagnosis is identified,
determine whether the diagnosis is active.
As previously stated, you would not include diseases
or conditions that have been resolved
or do not affect the patient's current functional, cognitive,
mood or behavior status, medical treatments,
nurse monitoring, or risk of death at the time of assessment.
Sources of documentation are those shown on slide seven,
such as transfer documents, consults,
and official diagnostic reports, medication records, et cetera.
As previously mentioned,
only diagnoses confirmed by the physician
or other licensed independent practitioners,
that are active should be coded on the LTCH Care Data Set.
The LTCH Care Data Set should reflect what was known
and documented at the time of the assessment.
An important point when completing these data elements,
if information regarding active diagnoses
is learned after the assessment reference state,
the LTCH should notify the LTCH--
modify the LTCH Care Data Set
in accordance with the instructions in chapter four
under correcting errors in LTCH Care Data Set assessment records
that have been accepted into the QIES ASAP system.
This slide reviews the item set
for primary medical condition categories
as previously described.
Once you have entered the patient's primary
medical condition, proceed to the list
of comorbidities and co-existing conditions.
This slide depicts the neurological domain
as an example of the comorbidities
and co-existing conditions component of Section I.
If a patient has any of these conditions,
the person completing the data set
should check all that applies.
This section is completed
only if A2050, reasons for the assessment,
equals 01 admission.
You should code diseases or conditions that have
a documented diagnosis at the time of the assessment
and are active.
As previously stated, oops--
As stated earlier in the presentation,
the list of comorbidities and co-existing conditions
have been expanded.
Version 3.0 of the LTCH Care Data Set has eight categories
representing 23 diagnoses,
and a place to indicate that none of the above
apply to the patient being assessed.
In addition to the neurological category
displayed on this slide,
the expanded-- on the previous slide,
the expanded list of comorbidities
and co-existing conditions comprise cancer,
heart circulation, genitourinary infections,
metabolic, musculoskeletal,
nutritional, or none of the above.
If the patient does not have any of the active diagnoses
listed above, you would check I7900.
As previously stated,
there must be specific documentation
in the medical record by a physician, or their designee,
of the disease or condition being an active diagnosis.
The physician or designee may specifically indicate
that a diagnosis is active.
Specific documentation areas in the medical record
may include, but are not limited
to, the previously mentioned sources of documentation.
The physician or designee, for example, documents
at the time of the assessment that the patient has
inadequately controlled diabetes,
and requires an adjustment of the medication regimen.
This would be sufficient documentation
of an active diagnosis,
and would require no additional confirmation,
because the physician documented the diagnosis
and also confirmed that the medication regimen
needs to be modified.
This slide shows the eight categories
and their associated diagnoses.
The comorbidities and co-existing conditions
were identified through the PAC-PRD research,
developed these data set elements.
In that study, the diabetes group
was the most common comorbidity
identified overall in post acute-care settings
and 78% of LTCHs reported this
as the most frequently occurring group.
Orthopedic infections were also reported in 40% of LTCHs.
So giving some examples of how you would
use these comorbidities and co-existing conditions
and how you would code them.
So, for example, you would check I0101, cancer,
if the patient has metastatic cancer,
defined as acute leukemia, lung cancer,
multiple myeloma, and lymphoma.
You would check I0900, heart circulation,
if the patient has peripheral vascular disease
or peripheral artery disease.
You would check I2101, infection category,
if the patient has an active diagnosis
of septicemia, sepsis,
or stomach inflammatory response syndrome, or shock.
You would check I4501, stroke, if the patient had, for example,
a diagnosis of cerebral hemorrhage,
ischemic or unspecified stroke,
lead effects of cerebrovascular disease.
And the last example is, you would check I5000, paraplegia,
if the patient had a fracture at the T-1 to T-6 level
with complete lesion of the spinal cord,
fracture of T-7 to T-12 level
with complete lesion of the spinal cord.
One of the items that's changed on the comorbidities list
is the nutritional section.
Previously, in version 2.0, this was I5600.
In version 3.0, nutritional
has been separated into two components,
I5601, malnutrition,
and I5602, which is at risk for malnutrition.
The next several slides will depict four scenarios
that will illustrate how to code
the comorbidities and co-existing conditions.
As we go through the scenarios,
please call out the diagnoses from the list,
because we don't have cards for the item sets.
There will be too many.
The list of comorbidities is on page I3 of the manual,
or on the LTCH Care Data Assessment form.
In the first scenario,
the patient has amyotrophic lateral sclerosis
and requires a ventilator to breathe.
The physician's progress note documents the diagnosis of ALS.
How would you code section I?
And what is your rationale?
Now you all had lunch,
so you should have some energy out there.
[LAUGHTER]
I know the brain is working.
Anyone want to be-- to guess?
- 450.
- That is correct.
[APPLAUSE]
Thank you!
I5450 ALS is the correct response.
And this is considered an active diagnosis,
because the physician's progress note documents
the ALS diagnosis resulting in the need for ventilation.
Scenario two,
Mrs. I underwent a below-the-knee amputation
due to gangrene associated with peripheral vascular disease.
She requires dressing changes to the stump
and monitoring for wound healing.
In addition, peripheral pulse monitoring is ordered.
The nurse practitioner's progress note
documents PVD and left BKA,
how would you code Section I and what is your rationale?
- I4100... [indistinct]
- Thank you, that is correct.
The patient has two active diagnoses,
as our audience member correctly identified.
Both of these would be checked as they are active diagnoses,
as documented in the nurse practitioner's progress notes,
as PVD, with peripheral pulse monitoring and recent BKA
with dressing changes and wound status monitoring.
In the third scenario,
the patient underwent a total knee replacement
six months ago and developed a tibial infection.
The total knee prosthesis was removed and a spacer was placed
to maintain proper positioning of the limb.
The physician's progress note documents the diagnosis
of bone infection, and the need for antibiotic therapy.
How would you code this section?
- [indistinct]
- That is correct. Thank you.
You would code I2600
because bone, joint, muscle infections, necrosis
are included in this category,
and because the physician progress note
documents that bone infection
and the need for antibiotic therapy.
The fourth and final scenario involves a patient
who had a malignant spinal cord tumor
removed at level T-6,
and experienced complete paraplegia.
The physician's progress note
documents the diagnosis of malignancy,
and the need for further treatment
with chemotherapy and radiation.
What would be the code for this scenario?
- [indistinct]
- That is correct.
Thank you again.
You would check both of these,
I0101, severe and metastatic cancers,
and I5000, paraplegia,
because the physician's progress note
documents the diagnoses of cancer and paraplegia.
This concludes the example scenarios.
In summary, Section I, active diagnoses,
captures select diagnoses that could influence
a patient's functional outcomes or risk for pressure ulcers.
The new item I0050
captures the patient's primary medical condition,
and the new item I005A,
requires the data collector to enter an ICD code
if the patient has a primary medical condition
not included in the four diagnoses categories.
The list of comorbidities
and co-existing conditions is expanded.
The nutritional category now has two conditions,
I5601, malnutrition,
and I5602, at risk for malnutrition.
The last slide-- oops!
I'm behind or ahead of myself, any ways.
The last slide, are my recommendations
for what to cover with your staff
when you return to your hospital.
Review Section I in its entirety
with an emphasis on the steps for assessment,
including identification
of the patient's primary medical condition,
and comorbidities and co-existing conditions.
Reinforce the importance
of documenting the needed information
in the medical record, and using only documented
comorbidities and co-existing conditions
to complete this section.
Reinforce that staff should not infer a diagnosis
from documentation that is not consistent
with the specific diagnoses.
So for example, weight loss in a patient's progress notes
should not be inferred to mean malnutrition.
This ends the presentation of Section I.