Q&A: If an open area is found on day four after admission, is that still present on admission (7-day look-back period)? The definition of “present on admission” is “as close to admission as possible.”

MDS 3.0 and the RAI Process / NAC / Q&A

Question: If an open area is found on day four after admission, is that still present on admission (7-day look-back period)? The definition of “present on admission” is “as close to admission as possible.” Answer from Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: I do not think this would …

Q&A: A long-term resident went out to the hospital and returned on a skilled stay using his Managed Care plan. He has both a 5-Day and Annual scheduled for the same day, but at separate times. Do both of these get coded as “the first assessment” in A0310E?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: A long-term resident went out to the hospital and returned on a skilled stay using his Managed Care plan. He has both a 5-Day and Annual scheduled for the same day, but at separate times. Do both of these get coded as “the first assessment” in A0310E? Answer from …

Q&A: For section GG, the nurse aides use a mechanical lift transfer with two-person assist for transfers four times, but physical therapy transfers with one person and maximal assist once. Part of the dependent definition is “helper does all the effort” – but this was not true for all transfers—would this be dependent or maximal assistance?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: For section GG, the nurse aides use a mechanical lift transfer with two-person assist for transfers four times, but physical therapy transfers with one person and maximal assist once. Part of the dependent definition is “helper does all the effort” – but this was not true for all transfers—would …

Crack the Code: Staff Assessment for Mental Status Items

Article / MDS 3.0 and the RAI Process / NAC

The nurse assessment coordinator (NAC) plays an essential role in capturing a resident’s cognitive status by coordinating and coding the Staff Assessment for Mental Status in the Minimum Data Set (MDS). The Brief Interview for Mental Status (BIMS) remains the preferred approach. But in certain situations, staff observations must be …

Documentation Template: Isolation for Active Infectious Disease

MDS 3.0 and the RAI Process / NAC / Tool

The strict coding criteria for O0110M1, Isolation or quarantine for active infectious disease, requires precise documentation to support the MDS. AAPACN’s new Documentation Template: Isolation for Active Infectious Disease tool can help nurse assessment coordinators (NACs) educate nurses on the key areas of required documentation for residents in isolation. Want …

TIP: CMS Released Final RAI User’s Manual for Oct. 1, 2025

MDS 3.0 and the RAI Process / NAC / Tip

The Centers for Medicare & Medicaid Services (CMS) recently released the final version of the RAI User’s Manual, version 1.20.1, which goes into effect Oct. 1, 2025. While the draft version has been available for several months, CMS made several additional changes, including a new definition for falls and major injury, …

Patient Health Questionnaire Completion Determination

MDS 3.0 and the RAI Process / NAC / Tool

Effective Oct. 1, 2023, the full Patient Health Questionnaire (PHQ)-9 will only be completed if the resident responds to the gateway PHQ-2 questions in a certain way. The Patient Health Questionnaire Completion Determination chart clarifies when to stop the PHQ after the PHQ-2, how to code the Total Severity Score, …

Oct. 1, 2025: MDS Changes At-a-Glance

MDS 3.0 and the RAI Process / NAC / Tool

The Centers for Medicare & Medicaid Services (CMS) released unexpected changes in the final RAI User’s Manual, version 1.20.1, which goes into effect Oct. 1, 2025. The AAPACN MDS Changes At-a-Glance tool provides a high-level overview and key takeaways from the changes.  This AAPACN resource is copyright protected. AAPACN individual …

Top Four GG Strategies: Preparing for the October Updates

Article / MDS 3.0 and the RAI Process / NAC

The importance of accurate coding of section GG, Functional Abilities, continues to grow as this data is used in care planning, Quality Measures, reimbursement, and regulatory compliance. The Centers for Medicare & Medicaid Services (CMS) released the final RAI User’s Manual, v1.20.1, in late August. It includes several clarifications for …

PDPM HIPPS Code At-a-Glance

Billing and Reimbursement / NAC / Tool

The Patient-Driven Payment Model (PDPM) 5-Character HIPPS code can be difficult to decipher. The PDPM HIPPS Code At-a-Glance tool will help nurse assessment coordinators quickly identify the key elements impacting Medicare reimbursement.  This AAPACN resource is copyright protected. AAPACN individual members may download or print one copy for use within …