Minimum Data Set 3.0 Resident Assessment Instrument User`s Manual
Contents
1. hypercholesterolemia e 13400 thyroid disorder e g hypothyroidism hyperthyroidism Hashimoto s thyroiditis October 2011 Page l 5 CMS s RAI Version 3 0 Manual CH 3 MDS Items I I Active Diagnoses in the Last 7 Days cont Musculoskeletal 13700 arthritis e g degenerative joint disease DJD osteoarthritis rheumatoid arthritis RA 13800 osteoporosis 13900 hip fracture any hip fracture that has a relationship to current status treatments monitoring e g subcapital fractures and fractures of the trochanter and femoral neck 14000 other fracture Neurological 14200 Alzheimer s disease 14300 aphasia 14400 cerebral palsy 14500 cerebrovascular accident CVA transient ischemic attack TIA or stroke 14800 dementia e g Lewy Body dementia vascular or multi infarct dementia mixed dementia frontotemporal dementia such as Pick s disease and dementia related to stroke Parkinson s disease or Creutzfeldt Jakob diseases 14900 hemiplegia or hemiparesis 15000 paraplegia 15100 quadriplegia 15200 multiple sclerosis MS 15250 Huntington s disease 15300 Parkinson s disease 15350 Tourette s syndrome 15400 seizure disorder or epilepsy 15500 traumatic brain injury TBI Nutritional 15600 malnutrition protein or calorie or at risk for malnutrition Psychiatric Mood Disorder 15700 anxiety disorder 15800 depression other than bipolar 15900 manic depression2. bipolar disease 15950 psychotic disorder other than schizophrenia 16000 schizophrenia e g schizoaffective and schizophreniform disorders 16100 post traumatic stress disorder PTSD April 2012 Page I 6 CMS s RAI Version 3 0 Manual CH 3 MDS Items I I Active Diagnoses in the Last 7 Days cont Pulmonary e 16200 asthma chronic obstructive pulmonary disease COPD or chronic lung disease e g chronic bronchitis and restrictive lung diseases such as asbestosis e 16300 respiratory failure Vision e 16500 cataracts glaucoma or macular degeneration None of Above e 7900 none of the above active diagnoses within the past 7 days Other e 18000 additional active diagnoses Coding Tips The following indicators may assist assessors in determining whether a diagnosis should be coded as active in the MDS e There may be specific documentation in the medical record by a physician nurse practitioner physician assistant or clinical nurse specialist of active diagnosis The physician may specifically indicate that a condition is active Specific documentation may be found in progress notes most recent history and physical transfer notes hospital discharge summary etc For example the physician documents that the resident has inadequately controlled hypertension and will modify medications This would be sufficient documentation of active disease and would require no additional confirmation e In t
3. difficulties standing and leaning over Coding Hip Fracture item 13900 would not be checked Rationale Although the resident has mobility and self care limitations in ambulation and ADLs due to the hip fracture he has not received therapy services during the 7 day look back period thus Hip Fracture would be considered inactive October 2011 Page l 10
4. CMS s RAI Version 3 0 Manual CH 3 MDS Items I SECTION I ACTIVE DIAGNOSES Intent The items in this section are intended to code 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 I Active Diagnoses in the Last 7 Days Active Diagnoses in the last 7 days Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all inclusive lists eo ae ee nay O 10100 Cancer with or without metastasis Heart Circulation Anemia e g aplastic iron deficiency pernicious and sickle cell Atrial Fibrillation or Other Dysrhythmias e g bradycardias and tachycardias Coronary Artery Disease CAD e g angina myocardial infarction and atherosclerotic heart disease ASHD Deep Venous Thrombosis DVT Pulmonary Embolus PE or Pulmonary Thrombo Embolism PTE Heart Failure e g congestive heart failure CHF and pulmonary edema Hypertension Orthostatic Hypotension Peripheral Vascular Disease PVD or Peripheral Arterial Disease PAD 11100 11200 11300 Gastrointestinal Cirrhosis Gastroesophageal Reflux Disease GERD or Ulcer e g esophageal gastric and peptic ulcers Ulce
5. at 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 Do 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 7 day look back period as these would be considered inactive diagnoses May 2013 Page I 3 CMS s RAI Version 3 0 Manual CH 3 MDS Items I I Active Diagnoses in the Last 7 Days cont Item 2300 UTI has specific coding criteria and does not use the active 7 day look back Please refer to Page I 8 for specific coding instructions for Item 2300 UTI Check the following information sources in the medical record for the last 7 days to identify active diagnoses 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 and other sources as available Coding Instructions Code diseases that have a documented diagnosis in the last 60 days and 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 during the 7 day look back period except Item 12300 UTI which does not use the active diagnosis 7 day look ba
6. ck Please refer to Item 12300 UTI Page I 8 for specific coding instructions Document active diagnoses on the MDS as follows Diagnoses are listed by major disease category Cancer Heart Circulation Gastrointestinal Genitourinary Infections Metabolic Musculoskeletal Neurological Nutritional Psychiatric Mood Disorder Pulmonary and Vision Examples of diseases are included for some disease categories Diseases to be coded in these categories are not meant to be limited to only those listed in the examples For example 10200 Anemia includes anemia of any etiology including those listed e g aplastic iron deficiency pernicious sickle cell Check off each active disease Check all that apply If a disease or condition is not specifically listed enter the diagnosis and ICD code in item I8000 Additional active diagnosis Computer specifications are written such that the ICD code should be automatically justified The important element is to ensure that the ICD code s decimal point is in its own box and should be right justified aligned with the right margin so that any unused boxes and on the left If a diagnosis is a V code another diagnosis for the related primary medical condition should be checked in items I0100 I7900 or entered in 18000 Cancer 10100 cancer with or without metastasis Heart Circulation 10200 anemia e g aplastic iron deficiency pernicious sickle cell 10300 atrial fibri
7. g chronic bronchitis and restrictive lung diseases such as asbestosis 16300 Respiratory Failure Vision 16500 Cataracts Glaucoma or Macular Degeneration None of Above 17900 None of the above active diagnoses within the last 7 days Other 18000 Additional active diagnoses Enter diagnosis on line and ICD code in boxes Include the decimal for the code in the appropriate box April 2012 Page l 2 CMS s RAI Version 3 0 Manual CH 3 MDS Items I I Active Diagnoses in the Last 7 Days cont Item Rationale Health Related Quality of Life Disease processes can have a significant adverse affect on an individual s health status and quality of life Planning for Care This section identifies active diseases and infections that drive the current plan of care Steps for Assessment There are two look back periods for this section 1 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 12300 UTI which does not use the active 7 day look back period Identify diagnoses The disease conditions in this section require a physician documented diagnosis or by a nurse practitioner physician assistant or clinical nurse specialist if allowable under state licensure laws in the last 60 days Medical record sources for physician diagnoses include progress notes the most recent history a
8. ge I 8 CMS s RAI Version 3 0 Manual CH 3 MDS Items I Active Diagnoses in the Last 7 Days cont organism An appropriate culture will help to ensure the diagnosis of infection is correct and the appropriate antimicrobial is prescribed to treat the infection The CDC does not recommend routine antimicrobial treatment for the purposes of attempting to eradicate colonization of MRSA or any other antimicrobial resistant organism The CDC s Healthcare Infection Control Practices Advisory Committee HICPAC has released infection prevention and control guidelines that contain recommendations that should be applied in all healthcare settings At this site you will find information related to UTIs and many other issues related to infections in LTC http www cdc gov ncidod dhgp gl_longterm_care html Examples of Active Disease 1 A resident is prescribed hydrochlorothiazide for hypertension The resident requires regular blood pressure monitoring to determine whether blood pressure goals are achieved by the current regimen Physician progress note documents hypertension Coding Hypertension item 10700 would be checked Rationale This would be considered an active diagnosis because of the need for ongoing monitoring to ensure treatment efficacy Warfarin is prescribed for a resident with atrial fibrillation to decrease the risk of embolic stroke The resident requires monitoring for change in heart rhythm for bleeding and fo
9. he 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 Examples of a recent onset or acute exacerbation include the following new diagnosis of pneumonia indicated by chest X ray hospitalization for fractured hip or a blood transfusion for a hematocrit of 24 Sources may include radiological reports hospital discharge summaries doctor s orders etc Symptoms and abnormal signs indicating ongoing or decompensated disease in the last 7 days For example intermittent claudication lower extremity pain on exertion in conjunction with a diagnosis of peripheral vascular disease would indicate active disease Sometimes signs and symptoms can be nonspecific and could be caused by several disease processes Therefore a symptom must be specifically attributed to the disease For example a productive cough would confirm a diagnosis of pneumonia if specifically noted as such by a physician Sources may include radiological reports nursing assessments and care plans progress notes etc October 2011 Page I 7 CMS s RAI Version 3 0 Manual CH 3 MDS Items I I Active Diagnoses in the Last 7 Days cont Listing a disease diagnosis e g arthritis on the resident
10. icates stroke and the resident is receiving medication and therapies to manage continued symptoms from stroke Examples of Inactive Diagnoses do not code 1 The admission history states that the resident had pneumonia 2 months prior to this admission The resident has recovered completely with no residual effects and no continued treatment during the 7 day look back period Coding Pneumonia item 12000 would not be checked Rationale The pneumonia diagnosis would not be considered active because of the resident s complete recovery and the discontinuation of any treatment during the look back period The problem list includes a diagnosis of coronary artery disease CAD The resident had an angioplasty 3 years ago is not symptomatic and is not taking any medication for CAD Coding CAD item 10400 would not be checked Rationale The resident has had no symptoms and no treatment during the 7 day look back period thus the CAD would be considered inactive Mr J fell and fractured his hip 2 years ago At the time of the injury the fracture was surgically repaired Following the surgery the resident received several weeks of physical therapy in an attempt to restore him to his previous ambulation status which had been independent without any devices Although he received therapy services at that time he now requires assistance to stand from the chair and uses a walker He also needs help with lower body dressing because of
11. llation or other dysrhythmias e g bradycardias tachycardias 10400 coronary artery disease CAD e g angina myocardial infarction atherosclerotic heart disease ASHD May 2013 Page I 4 CMS s RAI Version 3 0 Manual CH 3 MDS Items I I Active Diagnoses in the Last 7 Days cont e 0500 deep venous thrombosis DVT pulmonary embolus PE or pulmonary thrombo embolism PTE e 10600 heart failure e g congestive heart failure CHF pulmonary edema e 10700 hypertension e 10800 orthostatic hypotension e 0900 peripheral vascular disease or peripheral arterial disease Gastrointestinal e 11100 cirrhosis e 11200 gastroesophageal reflux disease GERD or ulcer e g esophageal gastric and peptic ulcers e 11300 ulcerative colitis or Crohn s disease or inflammatory bowel disease Genitourinary e 11400 benign prostatic hyperplasia BPH e 11500 renal insufficiency renal failure or end stage renal disease ESRD e 11550 neurogenic bladder e 11650 obstructive uropathy Infections e 11700 multidrug resistant organism MDRO e 2000 pneumonia e 2100 septicemia e 12200 tuberculosis e 2300 urinary tract infection UTI last 30 days e 12400 viral hepatitis e g hepatitis A B C D and E e 12500 wound infection other than foot Metabolic e 2900 diabetes mellitus DM e g diabetic retinopathy nephropathy neuropathy e 13100 hyponatremia e 3200 hyperkalemia e 13300 hyperlipidemia e g
12. nd physical transfer documents discharge summaries diagnosis problem list and other resources as available If a diagnosis problem list is used only diagnoses confirmed by the physician should be entered DEFINITIONS ACTIVE DIAGNOSES 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 during the 7 day look back period FUNCTIONAL LIMITATIONS Loss of range of motion contractures muscle weakness fatigue decreased ability to perform ADLs paresis or paralysis NURSING MONITORING Nursing Monitoring includes clinical monitoring by a licensed nurse e g serial blood pressure evaluations medication management etc 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 to ensure follow up Diagnostic information including past history obtained from family members and close contacts must also be documented in the medical record by the physician to ensure validity and follow up Determine whether diagnoses are active Once a diagnosis is identified it must be determined if the diagnosis is active Active diagnoses are diagnoses th
13. or Stroke Non Alzheimer s Dementia e g Lewy body dementia vascular or multi infarct dementia mixed dementia frontotemporal dementia such as Pick s disease and dementia related to stroke Parkinson s or Creutzfeldt Jakob diseases Neurological Diagnoses continued on next page April 2012 Page l 1 CMS s RAI Version 3 0 Manual CH 3 MDS Items I Active Diagnoses in the Last 7 Days cont Active Diagnoses in the last 7 days Check all that apply Diagnoses listed in parentheses are provided as examples and should not be considered as all inclusive lists O CL 0 O 0 0 O 0 0 0O O 0O CL O 0O CL O 0 O CL Neurological Continued 14900 Hemiplegia or Hemiparesis 15000 Paraplegia 15100 Quadriplegia 15200 Multiple Sclerosis MS 15250 Huntington s Disease 15300 Parkinson s Disease 15350 Tourette s Syndrome 15400 Seizure Disorder or Epilepsy 15500 Traumatic Brain Injury TBI Nutritional 15600 Malnutrition protein or calorie or at risk for malnutrition Psychiatric Mood Disorder 15700 Anxiety Disorder 15800 Depression other than bipolar 15900 Manic Depression bipolar disease 15950 Psychotic Disorder other than schizophrenia 16000 Schizophrenia e g schizoaffective and schizophreniform disorders 16100 Post Traumatic Stress Disorder PTSD Pulmonary 16200 Asthma Chronic Obstructive Pulmonary Disease COPD or Chronic Lung Disease e
14. r anticoagulation Coding Atrial fibrillation item 10300 would be checked Rationale This would be considered an active diagnosis because of the need for ongoing monitoring to ensure treatment efficacy as well as to monitor for side effects related to the medication A resident with a past history of healed peptic ulcer is prescribed a non steroidal anti inflammatory NSAID medication for arthritis The physician also prescribes a proton pump inhibitor to decrease the risk of peptic ulcer disease PUD from NSAID treatment Coding Arthritis item 13700 would be checked Rationale Arthritis would be considered an active diagnosis because of the need for medical therapy Given that the resident has a history of a healed peptic ulcer without current symptoms the proton pump inhibitor prescribed is preventive and therefore PUD would not be coded as an active disease The resident had a stroke 4 months ago and continues to have left sided weakness visual problems and inappropriate behavior The resident is on aspirin and has physical therapy and occupational therapy three times a week The physician s note 25 days ago lists stroke Coding Cerebrovascular Vascular Accident CVA Transient Ischemic Attack TIA or Stroke item 14500 would be checked May 2013 Page l 9 CMS s RAI Version 3 0 Manual CH 3 MDS Items I I Active Diagnoses in the Last 7 Days cont Rationale The physician note within the last 30 days ind
15. rative Colitis Crohn s Disease or Inflammatory Bowel Disease Genitourinary 11400 11500 11550 11650 Benign Prostatic Hyperplasia BPH Renal Insufficiency Renal Failure or End Stage Renal Disease ESRD Neurogenic Bladder Obstructive Uropathy 11700 12000 12100 12200 12300 12400 12500 Infections Multidrug Resistant Organism MDRO Pneumonia Septicemia Tuberculosis Urinary Tract Infection UTI LAST 30 DAYS Viral Hepatitis e g Hepatitis A B C D and E Wound Infection other than foot Metabolic 12900 13100 13200 13300 13400 Diabetes Mellitus DM e g diabetic retinopathy nephropathy and neuropathy Hyponatremia Hyperkalemia Hyperlipidemia e g hypercholesterolemia Thyroid Disorder e g hypothyroidism hyperthyroidism and Hashimoto s thyroiditis Musculoskeletal 13700 13800 13900 14000 Arthritis e g degenerative joint disease DJD osteoarthritis and rheumatoid arthritis RA Osteoporosis Hip Fracture any hip fracture that has a relationship to current status treatments monitoring e g sub capital fractures and fractures of the trochanter and femoral neck Other Fracture 14200 O O 0O O O O O 0O O O 0 O O 0O 0O O O a O 0 O O 0O O O O O 0 0O O O O 0 0 gical Alzheimer s Disease Aphasia Cerebral Palsy Cerebrovascular Accident CVA Transient Ischemic Attack TIA
16. s a look back period of 30 days for active disease instead of 7 days Code only if all the following are met 1 Physician nurse practitioner physician assistant or clinical nurse specialist or other authorized licensed staff as permitted by state law diagnosis of a UTI in last 30 days 2 Sign or symptom attributed to UTI which may or may not include but not be limited to fever urinary symptoms e g peri urethral site burning sensation frequent urination of small amounts pain or tenderness in flank confusion or change in mental status change in character of urine e g pyuria 3 Significant laboratory findings The attending physician should determine the level of significant laboratory findings and whether or not a culture should be obtained and 4 Current medication or treatment for a UTI in the last 30 days In response to questions regarding the resident with colonized MRSA we consulted with the Centers for Disease Control CDC who provided the following information A physician often prescribes empiric antimicrobial therapy for a suspected infection after a culture is obtained but prior to receiving the culture results The confirmed diagnosis of UTI will depend on the culture results and other clinical assessment to determine appropriateness and continuation of antimicrobial therapy This should not be any different even if the resident is known to be colonized with an antibiotic resistant October 2011 Pa
17. s medical record problem list is not sufficient for determining active or inactive status To determine if arthritis for example is an active diagnosis the reviewer would check progress notes including the history and physical during the 7 day look back period for notation of treatment of symptoms of arthritis doctor s orders for medications for arthritis and documentation of physical or other therapy for functional limitations caused by arthritis Ongoing therapy with medications or other interventions to manage a condition that requires monitoring for therapeutic efficacy or to monitor potentially severe side effects in the last 7 days A medication indicates active disease if that medication is prescribed to manage an ongoing condition that requires monitoring or is prescribed to decrease active symptoms associated with a condition This includes medications used to limit disease progression and complications If a medication is prescribed for a condition that requires regular staff monitoring of the drug s effect on that condition therapeutic efficacy then the prescription of the medication would indicate active disease e It is expected that nurses monitor all medications for adverse effects as part of usual nursing practice For coding purposes this monitoring relates to management of pharmacotherapy and not to management or monitoring of the underlying disease e Item 2300 Urinary tract infection UTI The UTI ha
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