Starting October 1, 2024, the Centers for Medicare & Medicaid Services (CMS) implemented updates to the Minimum Data Set (MDS) that directly affect how diagnoses are captured and coded in Section I, Active Diagnoses. These updates matter because they impact reimbursement, care planning, and regulatory compliance.
If you have not revisited your diagnosis coding process recently, now is the time.
Who is Qualified to Diagnose, and Where to Find these Diagnoses?
Understanding who can diagnose is foundational. Only specific licensed healthcare professionals are authorized to diagnose a patient officially. This includes physicians like attending doctors, covering doctors, radiologists, specialists, as well as physician extenders such as nurse practitioners, clinical nurse specialists, and physician assistants. For this blog, we will use “provider” to refer to the Qualified healthcare professional who can establish the diagnosis.
Diagnoses can be found in several key locations within the medical record, including prescriptions, referrals, the most recent history and physicals, ER records, hospital records, discharge summaries, x-ray reports, CT scan and MRI reports, other diagnostic reports, surgical reports, transfer records, and physician progress notes.
There are certain exceptions where code assignment may be based on documentation from clinicians. The CMS definition of a clinician is a healthcare professional who is permitted, based on regulatory or accreditation requirements or internal hospital or facility policies, to document in a patient’s official medical record; the nurse, therapists (physical, occupational, and speech-language pathologists), dieticians are some of the examples of a clinician. To code a diagnosis based on a clinician’s documentation, the provider must have documented an “associated diagnosis”. For example:
- The provider noted the patient is overweight; the ICD-10-CM has no code for overweight. To get the specific code, the dietitian’s documentation of the patient’s BMI can be used to identify the appropriate code.
- If the provider documented that the patient has a wound or the wound treatment, to identify the specific code, use the nursing documentation for the stage of the pressure ulcer.
Remember, if the clinician’s documentation is used to identify the code for the diagnosis, it can only be reported as secondary diagnoses. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the provider should be queried for clarification.
How to Determine the ICD-10-CM Code?
To determine the correct ICD-10-CM code, professionals must use the current ICD-10-CM coding manual. Coding should not be done using the internet, phones, or pre-made lists of code. It is essential to identify the main term of the diagnosis and, if unclear, query the provider. Only diagnoses documented by the provider in the medical record should be coded.
Updates on MDS I2100, Septicemia
A key focus area for October 2024 is the coding of Septicemia refers to the presence of bacteria in the blood, often leading to a serious infection. Sepsis, by contrast, is a broader condition where the body’s response to an infection triggers widespread inflammation, which can lead to septic shock, organ failure, or even death if not diagnosed and treated early. While sepsis often arises from septicemia, it can also result from infections elsewhere in the body. Proper assessment and documentation of symptoms and supporting documentation for the microbial process are essential.
The RAI Manual Version 1.19.1, Chapter 3, Section I, updated the guidance for coding I2100, Septicemia. It stated, “For sepsis to be considered septicemia, there needs to be inflammation due to sepsis and evidence of a microbial process. If the medical record reflects inflammation due to sepsis and evidence of a microbial process, I2100, Septicemia, may be coded. If the medical record does not reflect inflammation due to sepsis and no evidence of a microbial process, enter the sepsis diagnosis and ICD code in item I8000, Additional Active Diagnoses, meaning I2100, Septicemia must not be checked.”
A common error is checking the box for septicemia when documentation supports only sepsis. This is a critical discussion point for the interdisciplinary team (IDT), and it is important not to rely on automated tools or scrubbers that pull terms without verifying whether the documentation supports the coding definition. Before coding septicemia under I2100, the IDT should discuss the requirements, communicate with the provider, and ensure that nursing documentation supports the symptoms.
When a patient is admitted with sepsis, the IDT must conduct thorough assessments to document the patient’s condition. Sepsis is a systemic inflammatory response, which can present in various ways. Nurses should assess and document any signs of inflammation, including: (note that it is not an all-inclusive list)
- Fever
- Hypothermia
- Tachycardia,
- Abnormal breathing
- Loss of consciousness
- Agitation, confusion or mental changes
- Specific symptoms to the type of infection, for example – painful or burning urination for UTI; cough for pneumonia.
- Severe pain
- Redness, swelling, and edema in the affected parts of the body
- Loss of function of parts of the body
- Extreme fatigue
- Shaking or chills
- Skin rash
- Warm or clammy or sweaty skin
The IDT may also need to request medical records from the hospital to gather evidence of a microbial process. These records may include:
- Laboratory records (e.g., blood tests, cultures)
- Documented source of infection (e.g., wounds, pneumonia, urinary tract infection)
- Imaging studies (e.g., X-rays, CT scans)
- Notes from recent consultations
- Physician documentation of infection or treatments
It is also crucial to stay informed about ICD-10 mapping changes, particularly under the Patient-Driven Payment Model (PDPM). Make it a routine to check the CMS PDPM ICD-10 mapping for updates regularly; the latest mapping can be accessed at https://www.cms.gov/files/zip/fy-2025-pdpm-icd-10-code-mapping.zip.
PDPM ICD-10 Mapping Changes
CMS made modifications to the PDPM mapping of certain ICD-10 codes. Four ICD-10 codes that were classified under Medical Management will now be categorized as Return to Provider codes beginning October 1, 2024:
- E88.10 Metabolic Syndrome
- E88.811 Insulin Resistance Syndrome, Type A
- E88.818 Other Insulin Resistance
- E88.819 Insulin Resistance, Unspecified
Proposed Future Changes to the Non-Therapy Ancillary (NTA) Component
Looking ahead, proposed updates to the Non-Therapy Ancillary (NTA) component include modifying where the NTA points originate. Currently, NTA points can be gathered either from MDS checkboxes or by adding ICD-10 codes in Section I8000. However, this can create confusion because some point categories appear in both locations. To streamline this, CMS plans to prioritize MDS checkboxes whenever possible.
Additionally, CMS is exploring changes to the point values assigned to various conditions in the NTA component, which could further impact how conditions are scored and reported. Some examples under consideration are: HIV/AIDS reported on the claim form, UB-04, currently 8 NTA points – the proposed change to 7 points; lung transplant status coded in I8000 presently captures 3 NTA points, the proposed change to 5 NTA points.
By staying updated and following these revised practices, providers and clinicians can enhance coding accuracy and create clear patient records. This focus on quality helps improve clinical care, ensures compliance with regulatory guidelines, enhances patient outcomes, and reduces the chances of errors or risks. The commitment to best practices supports overall patient care and appropriate services.
LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can assist your organization in maintaining compliance, identifying trends, providing education and training, or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!
