Place diagnoses in M1010 when treatment goes beyond standard medications

CMS has given guidance on when to list inpatient diagnoses, M1010, and the agency specifically answers the question of whether giving medicines is “active treatment.”

Question:

If a patient is hospitalized (or in a SNF) and is given his/her routine medications BUT some of those medications are for diagnoses that are not the reason for the hospitalization, are the diagnoses for which the routine meds are given considered as being “treated” during the stay. For example: the patient is admitted to the hospital for surgery. While in the hospital, he is given his routine medication for HTN, atrial fib, GERD, etc. Should those dx be listed at M1010?

CMS answer:

When completing M1010, Inpatient Diagnoses, only include the diagnoses actively treated during the inpatient facility stay within the past 14 days, not all the diagnoses the patient may have. “Actively treated” should be defined as receiving something more than the regularly scheduled medications and treatments necessary to maintain or treat an existing condition. In the scenario you provided, Hypertension would not be included in M1010 if the patient only received their maintenance dose of antihypertensive.

Here is the site reference to the April 2010 Q&As.

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