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.
- Why Directors of Nursing Services Must Be Well-Versed in PDPM and How to Ensure Documentation AccuracyListen to this article Your browser does not support the audio element. In today’s skilled nursing facility (SNF) landscape, the director of nursing services (DNS) is critical not only in overseeing resident care but also …
- Q&A: Is a Significant Change in Status Assessment (SCSA) required for a new pressure ulcer?Question: Is a Significant Change in Status Assessment (SCSA) required for a new pressure ulcer? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: A Significant Change in Status Assessment is required if there are …
- Q&A: If a Discharge – return not anticipated was completed for a resident discharge against medical advice (AMA), and he returned less than 30 days later, is a new OBRA Admission assessment required?Question: If a Discharge – return not anticipated was completed for a resident discharge against medical advice (AMA), and he returned less than 30 days later, is a new OBRA Admission assessment required? Answer from …
- Major Changes on Falls with Major Injury QMsListen to this article Your browser does not support the audio element. The Oct. 1, 2025, update to the definitions of “fall” and “major injury” in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s …
- iQIES MDS Error Message Reference Guide and Message List v1.1This user guide addresses Minimum Data Set (MDS) error messages and troubleshooting. iQIES MDS Error Message Reference Guide v1.1 (posted 12/29/2025) iQIES MDS Error Messages v1.1 (posted 12/29/2025) From https://qtso.cms.gov/providers/nursing-home-mdsswing-bed-providers/reference-manuals
- SNF QRP/SNF VBP: CMS Video Offers MDS Data Validation Process OverviewThe Centers for Medicare & Medicaid Services (CMS) is offering a recorded presentation which describes the new data validation process. This training will support facilities in understanding the purpose and structure of the data validation …
- iQIES User Roles Matrix Job AidThis job aid outlines the user roles and privileges in iQIES. All users must have a role in iQIES. iQIES User Roles Matrix Job Aid v4.7 (posted 12/22/2025)
- CMS Nursing Home Data Sets UpdatedMedicare Claims Quality Measures Quality measures that are based on Medicare claims data. Each row contains a specific quality measure for a specific nursing home and includes the risk-adjusted score. Last Modified: December 1, 2025 Released: January …
- FY 2026 ICD-10-CM Code Updates Effective April 1, 2026These files include updates for FY 2026. Use these codes for discharges occurring from April 1, 2026 – September 30, 2026, and for patient encounters occurring from April 1, 2026– September 30, 2026. https://www.cms.gov/medicare/coding-billing/icd-10-codes
- SNF QRP and SNF VBP MDS Data Validation Program FAQs UpdatedOverview What is the SNF Validation Program? The SNF Validation Program is an audit-driven initiative aimed at evaluating the accuracy of quality measure data elements derived from the Minimum Data Set (MDS), which are used …
- Q&A: A resident has a healing pressure ulcer that was described as “100% epithelial, with slow blanching erythema” during the ARD window. Would this still be coded as a pressure ulcer? Question: A resident has a healing pressure ulcer that was described as “100 % epithelial, with slow blanching erythema” during the ARD window. Would this still be coded as a pressure ulcer? Answer from …
- Q&A: If a resident is losing weight and ordered supplements as an intervention, can we code as a therapeutic diet?Question: If a resident is losing weight and ordered supplements as an intervention, can we code as a therapeutic diet? Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC:If the supplements were ordered by a …
- MDS 3.0 Quality Measures (QM) User’s Manual v18.0 Effective Jan. 1, 2026 and Associated FilesThe Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual Version (V)18.0 is now available along with associated files. Additionally, the updated .zip file titled MDS 3.0 QM User’s Manual v18.0 Effective 1-1-2026 and …
- Q&A: Can I code a diagnosis of pneumonia when the nurse practitioner initiated antibiotics for a documented reason of pneumonia, but there was not a chest x-ray completed to confirm the diagnosis?Question: Can I code a diagnosis of pneumonia when the nurse practitioner initiated antibiotics for a documented reason of pneumonia, but there was not a chest x-ray completed to confirm the diagnosis? Answer from Carol …
- Q&A: What date would be used in A2400C (Medicare end date) for an unplanned discharge to the hospital when the assessment is a combined a 5-Day, OBRA discharge, and a PPS discharge?Question: What date would be used in A2400C (Medicare end date) for an unplanned discharge to the hospital when the assessment is a combined a 5-Day, OBRA discharge, and a PPS discharge? Answer from Carol …
- Weight Loss/Gain Calculation Worksheets and Documentation Tip Sheets to Support MDS CodingAAPACN’s Weight Loss/Gain Calculation Worksheets and Documentation Tip Sheets to Support MDS Coding helps clinicians accurately calculate and document weight changes to support compliant MDS section K coding. This easy-to-use resource outlines how to identify …
- Crack the Code: E0800, Rejection of CareUnderstanding and accurately coding E0800, Rejection of Care, is essential both to reflect the resident’s behavior patterns and to ensure the care plan captures both the resident’s behaviors and his or her preferences. Misinterpreting rejection …
- Falls With Major Injury (FMI) NHQI Technical Specification ReportThe Centers for Medicare & Medicaid Services (CMS) has released the official Technical Specification Report for the Falls with Major Injury (FMI) measure. This report incorporates feedback received during the cross-setting Technical Expert Panel (TEP) …
- OIG: First SNF PDPM Audit ReportNearly All Skilled Nursing Services Provided by Pinnacle Multicare Nursing and Rehabilitation Center Did Not Meet Medicare Payment Requirements Issued on 11/14/2025 | Posted on 11/18/2025 | Report number: A-02-22-01017 Report Materials Why OIG Did This Audit What OIG Found What …
- iQIES Assessment Management: Assessment Submitter ManualThis document shows how to upload assessments, create and manage assessments, complete change requests, and review Final Validation Reports (FVR) in iQIES. Nov 18, 2025 CMS iQIES Assessment Management for Assessment Submitter v2.2 From https://qtso.cms.gov/software/iqies/reference-manuals
- MDS Item I1700: Navigate the Complexities of Coding MDROsMultidrug-resistant organisms (MDROs) are a red flag for a nursing home’s infection prevention and control program that either contact precautions or enhanced barrier precautions may need to be initiated, points out Carol Maher, RN, GERO-BC, …
- Q&A: If the stay is only 15 days, how do I calculate the 30-day weight loss for section K?Question: If the stay is only 15 days, how do I calculate the 30-day weight loss for section K? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: You use the weight that is closest …
- Q&A: What ARD is used for a Death in Facility record if the resident expires before midnight, but the mortuary did not pick up until after midnight? Question: What ARD is used for a Death in Facility record if the resident expires before midnight, but the mortuary did not pick up until after midnight? Answer from Jeff Taylor: The actual time/date …
- Back to PDPM Basics – Part 5: The NTA ComponentThe Non-Therapy Ancillary (NTA) component of the Patient-Driven Payment Model (PDPM) accounts for the medical complexity and resource-intensive services provided to residents in nursing facilities. This component is calculated using a combination of clinical diagnoses, …
- Crack the Code: B1000, VisionAn assessor does not need perfect eyesight to see that vision plays a significant role in the quality of life of residents in long-term care. Accurately evaluating vision, and how it is coded at B1000, …
- How to Manage Challenging Admission AssessmentsWritten by Brenda Schumacher, Staff Writer, AAPACN When a resident discharges before the Admission assessment is complete, nurse assessment coordinators (NACs) must make decisions that directly affect compliance, survey readiness, and resident care planning. Jessie …
- 2025 Section GG UpdatesIn this LTC NAC Chat podcast episode, 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, senior curriculum development specialist for AAPACN, discuss recent …
- Q&A: What is the look-back period for K0100? The RAI User’s Manual does not mention the look-back period or if this can include days during the hospital stay?Question: What is the look-back period for K0100? The RAI User’s Manual does not mention the look-back period or if this can include days during the hospital stay? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, …
- OBRA Scheduling Tools for Calendar Year 2026AAPACN offers two great tools to assist nurse assessment coordinators (NACs) in scheduling OBRA assessments. Be prepared for 2026 with these two tools that are free to members: This AAPACN resource is copyright protected. AAPACN …
- MDS Data Collection for the NAC ToolDo you have an organized approach to collect MDS data during the 7- and 14-day look-back periods? AAPACN’s MDS Data Collection for the NAC tool provides an organized approach to gathering supporting data from the …
- MDS Item L0200: Teeth Matter—and Not Just to DentistsMDS section L (Oral/Dental Status) is one of the most frequently undervalued areas of the MDS, says Eleisha Wilkes, RN, GERO-BC, RAC-CT, RAC-CTA, DNS-CT, QCP, a senior consultant with Proactive LTC Consulting in Evansville, IN. …
- Back to PDPM Basics – Part 4: The Nursing Component – Clinically Complex, Behavioral Symptoms and Cognitive Performance, and Reduced Physical FunctionThe nursing component of the Patient-Driven Payment Model (PDPM) may appear straightforward: calculate a section GG Nursing Function Score and assign the resident to one of six nursing categories. But accuracy relies on a detailed …
- Q&A: Is a Pure Wick catheter coded as an external catheter? Question: Is a Pure Wick catheter coded as an external catheter? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: Yes, this would meet the definition of an external catheter in the …
- Q&A: When assessing a fall with an injury to the head, such as a laceration, bruise, or hematoma, would this automatically be considered a major injury? Question: When assessing a fall with an injury to the head, such as a laceration, bruise, or hematoma, would this automatically be considered a major injury? Answer from Jessie McGill RN, BSN, RAC-MTA, RAC-CTA and …
- Follow Up Q&A for AAPACN Sept. 28, 2025 Webinar – Ready or Not: Oct. 1, 2025 MDS ChangesIn this LTC NAC Chat podcast episode, Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, curriculum development specialist for AAPACN, and Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, senior curriculum development specialist for AAPACN, answer some follow-up …
- TIP: COVID-19 Recommendations UpdatedThe Centers for Disease Control and Prevention (CDC) recently updated guidance for the COVID-19 vaccine administration and the adult immunization schedule. The CDC’s Adult Immunization Schedule webpage was updated Oct. 7, 2025, which changed the …
- Resident Interview ToolkitThe AAPACN Resident Interview Toolkit helps nursing home staff conduct effective resident interviews as part of the MDS 3.0 assessment process. It provides clear guidance and resources for the entire interdisciplinary team—nurses, dietary managers, social …
- TIP: Updated MDS 3.0 RAI User’s Manual Changes – New Definitions for Fall, Injury, and Major InjuryThe Centers for Medicare & Medicaid Services (CMS) released the final version of the RAI User’s Manual, version 1.20.1, which went into effect Oct. 1, 2025. CMS made several changes, including a new definition for …
- CMS iQIES Reports User Manual v2.9This 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. From https://qtso.cms.gov/software/iqies/reference-manuals
- Respiratory Therapy MDS Coding ChecklistRespiratory therapy, coded at O0390D and O0400D, must meet definitions and complex instructions per the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual). AAPACN’s Respiratory Therapy MDS Coding Checklist tool delineates the requirements …
- Q&A: How do you code walking if the resident only walks with therapy staff?Question: How do you code walking if the resident only walks with therapy staff? Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, and Jessie McGill, RN, BSN, RAC-MTA, RAC-CTA: If the resident only walked …
- Q&A: With the new definition of fall with major injury, would a bump on the head or a laceration be a head injury? With the new definition of fall with major injury, would a bump on the head or a laceration be a head injury?Question: With the new definition of fall with major injury, would a bump on the head or a laceration be a head injury? With the new definition of fall with major injury, would a bump …
- Q&A: I am confused by the new section GG guidance for when the activity “is being/will be” routinely performed. What does “will” mean?Question: I am confused by the new section GG guidance for when the activity “is being/will be” routinely performed. What does “will” mean? Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, and Jessie McGill, …
- QAPI Focus: Section GGAAPACN’s QAPI Focus: Section GG tool can be used at quality assurance and performance improvement (QAPI) meetings to focus specifically on concerns regarding section GG documentation and coding accuracy. This tool identifies specific section GG …
- TIP: CMS Released Additional Updates to RAI User’s Manual v1.20.1On Sept. 24, 2025, the Centers for Medicare & Medicaid Services (CMS) released an updated RAI User’s Manual version 1.20.1 and updated MDS item sets v1.20.1v4. The last-minute updates aligned the MDS item sets with …
- Should SNFs Collect Removed Section R MDS Data—and Why Do HRSN Even Matter?MDS section R (Health-Related Social Needs) did not go into effect on Oct. 1, 2025. The Centers for Medicare & Medicaid Services (CMS) followed through on its proposal and eliminated—prior to implementation—items R0310 (Living Situation), …
- Section O Overhaul: Changes to Therapy CodingThe Long-Term Care Resident Assessment Instrument (RAI) 3.0 User’s Manual (RAI User’s Manual) version 1.20.1, effective Oct. 1, 2025, will bring major changes to section O of the MDS 3.0. The most significant update introduces …
- PDPM Grouper JAR Package V2.4000This release was updated to support FY2026 ICD-10 codes which are used with MDS assessments with a target date on or after October 1, 2025. As part of this release, 487 clinical category mappings were added, …
- AAPACN Resources to Help Prepare for Oct. 1, 2025, MDS ChangesAAPACN Resources to Help Prepare for Oct. 1, 2025, MDS Changes The Long Term-Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual version 1.20.1 from the Centers for Medicare & Medicaid Services (CMS) goes into …
- Oct. 2025 RAI User’s Manual – Unexpected Updates In this LTC NAC Chat podcast episode, 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, senior curriculum development specialist for AAPACN, discuss some …
- SNF QRP Measure Calculations and Reporting User’s Manual V7.0, Change Table, Risk Adjustment and Imputation Appendix Files, and HCC ICD-10 CrosswalksThe Skilled Nursing Facility Quality Reporting Program (SNF QRP) Measure Calculations and Reporting User’s Manual v7.0 and accompanying files are now available. These materials serve as an update to the specifications used to calculate quality measures that …
- OIG: Nursing Homes Failed To Report 43 Percent of Falls With Major Injury and Hospitalization Among Their Medicare-Enrolled ResidentsIssued on 09/15/2025 | Posted on 09/18/2025 | Report number: OEI-05-24-00180 Report Materials Why OIG Did This Review What OIG Found Nursing homes failed to report 43 percent of falls with major injury and hospitalization among Medicare-enrolled residents, as required, in …
- Q&A: We had a resident on a Medicare Part A stay admit and discharge back to the hospital that same evening after a few hours. We could not assess much information during that brief amount of time. What are all the required MDS assessments that need to be completed on this resident? I know an entry tracker and an OBRA discharge, but do we need to also complete a 5-Day PPS?Question: We had a resident on a Medicare Part A stay admit and discharge back to the hospital that same evening after a few hours. We could not assess much information during that brief amount …
- Q&A: The new definition of a fall includes an overwhelming external force, but the definition of fracture related to a fall states, “Do not include fractures caused by trauma related to car crashes or pedestrian versus car accidents or impact of another person or object against the resident.” Does this instruction contradict the new definition of a fall?Question: The new definition of a fall includes an overwhelming external force, but the definition of fracture related to a fall states, “Do not include fractures caused by trauma related to car crashes or pedestrian versus …
- MDS Item J2100 Feeds Into PDPM: Learn What’s at Stake and How to Boost AccuracyMDS item J2100 (Did the Resident Have a Major Surgical Procedure During the Prior Inpatient Hospital Stay That Requires Active Care During the SNF Stay?) is the gateway question for receiving enhanced reimbursement in the …
- Q&A: Can Isolation be coded for methicillin-resistant staphylococcus aureus (MRSA) on a wound?Question: Can Isolation be coded for methicillin-resistant staphylococcus aureus (MRSA) on a wound? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: No, the RAI User’s Manual specifically states that isolation cannot be coded for …
- FY 2028 (CY 2026 Data) SNF QRP Reporting Requirements and Data Submission DeadlinesSNF QRP Data Collection and Final Submission Deadlines The SNF QRP Data Collection and Final Submission Deadlines have been updated to provide the data collection time frames and final submission deadlines for the FY 2028 …
- FY 2027 (CY 2025 Data) Revised 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 …
- FY 2026 ICD-10 PDPM Mappings FileThis file can be used by NACs to determine how ICD-10-CM codes entered on the MDS “map” to PDPM payment components. https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/patient-driven-model
- 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.”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 …
- 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?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 …
- 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?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 …
- Crack the Code: Staff Assessment for Mental Status ItemsThe 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 …
- Documentation Template: Isolation for Active Infectious DiseaseThe 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 …
- TIP: CMS Released Final RAI User’s Manual for Oct. 1, 2025The 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 …
- Patient Health Questionnaire Completion DeterminationEffective 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 …
- Oct. 1, 2025: MDS Changes At-a-GlanceThe 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 …
- Top Four GG Strategies: Preparing for the October UpdatesThe 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) …
- MDS Data Specifications V3.10.2 (FINAL) for Oct. 1, 2025The MDS Data Specifications V3.10.2 (FINAL) are now available for download. This version reflects changes finalized in the FY 2026 SNF PPS final rule (90 FR 37310). Note that there are some minor changes since DRAFT 3 …
- A New Way to Validate Your NAC KnowledgeIn this LTC NAC Chat podcast episode, 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, senior curriculum development specialist for AAPACN, discuss a …
- Back to PDPM Basics – Part 2: The SLP ComponentSince the implementation of the Patient-Driven Payment Model (PDPM), nursing facilities have had to take a more nuanced approach to how a resident’s needs are assessed and documented. As discussed in part 1 of this …
- Q&A: Can I count IV fluids and IV antibiotics that were administered in the hospital before admission and within the 7-day look-back period?Question: Can I count IV fluids and IV antibiotics that were administered in the hospital before admission and within the 7-day look-back period? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: IV fluid provided …
- Q&A: I miscalculated the ARD window for a 5-Day and scheduled the 5-Day/PPS Discharge on day 9 of the Medicare stay. What do I need to do?Question: I miscalculated the ARD window for a 5-Day and scheduled the 5-Day/PPS Discharge on day 9 of the Medicare stay. What do I need to do? Answer from Jeff Taylor:Leave everything as it is …
- Q&A: Does the 14-day look-back period for section O include days prior to entry into the facility?Question: Please clarify if section O “while a resident.” Per the RAI User’s Manual, “Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within …
- May 2025 Falls With Major Injury Technical Expert Panel (TEP) Summary ReportThe Centers for Medicare & Medicaid Services (CMS) convened a Technical Expert Panel (TEP) on May 12 and 14, 2025, to obtain input on potential cross-setting updates to the Falls with Major Injury (FMI) measure. …
- FY 2026 ICD-10-CM Code Updates and Coding Guidelines for Oct. 1, 2025 From CMS/CDCCDC announces new ICD-10-CM codes effective October 1, 2025. The October 1, 2025 diagnosis code update files are now available. Use these files for discharges occurring from October 1, 2025 – September 30, 2026, and for …
- Q&A: When should I set an assessment reference date (ARD) for a Significant Change in Status Assessment (SCSA) after a resident elected hospice?Question: When should I set an assessment reference date (ARD) for a Significant Change in Status Assessment (SCSA) after a resident elected hospice? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: The …
- Q&A: I know that McGeer criteria must be met when coding a UTI that develops in-house during the SNF stay, but what is required when a resident is transferred to the hospital and returns to the SNF with a documented UTI diagnosis (e.g., listed on the discharge summary and on antibiotics)?Question: I know that McGeer criteria must be met when coding a UTI that develops in-house during the SNF stay, but what is required when a resident is transferred to the hospital and returns to …
- TIP: CMS Finalizes Removal of Section RThe Centers for Medicare & Medicaid Services (CMS) noted in the FY 2026 SNF PPS Final Rule, “After consideration of the public comments, we are finalizing our proposal to remove four standardized patient assessment data …
- MDS Nutrition Is Not Limited to Section KWritten by Kristine Martinez, BSN, RN, RAC-CT, RAC-CTA, QCP, DNS-CT, MDS Consultants Often, section K on the minimum data set (MDS), along with the associated care area assessments (CAAs) and care planning are delegated to …
- Nurse Assessment Coordinator FTE Calculator ToolAAPACN has re-released the Nurse Assessment Coordinator (NAC) FTE Calculator for SNF leaders to estimate the time needed to complete assessments as well as project how many hours the NAC needs for meetings and other …
- FY 2026 SNF PPS Final Rule PostedOn July 31, 2025, the Centers for Medicare & Medicaid Services (CMS) issued a final rule for updates to Medicare payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility Prospective Payment …
- Back to PDPM Basics – Part 1: The PT and OT ComponentsIn skilled nursing facilities (SNFs), staff members often find the Patient-Driven Payment Model (PDPM) process complex and unfamiliar, especially when determining how Medicare (and, in many states, Medicaid) payment is calculated. PDPM is based on …
- Q&A: A resident elected hospice on July 9, 2025. What is the required completion date for the Significant Change in Status Assessment (SCSA), and what steps should be taken if the resident passes away before the assessment is completed?Question: A resident elected hospice on July 9, 2025. What is the required completion date for the Significant Change in Status Assessment (SCSA), and what steps should be taken if the resident passes away before …
- Q&A: Is aspirin coded as an antiplatelet in N0415I?Question: Is aspirin coded as an antiplatelet in N0415I? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: The RAI User’s Manual includes aspirin as an antiplatelet medication on page N-9: “N0415I1. Antiplatelet: Check if …
- Q&A: How do we code interviews that were not complete when a Medicare resident has an unplanned discharge to the hospital?Question: How do we code interviews that were not complete when a Medicare resident has an unplanned discharge to the hospital? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: If the interviews were not …
- Crack the Code: A0310EWhen completing any Minimum Data Set (MDS) assessment, accurate coding of A0310E is critical. This item is completed on OBRA (Omnibus Budget Reconciliation Act), scheduled PPS (Prospective Payment System), and OBRA discharge assessments. It asks, …
- Myers and Stauffer Medicaid LinksMyers and Stauffer provides documentation resources and training opportunities for several state Medicaid programs. Learn more below. State Clients Alabama Iowa North Carolina Arkansas Kentucky Ohio California Louisiana Oregon Colorado Maryland Tennessee Connecticut Minnesota Texas …
- Q&A: If a resident initiates his/her discharge for the following day and the facility was able to organize home care, equipment, etc., is this considered a planned or unplanned discharge?Question: If a resident initiates his/her discharge for the following day and the facility was able to organize home care, equipment, etc., is this considered a planned or unplanned discharge? Answer from Jessie McGill RN, …
- Q&A: The RAI User’s Manual guidance for mechanically altered diet mentions “soft solids.” Would that include solids that are naturally soft or solids that we would “soften”?Question: The RAI User’s Manual guidance for mechanically altered diet mentions “soft solids.” Would that include solids that are naturally soft or solids that we would “soften”? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, …
- MDS Changes Oct. 2025 – What We Know Right NowIn this LTC NAC Chat podcast episode, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, senior curriculum development specialist with AAPACN, discuss the MDS …
- Coding High-Risk Drug Classes: How to Improve N0415 AccuracyN0415 (High-Risk Drug Classes: Use and Indication) is much more than just paperwork. This MDS item impacts resident care through the care area triggers (CATs) and the care area assessments (CAAs), as well as facility …
- Out the Door, On a Leave, or Gone for Good? Uncomplicating DischargesIn the fast-paced position of a nurse assessment coordinator (NAC), keeping track of all the residents’ whereabouts can be challenging. The NAC must know who is coming into the facility and if this resident is …
- From the CATs to the QMs: Key Impacts of MDS Section NMDS section N (Medications)—in particular item N0415 (High-Risk Drug Classes: Use and Indication)— plays a key role in a nursing home’s ability to provide comprehensive, resident-centered care via the care area triggers (CATs) and the …
- Q&A: If the resident was in the emergency department (ED) and then admitted to the hospital before readmitting to the nursing home, can I capture IV fluids at the ED visit? Question: If the resident was in the emergency department (ED) and then admitted to the hospital before readmitting to the nursing home, can I capture IV fluids at the ED visit? Answer from Jessie …
- Q&A: A long-term care resident has a Quarterly assessment due on 6/19 and an Annual assessment due on 6/27. Can I do the Annual assessment early, before the Quarterly deadline?Question: A long-term care resident has a Quarterly assessment due on 6/19 and an Annual assessment due on 6/27. Can I do the Annual assessment early, before the Quarterly deadline? Answer from Carol Maher, RN, …
- COVID-19 Vaccine “Up to Date” Guidance TrackerThe Centers for Disease Control and Prevention (CDC) has updated the “Staying Up to Date with COVID-19 Vaccines” guidance several times since requiring COVID-19 vaccinations to be coded on the MDS as of October 2024. …
- Q&A: When a resident returns from an interrupted stay, is an IPA required or any kind of readmission assessment if no change?Question: When a resident returns from an interrupted stay, is an IPA required or any kind of readmission assessment if no change? Answer from Jeff Taylor: IPAs are always optional. In an interrupted stay, no …
- Q&A: A resident on a Medicare Part A stay discharged return not anticipated. His last covered day of Medicare was the day before. Can I combine the Part A PPS Discharge with the OBRA discharged return not anticipated?Question: A resident on a Medicare Part A stay discharged return not anticipated. His last covered day of Medicare was the day before. Can I combine the Part A PPS Discharge with the OBRA discharged …
- Q&A: For section GG documentation, the direct care staff was given the wrong dates. It was supposed to be the ARD and the two days before, but they did the first 3 days of the look-back period. Am I able to use any of the GG documentation they completed?Question: For section GG documentation, the direct care staff was given the wrong dates. It was supposed to be the ARD and the two days before, but they did the first 3 days of the …