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Mastering MDS Section I: Coding Active Diagnoses

Our recent Skilled Nursing Facility (SNF) Targeted Probe and Educate (TPE) review identified a trend regarding the improper coding of active diagnoses in Section I of the Minimum Data Set (MDS) without meeting the criteria outlined in the CMS Resident Assessment Instrument (RAI) User’s Manual.

When coding active diagnoses, ensure you adhere to the mandatory 2-step verification process for every diagnosis entered on the MDS.

The 2-Step Verification Process

According to the RAI Manual, a diagnosis can’t be coded on the MDS unless it meets the 2-step process within the look-back period.

Step 1: Physician-Documented Diagnosis

There must be specific documentation by a physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowed by state law) that the resident has the diagnosis within the last 60 days.

Step 2: Active vs. Inactive Within the Look-Back Period

Once a documented diagnosis exists, it must be determined if the condition is active during the 7-day look-back period (except for Item I2300 UTI, which doesn’t use the active 7-day look-back period).

What Makes a Diagnosis "Active"?

To satisfy Step 2, the medical record must show active treatment, interventions beyond expected monitoring practices, medication administration, etc. specifically addressing the coded MDS item during the 7-day look-back period:

  • Medication Management: The resident receives a specific medication for the condition (e.g., Insulin for Diabetes, Lisinopril for Hypertension, Spiriva for COPD, Eliquis for CVA).
  • Active Treatments: The resident is receiving therapies, wound care, or specialized interventions (e.g., physical therapy for an Osteoarthritis flare-up, speech therapy for Dysphagia).
  • Interventions: The condition requires dietary modification and a high-calorie/high-protein supplement (e.g., Ensure, Med Pass and mechanically altered diet with fortified foods for Malnutrition (protein, calorie) or risk of malnutrition).

❌ Inactive vs. ✔️ Active: TPE Audit Scenarios

Diagnosis ❌ Inactive (Do Not Code) ✔️ Active (Code on MDS)
Diabetes Mellitus (Section I2900) Listed in the hospital history. The resident is on a regular diet, takes no diabetic medications, and has no blood sugar monitoring ordered or performed during the 7-day look-back period. Resident receives daily antidiabetic medication (e.g., Metformin, Insulin), has scheduled fingerstick blood sugar monitoring (which included a sliding scale of insulin coverage) as physician ordered, and is on a physician ordered diabetic diet.
Asthma/COPD/ Chronic Lung Disease (Section I6200) Resident has a history of Asthma but is currently on room air, has clear lung sounds, and has no respiratory medications or treatments scheduled or administered. Resident receives scheduled pulmonary medications, routine oxygen therapy, or required maintenance or rescue inhalers during the look-back period (e.g., Albuterol, Symbicort), due to an abnormal respiratory assessment and complaints of shortness of breath during the 7-day look-back window.
CVA/TIA/Stroke (Section I4500) Resident had a stroke 1 year ago. Has residual hemiparesis, but no new residual effects or related active therapies, no acute neurological symptoms, and CT findings were negative. Resident has a history of CVA and is currently receiving physical and occupational therapy to treat hemiparesis resulting from the CVA.
Anemia (Section I0200) Listed on the past medical history list, but no labs have been ordered, and no iron supplements or medications are prescribed. Documented by the physician, and the resident is taking daily iron supplements or had a CBC drawn during the look-back period to monitor it.

Best Practices to Prevent Future TPE Errors

  1. Scrutinize Section I: Active Diagnoses: Only code conditions here if they explicitly meet the 2-step criteria.
  2. Do Not Code "Resolved" Conditions: If a condition has cleared up (e.g., pneumonia that is completely resolved or an infection that has been fully treated), it is no longer active.
  3. Verify the Look-Back Window: Ensure the nursing notes, MARs, TARs, and therapy logs explicitly demonstrate active treatment, interventions or medication administered specific to the coded MDS items during the 7-day look-back period from the Assessment Reference Date (ARD).

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Published: 09.23.2026

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