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Discussion

Quarterly MDS

I'm an RHIT CCS-P in Medical Records in a LTC facility. I have been asked to review the ICD 9 codes in section I3. For a quarterly MDS in section I3 lets say the resident has Alzh Dementia along with other conditions. Wouldn't it be better to enter the ICD 9 code in section I3 for the Alzh Dementia on the quarterly instead of other conditions like PVD? I'm not a nurse but I would assume that the residents Alzh Dementia would require more care planning and ADL assistance than the PVD.

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rai p3-137 --

"the intent of this item on the quarterly assessment form is to update newly diagnosed diseases; however, 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 should be coded in this section."

i would assume the alz/dementia dx had already been captured in the full mds assm't. in which case there is no reason to add it again. certainly if recently identified you will enter the icd9 in i3.

i would also assume your mds coordinator is aware of this guideline.

I think this is decided on a case by case basis. If the resident has lower extremity stasis ulcer(s) w/ lots of treatments, leg pain, blah, blah.. all coded on the MDS and the alzheimers has already been captured on a previous full assessment, then I would have coded the PVD rather than dementia. (I would want something to substantiate all those other problems).

Ultimately, the MDS coordinator is signing the MDS, has presumably had the most training on the RAI process and should be the one making these decisions.

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