I am seeking assistance for accurate coding of CVA at item I4500 of the MDS. The physician acknowledges history of stroke in his progress note during the look-back period. The patient also receives daily aspirin and requires ongoing medication management for stroke prevention, nurses monitor for potential side effects from medication including signs & symptoms of bleeding and bruising. Would this meet the criteria to code active condition CVA at I4500?



In this scenario, it does not appear the stroke would meet active diagnosis criteria to be considered as a SLP comorbidity. The physician specifically notes “history of”, and the medication is administered for prevention, not to treat an active diagnosis. In order to be considered an active condition, the RAI (pg 1-7) provides specific steps for assessment:

        • 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.
        • 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.

Blog by Stacy Baker, OTR/L, RAC-CT, CHC, Proactive Medical Review

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