Steps for Assessment
There are two look-back periods for this section:
•
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 I2300 UTI, which
does not use the active 7-day look-back period).
1. 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 and 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.
•
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.
2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be
determined if the diagnosis is active. Active diagnoses are diagnoses that 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.
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.).
I0100–I8000: Active Diagnoses in the Last 7 Days (cont.)
•
Item I2300 UTI, has specific coding criteria and does not use the active 7-day look-back.
Please refer to Page I-13 for specific