MDS 3.0 and the RAI Process
The MDS 3.0 and the RAI (Resident Assessment Instrument) is a comprehensive nurse assessment and care planning process used by the long-term and post-acute care field as a requirement for reimbursement under Medicare and Medicaid. AAPACN nurse experts help you stay up to date on changes to the MDS with breaking news, articles, and practical tools.
- Q&A: A resident fell and was transported to the acute hospital for evaluation. X-rays were completed and the resident was admitted to the hospital for a fracture. Do we code the injury from the fall on the Discharge assessment or when the resident returns on the Significant Change in Status Assessment?Question: A resident fell and was transported to the acute hospital for evaluation. X-rays were completed and the resident was admitted to the hospital for a fracture. Do we code the injury from the fall …
- Q&A: If a resident’s skilled Medicare Part A stay ends and the resident remains in the facility an additional five days before discharging home, do I have to complete two discharge assessments?Question: If a resident’s skilled Medicare Part A stay ends and the resident remains in the facility an additional five days before discharging home, do I have to complete two discharge assessments? Answer from Scott …
- Q&A: If walking only occurs in the look-back period with therapy, can we use that to determine the usual performance or would we code not applicable or not attempted due to medical condition or safety concern?Question: If walking only occurs in the look-back period with therapy, can we use that to determine the usual performance or would we code not applicable or not attempted due to medical condition or safety …
- Boost MDS, CAA, and Care Plan Accuracy—and Show the Value of the NAC RoleThe MDS is more than a data collection tool, says Sabrena McCarley, MBA-SL, OTR/L, CLIPP, RAC-CT, QCP, FAOTA, RAC-CTA, vice president of clinical reimbursement and regulatory affairs for Transitional Care Management in Lisle, IL. McCarley …
- Uncomplicating Drug ClassificationsMedications are an essential part of the care and interventions provided to residents in a skilled nursing facility. These medications may be used to manage chronic conditions, slow disease progress, ease symptoms, or even prevent …
- Q&A: I am working in an older facility, and every bed has bilateral quarter-length side rails. The facility leadership states the rails are for mobility, but they cannot be lowered for any residents. Could these be a restraint?Question: I am working in an older facility, and every bed has bilateral quarter-length side rails. The facility leadership states the rails are for mobility, but they cannot be lowered for any residents. Could these …
- Q&A: A resident recently enrolled in hospice, and we scheduled a Significant Change in Status Assessment (SCSA) for 1/14/25. The resident expired on 1/10, before the ARD of the SCSA. Do I need to complete this assessment? Question: A resident recently enrolled in hospice, and we scheduled a Significant Change in Status Assessment (SCSA) for 1/14/25. The resident expired on 1/10, before the ARD of the SCSA. Do I need to complete …
- TIP: CMS Releases FY 2025 Expected Responsibilities of State RAI Coordinators and Appendix B UpdateThe Centers for Medicare & Medicaid Services (CMS) recently released the Fiscal Year (FY) 2025 Mission & Priorities document (MPD). This document includes the expected responsibilities of the State Resident Assessment Instrument (RAI) coordinator: CMS …
- FY 2025 ICD-10-CM Codes and Coding Guidelines: April UpdateCDC announces no new ICD-10-CM codes effective April 1, 2025. The April 1, 2025 diagnosis code update files now available address revisions and typographical errors. Use these files for discharges occurring from April 1, 2025 …
- CMS QSEP Appendix PP Training for March 24, 2025 ImplementationTo register at QSEP and take the course, you just need to provide an email address. https://qsep.cms.gov Updated: January 16, 2025 This course consists of four presentations by the Division of Nursing Homes outlining the …
- October 2025 MDS Draft Item Sets: The SDOH Should Drive the NAC’s PlanningOn Oct. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the draft MDS version 1.20.1 item sets and item matrix for implementation on Oct. 1, 2025. The change history included with the …
- Q&A: In section K and O of the RAI User’s Manual, there are items than can be checked “on admission.” Per the manual, this refers to an assessment period of days one through three of the skilled nursing facility Medicare Part A stay, starting with A2400B. Does this include services provided in the hospital prior to admission to the SNF on day one?Question: In section K and O of the RAI User’s Manual, there are items than can be checked “on admission.” Per the manual, this refers to an assessment period of days one through three of …
- MDS 3.0 QM User’s Manual V17.0 and Risk Adjustment AppendixThe Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual Version (V)17.0 is now available. The MDS 3.0 QM User’s Manual V17.0 contains detailed specifications for the MDS 3.0 QMs and includes a Notable …
- CMS Nursing Home Data Sets UpdatedData Set Links COVID-19 Vaccination Rates – State and National Averages State and National averages for facility resident and healthcare personnel COVID-19 vaccination rates. Data are presented as one row per state or territory plus …
- Upcoming iQIES Service Center Hold Times: February PBJ Submission Deadline Upcoming iQIES Service Center Hold Times Due to the Payroll Based Journal quarterly deadline, the iQIES Service Center is projecting an increase in the volume of calls and emails between January 2, 2025, and February …
- ICD-10-CM: Navigating the Term “With,” Combination Codes, and Complications of CareAccurate diagnosis coding is critical in nursing facilities (NFs) for care planning, reimbursement, and quality measurement. NF coders must understand ICD-10-CM conventions, general coding guidelines, and chapter-specific coding guidelines that affect how diagnoses are assigned. …
- Q&A: When a resident received IV fluids (K0520A) for hydration, but did not have any calories from the fluids, do we code K0710A (Proportion of total calories the resident received through parenteral or tube feeding) as 1. 25% or less?Question: When a resident received IV fluids (K0520A) for hydration, but did not have any calories from the fluids, do we code K0710A (Proportion of total calories the resident received through parenteral or tube feeding) …
- Q&A: A resident was admitted to our facility on Medicare Part A and passed in facility after only a couple of hours. I had scheduled a 5-Day/Admission for the 7th day before she passed. How do I set up MDS assessments?Question: A resident was admitted to our facility on Medicare Part A and passed in facility after only a couple of hours. I had scheduled a 5-Day/Admission for the 7th day before she passed. How …
- Demystifying the Discharge Function Score for Post-Acute CareBy Greg Seiple Navigating the complexities of healthcare, especially in post-acute care, can often feel daunting. For professionals involved in skilled nursing facilities, understanding the metrics that influence patient care is crucial. One of these …
- Why Getting MDS Right Is Non-Negotiable: The Importance of MDS AccuracyWritten by Kristine Martinez BSN, RN, RAC-CTA, QCP Completing a Minimum Data Set (MDS) correctly is no small task. With approximately 510 answers or choices on a comprehensive MDS (not including CAA investigation), and approximately530 answers …
- Mastering the Discharge Function Score for Skilled Nursing FacilitiesBy Greg Seiple Discharge planning is an essential component of patient care in skilled nursing facilities. But how do healthcare professionals determine when a resident is ready to leave and manage daily activities independently? Enter …
- Q&A: A resident was recently admitted with multiple fractures related to an ATV accident. Is it appropriate to use Z47.89, Encounter for other orthopedic aftercare, as the principal diagnosis code?Question: A resident was recently admitted with multiple fractures related to an ATV accident. Is it appropriate to use Z47.89, Encounter for other orthopedic aftercare, as the principal diagnosis code? Answer from Carol Maher, …
- Q&A: I am confused with what can be included at O0110A1, chemotherapy while a resident. A resident is currently receiving Ibrance, as part of her cancer treatment. Can I code oral chemotherapy? Question: I am confused with what can be included at O0110A1, chemotherapy while a resident. A resident is currently receiving Ibrance, as part of her cancer treatment. Can I code oral chemotherapy? Answer from Scott …
- Q&A: A resident recently admitted to us with over 20 pressure ulcers and 10 of these are deep tissue pressure injuries. M0300 only allows us to enter a single digit amount 0-9 on the MDS. How do we code when it is 10 or more?Question: A resident recently admitted to us with over 20 pressure ulcers and 10 of these are deep tissue pressure injuries. M0300 only allows us to enter a single digit amount 0-9 on the MDS. …
- GG0130 and GG0170: Using Clinical Judgment to Establish Usual PerformanceThe ability to exercise clinical judgment to define usual performance in MDS items GG0130 (Self-Care) and GG0170 (Mobility) offers nursing homes unprecedented opportunity to impact quality measures (QMs), says Rosanna Benbow, RN, CCM, ICC, IP, …
- OIG: Nursing Facility Industry Segment-Specific Compliance Program GuidanceFrom https://oig.hhs.gov/compliance/nursing-facility-icpg/ The Nursing Facility ICPG—together with OIG’s General Compliance Program Guidance (GCPG) that applies to all individuals and entities involved in the health care industry—serves as OIG’s updated and centralized source of voluntary compliance program guidance for …
- SNF ABN Update: What Changed and How to Keep the Process Running SmoothlyEffective Oct. 31, 2024, skilled nursing facilities (SNFs) now are required to use an updated Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNF ABN), also known as form CMS-10055, and the corresponding revised instructions …
- Q&A: I completed the pain interview with the resident two days before the ARD and he reported no pain. How do I code this when it conflicts with other medical record documentation?Question: I completed the pain interview with the resident two days before the ARD and he reported no pain. How do I code this when it conflicts with other medical record documentation? Answer from Jeff …
- Q&A: Would it be considered a delusion if a resident who has dementia states that they have a girlfriend in the absence of one, needs to go find their parents/spouse who are deceased, or needs to go find their truck so that they may go home?Question: Would it be considered a delusion if a resident who has dementia states that they have a girlfriend in the absence of one, needs to go find their parents/spouse who are deceased, or needs …
- Q&A: Is total parenteral nutrition (TPN) coded in MDS items O0110H (IV Medication), K0520A (Parenteral/IV Feeding), and K0710 (Percent Intake by Artificial Route)?Question: Is total parenteral nutrition (TPN) coded in MDS items O0110H (IV Medication), K0520A (Parenteral/IV Feeding), and K0710 (Percent Intake by Artificial Route)? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: TPN is an …
- Ethics and Ramifications of Backdating the MDSBackdating, or placing an earlier date than the actual date on a document, is only permissible in limited Minimum Data Set (MDS) scenarios. Has anyone asked the nurse assessment coordinator (NAC) to change the assessment …
- iQIES MDS Error Message Reference Guide v2.4This user guide addresses Minimum Data Set (MDS) error messages and troubleshooting. iQIES MDS Error Message Reference Guide v2.4 (posted 11/11/2024)
- Break the Bad Data Cycle: Keys to Boosting Accuracy in GG0130 and GG0170MDS items GG0130 (Self-Care) and GG0170 (Mobility) are a common source of headaches for both the nurse assessment coordinator (NAC) and the interdisciplinary team (IDT). While there is no one-size-fits-all approach for obtaining accurate documentation …
- Q&A: A resident had a right below-knee amputation (BKA) a month ago and a Significant Change in Status Assessment (SCSA) was completed at that time. The resident is now going back to have a revision done from the BKA to above-knee amputation (AKA). Would the second surgery be considered a significant change also?Question: A resident had a right below-knee amputation (BKA) a month ago and a Significant Change in Status Assessment (SCSA) was completed at that time. The resident is now going back to have a revision …
- Q&A: I transmitted an assessment with an ARD of 10/3/24. Our software scrubber said the assessment had an error because I signed Z0500 on 10/3/24. The assessment was accepted by CMS. Is there a penalty for early completion of the MDS?Question: I transmitted an assessment with an ARD of 10/3/24. Our software scrubber said the assessment had an error because I signed Z0500 on 10/3/24. The assessment was accepted by CMS. Is there a penalty …
- Follow-Up Answers to Q&A from ICD-10 Updates Sept. 12, 2024, AAPACN WebinarIn this podcast, AAPACN Curriculum Development Specialists, Jessie McGill, RN, BSN, RAC-MT, RAC-MTA and Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC, discuss a few of the questions asked during the recent AAPACN webinar, “How to …
- TIP: CDC Updates “Stay-Up-To-Date” Recommendation for People 65 Years and OlderOn Oct. 23, 2024, the Centers for Disease Control and Prevention (CDC) released a memo on the updated Advisory Committee on Immunization Practices’ (ACIP’s) recommendation for people 65 years and older and those who are …
- OBRA Scheduling Tools for Calendar Year 2025AAPACN offers two great tools to assist nurse assessment coordinators (NACs) in scheduling OBRA assessments. Be prepared for 2025 with these two tools that are free to members: This AAPACN resource is copyright protected. AAPACN …
- Additional Items Required by States for Nursing Home MDS 3.0 2024 ImplementationFrom https://qtso.cms.gov/vendors/minimum-data-set-mds-vendors/reference-manuals
- Hurricane Helene Resources: SC, TN, NC, GA, and FLFinal FEMA Exception Memo for Helene: https://www.cms.gov/medicare/quality/snf-quality-reporting-program/reconsideration-and-exception-extension Hurricane Helene – South Carolina and Tennessee (2024) Secretary Becerra used his authority in the Public Health Service Act to declare a public health emergency (PHE) on September 30, 2024, …
- Moving Forward Coalition Guide to Addressing Resident Goals, Preferences, and PrioritiesThe Moving Forward Coalition, in partnership with A.G. Rhodes, Kansas State University (KSU), Dash Media, and The John A. Hartford Foundation, presents “The Foundation of Our Work: What Matters Most to Residents”! Why do we …
- Section GG Strategies: Documentation and CollaborationSection GG has greatly evolved since 2016. It was first introduced as just a few functional items completed only for Medicare Part A residents, but now it requires 26 functional tasks for all long-term care …
- Improving Resident Care Through Effective Communication: The MDS 3.0 Scripted InterviewEffective communication with residents in skilled nursing facilities (SNFs) is essential to understand their needs and preferences. In accordance with Appendix D of the Long-Term Care Facility Resident Assessment 3.0 User’s Manual (RAI User’s Manual) …
- Q&A: Please clarify the law regarding ICD-10 coding of HIV (B20). Is it a HIPAA violation to include this diagnosis under the medical diagnoses section in the medical record? Question: Please clarify the law regarding ICD-10 coding of HIV (B20). Is it a HIPAA violation to include this diagnosis under the medical diagnoses section in the medical record? Answer from Carol Maher, RN, GERO-BC, …
- Q&A: If a long-term resident was transferred to the Emergency Department (ED) and passed away while at the ED, do I complete a Discharge Return Not Anticipated assessment or a Death-in-Facility record?Question: If a long-term resident was transferred to the Emergency Department (ED) and passed away while at the ED, do I complete a Discharge Return Not Anticipated assessment or a Death-in-Facility record? Answer from Scott …
- CMS iQIES Reports User Manual v2.7This user manual provides information for CMS, Providers, Vendors, Accrediting Organizations, Contractors, and State Agencies to effectively perform Reports functions and the processes necessary to request, view, download, and save reports in iQIES. Also see …
- Q&A: Can I use ICD-10 diagnoses that are included in physician notes within the last 60 days that are listed as ‘previous medical history’? These diagnoses have no medication orders and are not listed on the plan of care. Question: Can I use ICD-10 diagnoses that are included in physician notes within the last 60 days that are listed as ‘previous medical history’? These diagnoses have no medication orders and are not listed on …
- Q&A: Would bells on a bathroom door be coded as “other alarm” in section P? The bells are placed on the door to alert staff when a resident enters the bathroom alone.Question: Would bells on a bathroom door be coded as “other alarm” in section P? The bells are placed on the door to alert staff when a resident enters the bathroom alone. Answer from Denise …
- Q&A: How often should the trauma-informed care assessments be completed? Question: How often should the trauma-informed care assessments be completed? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: The following language is from F699. I would focus your assessment efforts on meeting …
- TIP: CDC Announced Changes to COVID-19 Vaccine ReportingIn a recent webinar series, the Centers for Disease Control and Prevention (CDC) announced changes to the definition of “up to date” for COVID-19 vaccine reporting in the National Healthcare Safety Network (NHSN). This change …
- Preparing for Next Oct. 1, 2025: Draft MDS 3.0 Item Sets v1.20.1 and Draft MDS Data Specs v3.10.0Draft MDS 3.0 Item Sets version 1.20.1 The draft Minimum Data Set (MDS) 3.0 Item Sets version (v)1.20.1 and Item Matrix are now available. The MDS Item Sets v1.20.1 will be effective beginning October 1, …
- PPS Discharge Assessment: 10 Steps to a More Complete, Accurate MDSThe Medicare Part A PPS Discharge assessment (i.e., the NPE item set) is now a crucial assessment with far-reaching impacts for skilled nursing facilities (SNFs) in the Skilled Nursing Facility Quality Reporting Program (SNF QRP), …
- CDC ICD-10 Browser Tool Updated for FY 2025Search ICD-10-CM Codes ICD-10-CM Browser Tool is available at https://icd10cmtool.cdc.gov/ From https://www.cdc.gov/nchs/icd/icd-10-cm/index.html
- Top 3 2024 MDS 3.0 UpdatesOn Aug. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the final MDS 3.0 RAI User’s Manual version 1.19.1 that will be effective Oct. 1, 2024. Although nurse assessment coordinators in skilled …
- Sepsis: Nurse Documentation Training AideStarting Oct. 1, 2024, additional supporting documentation is required to capture a diagnosis of sepsis at I2100, Septicemia on the MDS. Nurse assessment coordinators can use the AAPACN Sepsis: Nurse Documentation Training Aide to provide …
- GG Goals: Not Really GoneEffective Oct. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) removed column 2, discharge goals, from items GG0130 and GG0170 on the Minimum Data Set (MDS). Many nurse assessment coordinators will welcome the …
- I0020B: Avoid Common Sources of Confusion When Coding This MDS ItemThe ICD-10-CM code captured in MDS item I0020B (ICD-10 Code/Primary Medical Condition Category) is the foundation of case-mix classification for the Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) payment components in the …
- Q&A: Can the pain interview be completed during the 7-day look-back or does it need to be completed during the 5-day look-back period?Question: Can the pain interview be completed during the 7-day look-back or does it need to be completed during the 5-day look-back period? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: The pain interview …
- Top Five Changes in the RAI User’s Manual for October 2024In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, curriculum development specialist for AAPACN, discuss the top five changes coming to …
- Q&A: Can an End of PPS be done since a resident is not leaving the facility but just changing payor sources?Question: Can an End of PPS be done since a resident is not leaving the facility but just changing payor sources? Answer from Jeff Taylor: Yes, it’s required for any discharge from Medicare Part A …
- Q&A: A resident was placed in strict isolation and a COVID-19 test was completed due to complaints of a sore throat and cough. The test was negative, but the resident remains in isolation in room due to ongoing symptoms. Can isolation be coded on the MDS in this situation?Question: A resident was placed in strict isolation and a COVID-19 test was completed due to complaints of a sore throat and cough. The test was negative, but the resident remains in isolation in room …
- Q&A: If the registered dietitian writes that the resident is at risk for malnutrition, but the physician doesn’t review and sign that he agrees until after the ARD, should risk for malnutrition be coded on the MDS?Question: If the registered dietitian writes that the resident is at risk for malnutrition, but the physician doesn’t review and sign that he agrees until after the ARD, should risk for malnutrition be coded on …
- TIP: CMS Released Updated Links for the MDS 3.0 RAI User’s Manual, Version 1.19.1The Centers for Medicare & Medicaid Services (CMS) recently released the Hyperlink Update Supplement file to address external webpage changes. This file also addresses replacement links and replacement pages for the affected RAI User’s Manual …
- From Data Elements to Quality Measures: CMS TrainingThe Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides a high-level overview of how data elements within CMS patient/resident assessment instruments are used to construct quality measures (QMs) …
- SNF QRP FAQs for FY 2025An update to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) FreAn update to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Frequently Asked Questions (FAQs) document is now available. This document has …
- FY 2027 (CY 2025 Data) SNF QRP MDS Reporting Requirements and Data Submission DeadlinesSNF QRP Data Elements Used for Reporting Assessment-Based QMs and Standardized Patient Assessment Data Elements Affecting FY 2027 APU Determination and Data Collection and Final Submission Deadlines for FY 2027 posted The Skilled Nursing Facility …
- Section GG Web-based Training Series From CMSThe Centers for Medicare & Medicaid Services (CMS) is offering an updated series of web-based training courses that provide an overview of the assessment and guidance to promote accurate coding of the post-acute care (PAC) …
- Q&A: A resident went on leave of absence (LOA) and after being out for two weeks decided he wanted to be discharged and only return to pick up belongings and discharge paperwork. What is the official discharge date?Question: A resident went on leave of absence (LOA) and after being out for two weeks decided he wanted to be discharged and only return to pick up belongings and discharge paperwork. What is the official …
- Q&A: Does an Interim Payment Assessment (IPA) take the place of a Significant Change in Status Assessment (SCSA) for a Medicare Part A resident or should both be completed?Question: Does an Interim Payment Assessment (IPA) take the place of a Significant Change in Status Assessment (SCSA) for a Medicare Part A resident or should both be completed? Answer from Carol Maher, RN-BC, RAC-MTA, …
- TIP: CMS Released the Final MDS 3.0 RAI User’s Manual version 1.19.1The final Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual version (v)1.19.1 is now available in the Downloads section on the MDS 3.0 RAI Manual webpage. The MDS 3.0 RAI User’s Manual …
- FY 2025 I0020B Lookup File of ICD-10 CodesThe Microsoft Access database containing the International Classification of Diseases (ICD)-10 codes allowed for item I0020B has been updated to reflect the codes that will be active as of October 1, 2024 (FY2025). The ZIP …
- FY 2025 SNF PPS Final Rule (CMS 1802-F) and Fact SheetLink to rule: https://www.federalregister.gov/public-inspection/2024-16907/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities Wage index files: CMS-1802-F Wage Index Tables for FY 2025 – Final (ZIP) Fact Sheet: On July 31, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a final rule updating Medicare …
- FY 2025 PDPM ICD-10 Mappings FileFrom https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/patient-driven-model
- Preferences and Routines: Use Section F to Collaborate on the Care PlanThe Resident Assessment Instrument (RAI) process begins with the Minimum Data Set (MDS) assessment and ends with the resident-centered comprehensive care plan. In the MDS, section F focuses on the resident’s preferences for customary routines …
- Q&A: Is it acceptable to use a hospital weight obtained during the look-back of an admission MDS to code K0200?Question: Is it acceptable to use a hospital weight obtained during the look-back of an admission MDS to code K0200? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO Any weight taken in …
- Q&A: Is there a CMS document that states section GG usual performance can be determined after the 3-day window?Question: We received denial during a Medicare Advantage audit stating “clinical documentation does not support the PT, OT, and Nursing function score for all section GG payment items during the 1-3 of the skilled stay. …
- TIP: CMS Answers MDS-Related PBJ Questions in FAQThe Centers for Medicare & Medicaid Services (CMS) recently released an updated frequently asked questions (FAQs) document, Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Frequently Asked Questions which details how MDS assessments are used in …
- Template for Care Area Assessment Summary NoteAAPACN’s Template for Care Area Assessment (CAA) Summary Note can help guide the interdisciplinary team members through how to determine and document rationale for the care plan determination by summarizing the underlying causes, contributing factors, …
- CMS Patient Mood Interview (Patient Health Questionnaire PHQ-2 to 9) Video TutorialThe Centers for Medicare & Medicaid Services (CMS) is offering a video tutorial for completing D0150, Patient Mood Interview (PHQ-2 to 9) and D0160, Total Severity Score. This video depicts two scenarios that demonstrate the coding …
- 5-Star Helpline Available July 29 – Aug. 9The Five Star Preview Reports will be available on or around July 24, 2024. Provider Preview Reports have moved to iQIES as of August 2023. Please follow the steps below to locate the Provider Preview …
- CMS Training Course: What You Need to Know: PAC QRP Key Program Updates – FY/CY 2025What You Need to Know: PAC QRP Key Program Updates – FY/CY 2025 About This Course The Centers for Medicare & Medicaid Services (CMS) is offering this cross-setting web-based training course that provides an …
- Q&A: When is the appropriate timeframe to code question B0100 on the MDS?Question: When is the appropriate timeframe to code question B0100 on the MDS? Answer from Jeff Taylor After the ARD. The steps for assessment and coding instructions say to review the record for the observation period …
- Q&A: Would a chest strap be considered a restraint for a resident who makes no free movements, and it does not restrict him from any normal access to his body?Question: A long-term resident has used a seatbelt on his chair for several years. Recently, the occupational therapist fitted him with a chest support strap for postural support instead. I had been coding the seatbelt …
- PDPM Grouper to Support XML InputCurrently, the PDPM Grouper processes the MDS assessment in a fixed-length string format. To allow for future flexibility, the fiscal year 2025 release of the PDPM Grouper, effective October 1, 2024, will also support MDS …
- MDS Data Specifications V3.02.1 (FINAL) Plus Errata for Oct. 1, 2024 ImplementationFrom https://www.cms.gov/medicare/quality/nursing-home-improvement/minimum-data-set-technical-information
- Individualized Care Plan: Made to OrderThink about individualization like the almost endless variations of coffee drinks available these days. With an extra pump of this or a drizzle of that, we enjoy endless ways to individualize our order. Beyond coffee, …
- PPS Discharge Assessment: Why Is It More Important Than Ever?Nurse assessment coordinators (NACs) will soon begin preparing the interdisciplinary team for the finalized MDS 3.0 version 1.19.1 item set changes, as well as the revised coding instructions in the yet-to-be-finalized Long-Term Care Facility Resident …
- Q&A: Are section GG discharge goals providing a false error message that it impacts the provider threshold?Question: I thought starting Oct 2023 discharge goals for section GG were no longer required on the MDS. If discharge goals are not required is this a false error message that it is impacting the …
- TIP: CMS Released Final MDS 3.0 Item Matrix for Oct. 2024 Item SetsHistorically the Centers for Medicare & Medicaid Services (CMS) included the MDS item set matrix in the RAI User’s Manual in appendix F. However, CMS will now be posting the matrix and any updated independently …
- Draft RAI User’s Manual v1.19.1 Study Guide: Key Changes to ReviewWhat the MDS will look like effective Oct. 1, 2024, is beginning to take shape for nurse assessment coordinators (NACs) and the rest of the interdisciplinary team (IDT). Following up on the May 17, 2024, …
- Q&A: Is a “Level 7-Easy to Chew” diet coded as a mechanically altered diet?Question: Is a “Level 7-Easy to Chew” diet coded as a mechanically altered diet? Could there be ADR concerns? Note: “Level 7-Easy to Chew” is from the International Dysphagia Diet Standardization Initiative (IDDSI), more information …
- Q&A: To code isolation in section O, does the isolation need to be every day during the look-back period?Question: To code isolation in section O, does the isolation need to be every day during the look-back period? Also, if the resident has COPD and shortness of breath is not documented, but it is …
- FY 2025 Final MDS 3.0 Item Sets version 1.19.1 Effective Oct. 1, 2024The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.19.1 are now available. The MDS Item Sets v1.19.1 will be effective beginning October 01, 2024. Items in sections A, B, D, GG, I, J, …
- SNF QRP Quick Reference GuideAn updated Quick Reference Guide is now available. The Quick Reference Guide provides high-level information on the SNF Quality Reporting Program, including frequently asked questions and helpful links. PAC-SNF-QuickReferenceGuide-20240425 (PDF) From https://www.cms.gov/medicare/quality/snf-quality-reporting-program/submission-deadlines
- CMS iQIES Implements Inactive User Policy, Requiring Logins Every 60 DaysTo: iQIES Users, CMS Staff CMS security policy requires deactivation of user roles for inactive accounts.To align with CMS security policies, iQIES will begin implementing an inactive user policy this month. This will allow CMS …
- iQIES User Roles Matrix Job AidThis job aid outlines the user roles and privileges in iQIES. All users must have a role in iQIES. Version 4.2 is now available at iQIES User Roles Matrix Job Aid v4.2 – 05/08/2024 (PDF …
- Social Determinants of Health (SDOH) MDS Coding Explainer VideoThe Centers for Medicare & Medicaid Services is offering a 4-minute, animated explainer video, Social Determinants of Health (SDOH) Items: Using Sources Other Than the Resident to Code for SNF providers. This video is intended to assist providers …
- Q&A: If a resident is care planned for a certain expected behavior, must we code the behaviors on the MDS?Question: If a resident is care planned for a certain expected behavior, must we code the behaviors on the MDS? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC You must code any behaviors …
- Q&A: Can a weight taken after the ARD be used for the MDS?Question: Can a weight taken after the ARD be used for the MDS? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO No, data collected after the ARD cannot be coded on the …
- MDS Tools to Make the NAC’s Job EasierIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, and Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, curriculum development specialists for …