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: What is considered as the most updated COVID-19 vaccine to code on the MDS?Question: What is considered as the most updated COVID-19 vaccine to code on the MDS? Answer from Jessie McGill RN, BSN, RAC-MTA, RAC-CTA: To determine up to date, we must reference the Staying Up to …
- Q&A: For the PHQ-2 to 9 interview, if the resident is at least sometimes understood and the interview is attempted, but the resident did not respond to the first two questions, how is this coded and can we proceed to the Staff Interview of Mood?Question: For the PHQ-2 to 9 interview, if the resident is at least sometimes understood and the interview is attempted, but the resident did not respond to the first two questions, how is this coded …
- Deep Dive into ICD-10-CM: Diagnosis Sequencing GuidelinesThe International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code assignment continues to be a bit of an enigma in the long-term care setting. Members regularly ask questions about ICD-10-CM coding in AAPACN’s online …
- MDS Supporting Documentation From CMS re: FY 2026 SNF PPS Proposed Rule and Other Upcoming ChangesMinimum Data Set 3.0 Nursing Home and Swing Bed Prospective Payment System (PPS) for the Collection of Data Related to the Patient-Driven Payment Model and the Skilled Nursing Facility Quality Reporting Program (QRP) MODIFIED: o Item …
- Q&A: A resident discharged to the hospital with an unstageable pressure ulcer due to eschar (occurred in house). The wound was debrided in the hospital and then the resident returned with it being a Stage 3 pressure ulcer. Would this be presented upon reentry since it’s now a Stage 3?Question: A resident discharged to the hospital with an unstageable pressure ulcer due to eschar (occurred in house). The wound was debrided in the hospital and then the resident returned with it being a Stage …
- Q&A: A resident had a chest tube placed in the hospital and removed prior to re-admission. In the 5-Day look-back period, we have orders for an ointment and dressing to the area daily until resolved. Would I capture this under surgical wound and surgical wound care?Question: A resident had a chest tube placed in the hospital and removed prior to re-admission. In the 5-Day look-back period, we have orders for an ointment and dressing to the area daily until resolved. …
- Q&A: Is an OBRA Discharge assessment required when a non-skilled resident has an unplanned transfer to the hospital, was not admitted, but was there for 30 hours?Question: Is an OBRA Discharge assessment required when a non-skilled resident has an unplanned transfer to the hospital, was not admitted, but was there for 30 hours? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, …
- GG Trivia GameAAPACN’s GG Trivia Game is a fun education tool to help nurse aides and other direct care staff understand the performance levels and functional tasks for section GG. The nurse assessment coordinator or delegate hosts …
- Care Conference 101: Keys to a Meaningful MeetingA well-run care conference or care plan meeting can help the interdisciplinary team (IDT) improve the resident’s quality of care and quality of life by establishing a more resident-centered, individualized, culturally competent, and trauma-informed care …
- Q&A: On admission, our infection control nurse asks about the COVID-19 vaccine and documents the resident’s vaccine status and acceptance or refusal of the vaccine. Since we are no longer providing the vaccine in the facility, should I be dashing this item? Question: On admission, our infection control nurse asks about the COVID-19 vaccine and documents the resident’s vaccine status and acceptance or refusal of the vaccine. Since we are no longer providing the vaccine in the …
- Q&A: Do the medications gabapentin/Neurontin get coded in section J, Scheduled pain medication regimen, if the doctor noted they are for pain management, and are they also coded as anticonvulsants in section N?Question: Do the medications gabapentin/Neurontin get coded in section J, Scheduled pain medication regimen, if the doctor noted they are for pain management, and are they also coded as anticonvulsants in section N? Answer from …
- TIP: CMS Released Draft RAI User’s Manual for Oct. 2025The Centers for Medicare & Medicaid Services (CMS) released a draft of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual) v1.20.1, which is planned to become effective Oct. 1, 2025. This …
- October 2025: Draft MDS Item Sets and RAI User’s ManualThe Centers for Medicare & Medicaid Services (CMS) recently released a second version of the draft item set files for Oct. 1, 2025, updates, version 1.20.1v2, and the draft Long-Term Care Facility Resident Assessment Instrument …
- Respiratory Therapy MDS Coding ChecklistRespiratory therapy, coded at 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: When coding urinary tract infection (UTI) at I2300, if the diagnosis of UTI was made prior to resident admission, is it optional to use evidence-based criteria (e.g., NHSN), which would exclude the UTI prior to admission? Question: When coding urinary tract infection (UTI) at I2300, the RAI User’s Manual states that if diagnosis of UTI was made prior to resident admission it is not necessary to evaluate for evidence-based criteria and …
- Q&A: We recently had a state case-mix audit, and I had to correct an error that resulted in a new Care Area Assessment (CAA) triggering. My software gave me a warning that a significant correction was indicated. How do I know if a significant correction is needed and how do I schedule this?Question: We recently had a state case-mix audit, and I had to correct an error that resulted in a new Care Area Assessment (CAA) triggering. My software gave me a warning that a significant correction …
- Q&A: Should MDS Item I0020B always be the diagnosis from the qualifying hospital stay? How do I code this for a resident who has been in long-term care for many years and has no recent hospital stays?Question: Should MDS Item I0020B always be the diagnosis from the qualifying hospital stay? How do I code this for a resident who has been in long-term care for many years and has no recent …
- Breathe Easy: Code Respiratory Therapy AccuratelyIn long-term care (LTC) facilities, many residents need care for chronic and acute respiratory problems, such as chronic obstructive pulmonary disease (COPD), pneumonia, tracheostomy, and post-COVID complications. LTC nurses need to know how to manage …
- Draft MDS 3.0 RAI User’s Manual version 1.20.1 Effective Oct. 1, 2025The draft Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual version (v)1.20.1 is now available in the Downloads section on the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual page. The MDS 3.0 RAI User’s Manual v1.20.1 will …
- Oct. 1, 2025 Draft MDS 3.0 Item Sets v1.20.1v2 (REVISED) and Draft MDS Data Specs v3.10.0Draft MDS 3.0 Item Sets version 1.20.1v2 UPDATED: Draft MDS 3.0 Item Sets version 1.20.1v2 The draft Minimum Data Set (MDS) 3.0 Item Sets version (v)1.20.1v2 and Item Matrix are now available. The MDS Item …
- Ethics in MDS Coding: Reimbursement and Quality MeasuresIn long-term care, the Minimum Data Set (MDS) ensures appropriate care planning, accurate reimbursement, and quality measurement while maintaining compliance with federal and state regulations. However, MDS coding may pose some ethical challenges. Completing the …
- Q&A: When coding K0100, Swallowing Disorders, can we capture signs and symptoms if they were identified when the resident was working with speech-language pathology (SLP) and on a trial diet?Question: When coding K0100, Swallowing Disorders, can we capture signs and symptoms if they were identified when the resident was working with speech-language pathology (SLP) and on a trial diet? Answer from Jennifer LaBay RN, …
- Q&A: A resident enrolled in hospice services and expired the next day. Do I still need to complete a Significant Change in Status Assessment (SCSA)?Question: A resident enrolled in hospice services and expired the next day. Do I still need to complete a Significant Change in Status Assessment (SCSA)? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC The …
- CMS iQIES Reports User Manual v2.8This 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
- CMS Nursing Home Data Sets UpdatedData Set Links Provider Information General information on currently active nursing homes, including number of certified beds, quality measure scores, staffing and other information used in the Five-Star Rating System. Data are presented as one …
- Section GG Accuracy: Helping Nursing Homes Get Fair Payment and ReferralsThe ongoing staffing shortage amid growing economic turbulence and payment pressures means that every nursing home in the country is currently struggling with reimbursement, says Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC, director …
- 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 twice since requiring COVID-19 vaccinations to be coded on the MDS as of October 2024. Facility …
- Q&A: We have a Medicare Part A resident who was only skilled by nursing at the end of the stay. How do we code GG items that only therapy perform, such as car transfers and stairs, if the resident was no longer receiving therapy services during the 3-day look-back window at the time of discharge? Question: We have a Medicare Part A resident who was only skilled by nursing at the end of the stay. How do we code GG items that only therapy perform, such as car transfers and …
- Q&A: A Medicare Part A resident passed away in the emergency department. I know a Death in Facility record needs to be completed, but do I also need to complete a Medicare Part A PPS discharge assessment?Question: A Medicare Part A resident passed away in the emergency department. I know a Death in Facility record needs to be completed, but do I also need to complete a Medicare Part A PPS …
- Q&A: To code K0300A for a physician-ordered weight loss, does the physician need to write a progress note that weight loss is intended or will an order for a diuretic automatically make the weight loss planned?Question: To code K0300A for a physician-ordered weight loss, does the physician need to write a progress note that weight loss is intended or will an order for a diuretic automatically make the weight loss …
- Section S for MDS Data Specifications V3.10.1 (FINAL) Oct. 1, 2025 ImplementationThe Section S portion of the forthcoming MDS Data Specifications V3.10.1 (FINAL) is now available for download under the Downloads section at the bottom of this webpage. This MDS version will be implemented in production on October …
- iQIES Known Issues: MDS 3.0 Manual Individual Correction/Deletion RequestOpen Assessments MDS The electronic change request form titled “MDS 3.0 Manual Individual Correction/Deletion Request” can only be utilized for deletion requests at this time. Please submit A0410 Corrections using the manual process. We are …
- Care Conference: How Do Resident Rights Connect to Care Planning?Some nurse assessment coordinators (NACs) may believe that having a care conference (aka care plan meeting) with the resident and/or their responsible party or family member is a regulatory requirement. “However, no regulations actually use …
- Q&A: Our facility had an influenza-A outbreak with testing from lab. Can we write an ICD-10 code for this for all impacted residents?Question: Our facility had an influenza-A outbreak with testing from lab. Can we write an ICD-10 code for this for all impacted residents? Answer from Jeff Taylor: You need a provider (physician or physician extender) …
- Q&A: For GG0130A, Eating, the RAI User’s Manual states this is the ability to bring food/liquids to the mouth once the meal is placed in front of the resident. How do you code if the resident only needs help opening cartons? Question: For GG0130A, Eating, the RAI User’s Manual states this is the ability to bring food/liquids to the mouth once the meal is placed in front of the resident. How do you code if the …
- Q&A: A resident elected hospice with one company on 1/31 and we scheduled a Significant Change in Status Assessment (SCSA) on 2/10. The family decided to change companies and enrolled with a different hospice company on 2/6. Do I need to complete two SCSAs or just one?Question: A resident elected hospice with one company on 1/31 and we scheduled a Significant Change in Status Assessment (SCSA) on 2/10. The family decided to change companies and enrolled with a different hospice company …
- TIP: April 2025 ICD-10-CM UpdateThe Centers for Disease Control and Prevention (CDC) released the April diagnosis code update files on the CDC ICD-10 webpage. For the first time in several years, there are no new ICD-10-CM codes effective April …
- 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 …
- 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 …
- 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 …
- 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) …