All signs point to one universal truth for the nurse assessment coordinator (NAC): MDS accuracy is paramount, says Joel VanEaton, BSN, RN, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, executive vice president of post-acute care regulatory affairs and education for Broad River Rehab in Asheville, NC.
“If you are committed to MDS accuracy, that will then keep you focused on what’s important in terms of everything else that the MDS impacts,” says VanEaton. “That includes federal and often state reimbursement, the Nursing Home Quality Initiative (NHQI) and the Five-Star Quality Rating System quality measures (QMs), the Skilled Nursing Facility Quality Reporting Program (SNF QRP) QMs, the Skilled Nursing Facility Value-Based Purchasing program (SNF VBP) QMs, and the care area assessments (CAAs) and care plans.”
VanEaton recommends that the NAC take the following steps to boost MDS accuracy:
Build in ‘reading is fundamental’ time
The first step toward prioritizing MDS accuracy is to have a current Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual)—and to read it, stresses VanEaton. “NACs often think that they understand the coding instructions, so they just code that way without taking the time to review the instructions again.”
However, there are two critical problems with this approach, says VanEaton. “First, the coding instructions in the RAI User’s Manual are often complex and lengthy. The current version 1.20.1 manual, which went into effect on Oct. 1, 2025, has 1,001 total pages. Chapter 3, ‘Overview to the Item-by-Item Guide to the MDS 3.0,’ alone accounts for over half (535) of those pages. It’s impossible for anyone—even people who are considered coding experts—to comprehend everything that they need to know from reading the instructions on the MDS itself or even from doing a single read-through of the manual.”
The second issue is that the Centers for Medicare & Medicaid Services (CMS) updates the RAI User’s Manual at least annually, points out VanEaton. “CMS makes revisions to the manual that go into effect each Oct. 1 in conjunction with the start of the new fiscal year, as well as making off-schedule updates as needed. So, what you may have read in the manual or learned in a course last year or two years ago may no longer be accurate.”
The bottom line is that coding the MDS without routinely reading the manual is not good coding practice, says VanEaton. “Reading the RAI User’s Manual is fundamental to MDS accuracy. If you never read the manual, you are essentially guessing.”
At a minimum, the NAC should read chapter 3 twice a year, stresses VanEaton. “Even if you don’t read anything else, read chapter 3. It’s so important that you should build time into your weekly schedule for reading.”
Save a desktop manual for reference when coding questions occur
In addition, the NAC should maintain an electronic copy of the current RAI User’s Manual on the computer desktop, says VanEaton. “Keeping a copy on your desktop instead of relying on the manual that is built into different software systems means that you always can be 100 percent sure that you have access to the most current version. AAPACN and other organizations offer easily downloadable versions of the most up-to-date RAI User’s Manual.”
The NAC then can quickly use that desktop RAI User’s Manual as a reference tool during the MDS coding process, says VanEaton. “Going to the manual and reading the relevant section is the first step that you should take when you have a coding question and need to make a coding decision. I do that myself—I never answer MDS coding questions off the cuff. I always tell people, ‘Let’s open up the RAI User’s Manual and see what it has to say.’ Reading the manual on a regular basis and then going back to it when you have questions is a critical component of achieving consistently accurate MDS assessments.”
Find a community to discuss coding questions
The NAC should have access to some type of discussion forum, says VanEaton. “For example, the AAPACN communities allow you to have back-and-forth conversations with other NACs and MDS coding experts about coding questions that come up. That ability to connect is absolutely vital. You don’t want to sit in isolation with an MDS and say, ‘I’m not quite sure how to code this, so I’m just going to answer this way.’ You should talk with other people about your question.”
Another potentially valuable resource is the state RAI coordinator, says VanEaton. “CMS’s goal is for you to contact your state RAI coordinator with questions, but the position is vacant in some states and filled by backups in other states.” Note: Find the most recent Appendix B contact list for the state RAI coordinators here.
Find quickly accessible articles and Q&As
“AAPACN master teachers contribute monthly to MDS coding articles and questions and answers (Q&As) that are sent out in newsletters and then archived,” says VanEaton. “There are answers to a lot of complex questions if you do a search on the website. That can be really helpful for you to find valuable and valid MDS coding information.”
Check in with other MDS assessors in the facility
In the hubbub of a facility, the NAC often trusts that nursing staff and other disciplines are completing their MDS sections appropriately, says VanEaton. “But, that may not always be the case.”
VanEaton offers the following example: A SNF received an informational e-mail from Swingtech prior to the SNF QRP’s quarterly MDS data submission deadline stating that it was failing to meet the MDS submission threshold for that quarter. The SNF investigated using iQIES reports and discovered that the social services staff member who was completing D0150 (Resident Mood Interview (PHQ-2 to 9)) didn’t understand the skip pattern associated with D0100 (Should Resident Mood Interview Be Conducted?). As a result, they incorrectly dashed D0150 and completedD0500 (Staff Assessment of Resident Mood (PHQ-9-OV)) for multiple residents, and those dashes resulted in the SNF falling below the threshold compliance level until they made corrections to those MDS assessments.
“Neither the NAC nor anyone else noticed the improper dashing until the SNF received the Swingtech report,” points out VanEaton. “To prevent a scenario like this, you have to do your due diligence—not just assume that MDS coding is accurate.”
The NAC can jumpstart interdisciplinary focus on MDS accuracy by having some conversations with the rest of the team about MDS item Z0400 (Signatures of Persons Completing the Assessment or Entry/Death Reporting), suggests VanEaton. “Most people don’t pay attention to the accuracy attestation statement at Z0400, but you should. By signing, you are certifying the accuracy of that MDS data and acknowledging that you personally, as well as your organization, may be subject to ‘substantial criminal, civil, and/or administrative penalties for submitting false information.’ So, everyone signing off at Z0400 really needs to understand its importance.”
Note: For additional information about Z0400 and the potential ramifications of signing off on inaccurate MDS coding, see the March 2025 AAPACN articles “MDS Falsification: How MDS Coding Could Bring an OIG Referral During Survey” and “Ethics in MDS Coding: Reimbursement and Quality Measures.”
In addition, the NAC shouldn’t be the only MDS assessor who has access to a desktop RAI User’s Manual and other resources, says VanEaton. “Annual MDS education alone isn’t enough. For example, everyone in the facility who participates in MDS coding also should read their sections of the manual on a regular basis, review the manual when they have questions, and have ways to get insights from other MDS coders and experts about questions that the manual doesn’t seem to answer.”
Learn as a team
Team-focused education can be especially productive, suggests VanEaton. “For example, you could read sections of the RAI User’s Manual together as a group and then have a brief discussion about the supporting documentation that you need and any coding questions that come up.”
Another good group activity is for MDS assessors to spend time together on a regular basis watching CMS videos that demonstrate sound interview techniques, says VanEaton. “There are a number of significant resident self-report items on the MDS. Appendix D, ‘Interviewing Techniques to Increase Resident Voice in MDS Assessments,’ of the RAI User’s Manual provides written instructions for conducting more effective interviews.”
Fifteen years ago, CMS created the Video on Interviewing Vulnerable Elders (VIVE) and several component videos to show those interview techniques in action, says VanEaton. “Many of the MDS items discussed in the VIVE videos have changed quite a bit since MDS 3.0 implementation (e.g., the PHQ-9 has become the PHQ-2 to 9). However, the principles behind good interview skills, such as disentangling, remain the same.”
Note: Viewing options include the complete VIVE that is more than one hour long or its shorter component videos, including VIVE General Interview Techniques, VIVE Mood, VIVE Mood Self-Harm Scenario 1, VIVE Mood Self-Harm Scenario 2, VIVE Cognition,_The BIMS, VIVE Preferences, and VIVE Pain.
Do real-time, bite-size MDS audits
“A full-scale MDS audit is a daunting, almost impossible task for a busy NAC,” notes VanEaton. “The MDS is a massive document. The PPS (NP) item set is 50 pages, and the comprehensive (NC) item set runs 59 pages. Looking through the documentation to see if just one MDS is supported takes a significant amount of time.”
Instead, the NAC may need to take a different approach, says VanEaton. “You should consider doing real-time, bite-size audits. For example, you might focus on the accuracy of different MDS sections or the work of different disciplines every week as you complete each MDS.”
Pay attention to MDS-based QMs
The MDS-based QMs that feed into Five-Star, the SNF QRP, and the SNF VBP offer the NAC another opportunity to do bite-size audits, says VanEaton. “You can look at those QMs on a routine basis and just ask the question, ‘Do my numbers make sense?’ If they do, you can feel good about MDS accuracy. If they don’t, you need to ask, ‘Are we coding these MDS items appropriately?’”
VanEaton offers two simple examples of QMs that affect Five-Star:
- Percent of Residents with a Urinary Tract Infection (Long-Stay). “The numerator for this measure is based on long-stay residents who have a UTI coded in I2300 on the selected target assessments,” says VanEaton. “The coding criteria for I2300 in the RAI User’s Manual (pages I-14 – I-16 in chapter 3) are clear.”
- The resident must have met evidence-based criteria for a UTI in the last 30 days, and there must also be a physician- or nonphysician practitioner-documented diagnosis of UTI in the last 30 days, explains VanEaton. “If you have high numbers in this QM, you want to be sure that residents who have a UTI coded in I2300 meet all of the required coding criteria, not just some of them.”
- Note: CMS expects the evidence-based criteria (e.g., Loeb, updated McGeer, or National Healthcare Safety Network (NHSN)) that MDS assessors use to code I2300 to be the “same nationally recognized criteria” that the facility uses in the infection surveillance system that is a required component of its Infection Prevention and Control Program (IPCP) under F-tag 880 (Infection Prevention and Control). For example, a facility that uses the updated McGeer criteria in its IPCP also should use the updated McGeer to code I2300, not the Loeb or NHSN criteria. For more information, see page I-15 in chapter 3 of the RAI User’s Manual.
- Percent of Residents Who Have or Had a Catheter Inserted and Left in Their Bladder (Long-Stay). “The numerator is based on long-stay residents who have an indwelling catheter coded in H0100A on the selected target assessments,” says VanEaton. “The measure has two diagnostic exclusions: I1550 (Neurogenic Bladder) and I1650 (Obstructive Uropathy). If you see high numbers in this measure, you want to make sure that these exclusionary diagnoses are coded on the MDS when the section I coding criteria are met (or that the physician is queried for a diagnosis as appropriate).”
MDS-based QMs have specific criteria for triggering, points out VanEaton. “If you have a basic understanding of the technical specifications, you can accomplish two goals at once when you see high numbers. In other words, you can examine MDS accuracy at the same time that you validate the data going into these Five-Star measures.”
And the NAC can do the same with the MDS-based measures in the SNF QRP and the SNF VBP, stresses VanEaton. “This will help you dig into where you have MDS coding issues—and decide where you need to spend time helping the disciplines improve MDS accuracy.”
To do this, the NAC needs access to the most up-to-date technical specifications for the MDS-based measures, says VanEaton. “CMS updates these manuals pretty frequently. You want to stay on top of revisions as they occur so that you know what you need to focus on for MDS accuracy.”
These manuals include the following, according to VanEaton:
- NHQI/Five-Star QMs: The MDS 3.0 Quality Measures User’s Manual version 18.0 is maintained and available here;
- SNF QRP QMs: The SNF QRP Measure Calculations and Reporting User’s Manual version 7.0 is maintained and available here; and
- SNF VBP QMs: There currently is no technical specifications manual specific to the SNF VBP. A list of QMs, including when they go online to affect SNF VBP payment and where to find technical specifications, is maintained and available here.
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