On Dec. 23, 2022, the Centers for Medicare & Medicaid Services (CMS) released the nine revised MDS 3.0 v1.18.11 draft item sets so that nurse assessment coordinators (NACs) and other interdisciplinary team members can begin preparing for implementation on Oct. 1, 2023. The tentative next steps (pulled from the CMS website and the Dec. 6, 2022, Skilled Nursing Facility/Long-Term Care Open Door Forum) are as follows:
| CMS Action | Tentatively Scheduled |
| Finalized MDS 3.0 item sets v1.18.11* | Early 2023 |
| Draft revised Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual | Q2** 2023 |
| Online training resources | mid-May 2023 |
| Live workshops | June |
* AAPACN has identified at least two potential errors in the draft NPE item set. For example, A2105 (Discharge Status) is not currently on the draft NPE item set. However, the coding instructions for A2121, A2123, GG0130, and GG0170 on this item set all reference how A2105 is coded. Either it will need to be added to the NPE item set, or the instructions for those items will need to change. There may be other possible errors as well. So, it’s important to be clear that the current release is still in draft format.
** The second calendar quarter runs April – June. However, if online training is released by mid-May, it seems reasonable that the draft RAI User’s Manual could be released by mid-May as well.
The new draft NC item set: Changes from September to December versions
CMS originally issued a draft NC (Comprehensive) MDS item set on Sept. 1, 2022. The agency made a few notable changes to this draft in the Dec. 23, 2022 version. These primarily included revising the instructions for when to complete new items A2121 (Provision of Current Reconciled Medication List to Subsequent Provider at Discharge) and A2123 (Provision of Current Reconciled Medication List to Resident at Discharge), as well as clarifying when to complete GG0130 (Self-Care Functional Abilities and Goals) and GG0170 (Mobility Functional Abilities and Goals) at admission, at discharge, and for OBRA/interim assessments.
The MDS 3.0 Item Set Change History for October 2023 Version 1.18.11 included in the draft item set ZIP file identifies new items, revised items, and removed/retired items by item set type:
- NC (OBRA Comprehensive);
- NQ (Quarterly);
- ND (Standalone OBRA Discharge);
- NT/ST (Nursing Home or Swing-Bed Entry Tracking Record or Death in Facility Tracking Record);
- NPE (Standalone Part A PPS Discharge);
- NP (5-Day PPS);
- IPA (Interim Payment Assessment);
- SP (Swing-Bed 5-Day PPS); and
- SD (Swing-Bed Discharge).
On these drafts, the NT and IPA item sets escaped with the fewest changes by far. In terms of the sheer number of changes (additions, revisions, and removals combined), the NC, NQ, ND, NP, SP, and SD item sets will see similar levels of upheaval.
Items that are being added to the various item sets include items that are brand-new to the MDS. For example, new items A2121 (Provision of Current Reconciled Medication List to Subsequent Provider at Discharge) through A2124 (Route of Current Reconciled Medication List Transmission to Resident) will be added to the NC, NQ, ND, NPE, NP, SP, and SD item sets (the NT/ST and IPA item sets are the only ones exempted).
Other new items have comparable items on the existing MDS v1.17.2 item sets—items that are being removed to “offset” the new items. For example, A1005 (Ethnicity) and A1010 (Race) will be added to all nine MDS v.1.18.11 item sets. However, the existing item A1000 (Race/Ethnicity) will be removed from all nine item sets to make way for these new items.
NPE: Five times more new items than removed/retired items
In this context, the draft item set that stands out is the NPE (PPS Discharge). Most of the item sets have 4 to 10 more new items than removed/retired items. However, CMS is adding five times as many new items to the NPE as it is removing—meaning that NACs and other interdisciplinary team members should be prepared to spend a little more time on PPS Discharge assessments.
The following chart identifies the new items on the draft NPE item set that have no comparable existing item that will be removed:
| A1250 (Transportation (From NACHC)) |
| A2121 (Provision of Current Reconciled Medication List to Subsequent Provider at Discharge) |
| A2122 (Route of Current Reconciled Medication List Transmission to Subsequent Provider) |
| A2123 (Provision of Current Reconciled Medication List to Resident at Discharge) |
| A2124 (Route of Current Reconciled Medication List Transmission to Resident) |
| B1300 (Health Literacy) |
| C0100 (Should Brief Interview for Mental Status (C0200-C0500) Be Conducted?) |
| C0200 (Brief Interview for Mental Status (BIMS): Repetition of Three Words) |
| C0300 (BIMS: Temporal Orientation (Orientation to Year, Month, and Day)) |
| C0400 (BIMS: Recall) |
| C0500 (BIMS Summary Score) |
| C1310 (Signs and Symptoms of Delirium (From CAM)) |
| D0100 (Should Resident Mood Interview Be Conducted?) |
| D0150 (Resident Mood Interview (PHQ-2 to 9)) |
| D0160 (Total Severity Score) |
| D0700 (Social Isolation) |
| GG0130I, column 3 (Personal Hygiene Self-Care Discharge Performance) |
| GG0170FF, column 3 (Tub/Shower Transfer Self-Care Discharge Performance) |
| J0200 (Should Pain Assessment Interview Be Conducted?) |
| J0300 (Pain Assessment Interview: Pain Presence) |
| J0510 (Pain Assessment Interview: Pain Effect on Sleep) |
| J0520 (Pain Assessment Interview: Pain Interference With Therapy Activities) |
| J0530 (Pain Assessment Interview: Pain Interference With Day-to-Day Activities) |
| K0520 (Nutritional Approaches), column 4 (At Discharge) |
| N0415 (High-Risk Drug Classes: Use and Indication), column 1 (Is Taking) and column 2 (Indication Noted) |
| O0110 (Special Treatments, Procedures, and Programs), column C (At Discharge) |
Note: To see all the new items added to the NPE item set, as well as the new items that will be added to the other eight item sets, review “New Items Added by Draft Item Set” at the end of this article.
It’s worth noting that the NPE item set will include three resident interviews:
- The BIMS (C0100 – C0500);
- The PHQ-2 to 9 Resident Mood Interview (D0100 – D0160); and
- The Resident Pain Interview (J0200 – J0300 and J0510 – J0530).
Currently, the coding instructions for D0100 (Should Resident Mood Interview Be Conducted?) and J0200 (Should Pain Assessment Interview Be Conducted?) direct assessors to skip the PHQ-2 to 9 and pain interviews for unplanned discharges (i.e., A0310G (Type of Assessment) = 2 (Unplanned)). However, there is no skip pattern for unplanned discharges for C0100 (Should Brief Interview for Mental Status (C0200-C0500) Be Conducted?) on the draft NPE—even though that skip pattern is included on the draft ND (OBRA Discharge) item set. In addition, the draft NPE item set does not include the option of conducting the Staff Assessment for Mental Status like the ND item set does.
More items with an assessment period that is the last three days of the stay
The addition of items K0520, column 4 (Nutritional Approaches at Discharge) and O0110, column C (Special Treatments, Procedures, and Programs at Discharge) also is critical. First, the assessment reference period for both items is the last three days of the SNF PPS stay ending on A2400C (End Date of Most Recent Medicare stay). These join the new and existing items in GG0130, column 3 (Self-Care Functional Abilities and Goals at Discharge) and GG0170, column 3 (Mobility Functional Abilities and Goals at Discharge), which have an assessment period of the last three days of the stay.
K0520 will include the following subitems on the NPE, NC, NQ, NP, SP, and SD item sets, with some item response options blacked out for some columns (i.e., the question cannot be answered). For example, the options Mechanically Altered Diet and Therapeutic Diet are blacked out for column 2 (While Not a Resident) on the NC (Comprehensive) item set. On the NPE, all subitems will be active for column 4 (At Discharge). In comparison, only the IPA item set shortens the list of subitems, leaving out Therapeutic Diet as indicated by the asterisk (*) in the chart:
| A (Parenteral/IV Feeding); B (Feeding Tube (e.g., Nasogastric or Abdominal (PEG))); C (Mechanically Altered Diet—Require Change in Texture of Food or Liquids (e.g., Pureed Food, Thickened Liquids)); D (Therapeutic Diet (e.g., Low Salt, Diabetic, Low Cholesterol))*; and Z (None of the Above). |
O0110 on the NPE item set will include the same 33 subitems that will be used on the NC, NQ, NP, SP, and SD item sets. However, here too each item set has items blacked out depending on the column being coded. For column 3 on the draft NPE, only O0110K1 (Hospice Care) and O0110M1 (Isolation or Quarantine for Active Infectious Disease (Does Not Include Standard Body/Fluid Precautions)) are blacked out. In comparison, the O0110 items used on the IPA item set have been cut down to just 11, as indicated by the asterisks in the chart:
N0415 (High-Risk Drug Classes: Use and Indication) is another item with multiple subitems that will be added to every item set except NT/ST and IPA. While some of the other item sets have a similar item that is being retired, specifically N0410 (Medications Received), the existing NPE has nothing comparable to N0415. Assessors will need to complete column 1 (Is Taking) and column 2 (Indication Noted) for all of the following NPE items except for the one instance that is denoted by the shading in the following chart:
| Column 1: Is taking | Column 2: Indication noted | |
| A. Antipsychotic | ||
| B. Antianxiety | ||
| C. Antidepressant | ||
| D. Hypnotic | ||
| E. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin) | ||
| F. Antibiotic | ||
| G. Diuretic | ||
| H. Opioid | ||
| I. Antiplatelet | ||
| J. Hypoglycemic (including insulin) | ||
| Z. None of the above |
Note: Stay tuned for additional resources from AAPACN as nursing homes move closer to Oct. 1, 2023.
New Items Added by Draft Item Set
| New Items | NC | NQ | ND | NT/ST | NPE | NP | IPA | SP | SD |
| A1005 (Ethnicity) | X | X | X | X | X | X | X | X | X |
| A1010 (Race) | X | X | X | X | X | X | X | X | X |
| A1110 (Language) | X | X | X | NA | NA | X | X | X | NA |
| A1250 (Transportation (From NACHC)) | X | X | X | NA | X | X | NA | X | X |
| A1805 (Entered From) | X | X | X | X | X | X | NA | X | X |
| A2105 (Discharge Status) | X | X | X | X | X** | X | NA | X | X |
| A2121 (Provision of Current Reconciled Medication List to Subsequent Provider at Discharge) | X | X | X | NA | X | X | NA | X | X |
| A2122 (Route of Current Reconciled Medication List Transmission to Subsequent Provider) | X | X | X | NA | X | X | NA | X | X |
| A2123 (Provision of Current Reconciled Medication List to Resident at Discharge) | X | X | X | NA | X | X | NA | X | X |
| A2124 (Route of Current Reconciled Medication List Transmission to Resident) | X | X | X | NA | X | X | NA | X | X |
| B1300 (Health Literacy) | X | X | X | NA | X | X | NA | X | X |
| C0100 (Should Brief Interview for Mental Status (C0200-C0500) Be Conducted?) | NA | NA | NA | NA | X | NA | NA | NA | NA |
| C0200 (Brief Interview for Mental Status (BIMS): Repetition of Three Words) | NA | NA | NA | NA | X | NA | NA | NA | NA |
| C0300 (BIMS: Temporal Orientation (Orientation to Year, Month, and Day)) | NA | NA | NA | NA | X | NA | NA | NA | NA |
| C0400 (BIMS: Recall) | NA | NA | NA | NA | X | NA | NA | NA | NA |
| C0500 (BIMS Summary Score) | NA | NA | NA | NA | X | NA | NA | NA | NA |
| C1310 (Signs and Symptoms of Delirium (From CAM)) | NA | NA | NA | NA | X | NA | NA | NA | NA |
| D0100 (Should Resident Mood Interview Be Conducted?) | NA | NA | NA | NA | X | NA | NA | NA | NA |
| D0150 (Resident Mood Interview (PHQ-2 to 9)) | X | X | X | NA | X | X | X | X | X |
| D0160 (Total Severity Score) | X | X | X | NA | X | X | X | X | X |
| D0700 (Social Isolation) | X | X | X | NA | X | X | NA | X | X |
| GG0115A (Upper Extremity Functional Limitation in Range of Motion) and GG0115B (Lower Extremity Functional Limitation in Range of Motion) | X | X | NA | NA | NA | X | NA | X | NA |
| GG0120 (Mobility Devices), A – D and Z | X | X | NA | NA | NA | NA | NA | NA | NA |
| GG0130I (Personal Hygiene Self-Care) column 1 (Admission Performance), column 2 (Discharge Goal) blacked out | X | X | NA | NA | NA | NA | NA | NA | NA |
| GG0130I, column 3 (Personal Hygiene Self-Care Discharge Performance) | X | X | X | NA | X | X | NA | X | X |
| GG0130, column 5 (Self-Care Functional Abilities and Goals: OBRA/Interim Performance) | X | X | NA | NA | NA | NA | NA | NA | NA |
| GG0170FF (Tub/Shower Transfer Self-Care) column 1 (Admission Performance), column 2 (Discharge Goal) blacked out | X | X | NA | NA | NA | NA | NA | NA | NA |
| GG0170FF, column 3 (Tub/Shower Transfer Self-Care Discharge Performance) | X | X | X | NA | X | X | NA | X | X |
| GG0170, column 5 (Mobility Functional Abilities and Goals: OBRA/Interim Performance) | X | X | NA | NA | NA | NA | NA | NA | NA |
| J0200 (Should Pain Assessment Interview Be Conducted?) | NA | NA | NA | NA | X | NA | NA | NA | NA |
| J0300 (Pain Assessment Interview: Pain Presence) | NA | NA | NA | NA | X | NA | NA | NA | NA |
| J0410 (Pain Assessment Interview: Pain Frequency) | X | X | X | NA | NA | X | NA | X | NA |
| J0510 (Pain Assessment Interview: Pain Effect on Sleep) | X | X | X | NA | X | X | NA | X | X |
| J0520 (Pain Assessment Interview: Pain Interference With Therapy Activities) | X | X | X | NA | X | X | NA | X | X |
| J0530 (Pain Assessment Interview: Pain Interference With Day-to-Day Activities) | X | X | X | NA | X | X | NA | X | X |
| K0520 (Nutritional Approaches), columns 1 (On Admission), 2 (While Not a Resident), 3 (While a Resident), and 4 (At Discharge) | X | X | NA | NA | NA | X | NA | X | NA |
| K0520 (Nutritional Approaches), columns 2 (While Not a Resident) and 3 (While a Resident) | NA | NA | NA | NA | NA | NA | X | NA | NA |
| K0520 (Nutritional Approaches), columns 3 (While a Resident) and 4 (At Discharge) | NA | NA | X | NA | NA | NA | NA | NA | NA |
| K0520 (Nutritional Approaches), column 4 (At Discharge) | NA | NA | NA | NA | X | NA | NA | NA | X |
| N0415 (High-Risk Drug Classes: Use and Indication) | X | X | X | NA | X | X | NA | X | X |
| O0110 (Special Treatments, Procedures, and Programs), columns A (On Admission), B (While a Resident), and C (At Discharge) | X | X | NA | NA | NA | X | NA | X | NA |
| O0110 (Special Treatments, Procedures, and Programs), columns B (While a Resident) and C (At Discharge) | NA | NA | X | NA | NA | NA | NA | NA | NA |
| O0110 (Special Treatments, Procedures, and Programs), column C (At Discharge) | NA | NA | NA | NA | X | NA | NA | NA | X |
| O0110 (Special Treatments, Procedures, and Programs), column B (While a Resident) | NA | NA | NA | NA | NA | NA | X | NA | NA |
| Q0110 (Participation in Assessment and Goal Setting) | X | X | NA | NA | NA | X | NA | X | NA |
| Q0310A (Resident’s Overall Goal: Resident’s Overall Goal for Discharge Established During the Assessment Process) and Q0310B (Resident’s Overall Goal: Indicate Information Source for Q0310A) | X | X | NA | NA | NA | X | NA | X | NA |
| Q0500C (Return to Community: Indicate Information Source for Q0500B) | X | X | NA | NA | NA | X | NA | X | NA |
| Q0550C (Resident’s Preference to Avoid Being Asked Question Q0500B: Indicate information source for Q0550A) | X | X | NA | NA | NA | X | NA | X | NA |
| Q0610 (Referral) | X | X | X | NA | NA | X | NA | X | X |
| Q0620 (Reason Referral to Local Contact Agency (LCA) Not Made) | X | X | X | NA | NA | X | NA | X | X |
| Key: NC (OBRA Comprehensive) NQ (Quarterly) ND (Standalone OBRA Discharge) NT/ST (Nursing Home or Swing-Bed Entry Tracking Record or Death in Facility Tracking Record) NPE (Standalone Part A PPS Discharge) NP (5-Day PPS)IPA (Interim Payment Assessment) SP (Swing-Bed 5-Day PPS)SD (Swing-Bed Discharge) Notes: 1. These items include items that are brand-new to the MDS, new items that have comparable existing items that are being retired, and items that are just new to the indicated item set but are used routinely on other item sets. For example, the BIMS is listed because it is new to the NPE item set. 2. All item sets don’t use the same version of the new item. For example, there are three different versions of A1250, two of which have specific “complete only if” instructions for the affected item sets. 3. ** Item A2105 is not currently on the draft NPE item set. However, the coding instructions for A2121, A2123, GG0130, and GG0170 on this item set all reference how A2105 is coded. Either it will need to be added to the NPE item set, or the instructions for those items will need to change. |
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