Intent:
To document the presence of diseases or infections relevant to the person's current ADL status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. In general, these types of conditions are associated with the type and level of care needed by the person. Do not include conditions that have been resolved or no longer affect the person's functioning or care needs.
Definitions:
CARDIAC OR PULMONARY
Congestive heart failure — A condition in which the heart cannot pump out all the blood that enters it, which leads to an accumulation of blood in the vessels, fluid in the body tissues and lung congestion.
Coronary heart disease — A chronic condition marked by thickening and loss of elasticity of the coronary artery, and caused by deposits of plaque containing cholesterol, lipoid material and lipophages.
Chronic obstructive pulmonary disease — Any long-standing condition that impairs air flow in and out of the lungs.
MUSCULOSKELETAL
Hip fracture during last 30 days (or since last assessment if less than 30 days) — includes any hip fracture that occurred during the past 30 days (or since the last assessment) that continues to have a relationship to cur-rent status, treatments, monitoring, etc. Hip fracture diagnoses also include femoral neck fractures, fractures of the trochanter, and subcapital fractures.
Other fracture over last 30 days (or since last assessment if less than 30 days) — Any fracture other than hip bone (e.g. wrist) due to any condition – e.g. falls, weakening of the bone as a result of cancer, etc.
NEUROLOGICAL
Alzheimers disease — A degenerative and progressive dementia that is diagnosed by ruling out other dementias and physiological reasons for the dementia.
Dementia other than Alzheimers disease — Includes diagnoses of organic brain syndrome (OBS) or chronic brain syndrome (CBS), senility, senile dementia, multi-infarct dementia, and dementia related to neurological diseases other than Alzheimers (e.g. Pick’s, Creutzfeld-Jacob, Huntington’s disease, etc.)
Hemiplegia — Paralysis (temporary or permanent impairment of sensation, function, motion) of both limbs on one side of the body. Usually caused by cerebral hemorrhage, thrombosis, embolism or tumor. There must be a diagnosis of hemiplegia in the person’s record to code this item.
Multiple sclerosis — A disease in which there is demyelination through-out the central nervous system. Typical symptoms are weakness, uncoordination, paresthesias, speech disturbances and visual complaints.
Paraplegia — Paralysis (i.e., a temporary or permanent impairment of active motion) of the lower part of the body, including both legs.
Parkinson’s disease — A disorder of the brain characterized by tremor and difficulty with walking, movement and coordination.
Quadriplegia — Paralysis (temporary or permanent impairment of sensation, function, motion) of all four limbs and trunk.
Stroke/CVA — A sudden rupture or blockage of a blood vessel within the brain, causing serious bleeding or local obstruction.
PSYCHIATRIC
Anxiety — A non-psychotic mental disorder. There are five types, which include:
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder
Phobias
Post-Traumatic Stress Disorder
Depression — A mood disorder often characterized by a depressed mood (e.g. the person feels sad or empty, appears tearful); decreased ability to think or concentrate; loss of interest or pleasure in usual activities; insomnia or hypersomnia; loss of energy; change in appetite; or feelings of hopelessness, worthlessness, or guilt. May also include thoughts of death or suicide.
Bipolar disorder - Includes documentation of clinical diagnoses of either manic depression or bipolar disorder. "Bipolar disorder" is the current term for manic depressive illness.
Schizophrenia — A disturbance characterized by delusions, hallucinations, disorganized speech, grossly disorganized behavior, disordered thinking, or flat affect. This category includes schizophrenia subtypes (e.g. paranoid, disorganized, catatonic, undifferentiated, residual).
OTHER
Cancer — Any malignant growth or tumor caused by abnormal and un-controlled cell division. The malignant growth or tumor may spread to other parts of the body through the lymphatic system or the blood stream.
Diabetes mellitus — Any of several metabolic disorders marked by persistent thirst and excessive discharge of urine.
INFECTIONS
Pneumonia — Inflammation of the lungs, most commonly of bacterial or viral origin.
Urinary tract infection in last 30 days — Includes chronic and acute symptomatic infection(s) in the last 30 days. Code only if there is current supporting documentation and significant laboratory findings in the clinical record.
Process:
Talk to the person and review any available clinical records. Consult with the person’s primary physician or nurse practitioner. Talk with family members.
Coding:
For all diseases present, select the most appropriate code from those listed below.
0. Not present
2. Diagnosis present, receiving active treatment. Treatment can include medications, therapy, or other skilled interventions such as wound care or suctioning.
3. Diagnosis present, monitored but no active treatment. Person has a diagnosis that is being monitored (e.g., with laboratory tests or vital signs), but no active treatment is being provided.