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Chapter Section Page(s) version 1.20.1 Change X0310
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OLD NEW X0310
Coding Instructions for X03010, GenderSex
Enter the gendersex code 1 “Male,” or 2 “Female,” or – (dash value indicating unable to determine) exactly as submitted for item A08010, “Gender”Sex on the prior erroneous record to be modified/inactivated. Although a dash (indicating unable to determine) is no longer an acceptable value in A0800, a dash must be used in X0300 on a modification or inactivation request to locate a record if a dash was previously entered in A0800 on the original record. Note that the gendersex in X03010 does not have to match the current value of A08010 on a modification request. The entries may be different if the modification is correcting the gendersex. X0900
Coding Instructions for X0900B, Data Entry
Error Check the box if any errors in the prior record accepted into iQIES were caused by data entry errors. A data entry error includes any error made while encoding MDS assessment or tracking form information into the facility's computer system. An example is an error where the response to the individual minutes of physical therapy O040025C1 is incorrectly encoded as “3000” minutes rather than the correct number of “0030” minutes.
Chapter Section Page(s) version 1.20.1 Change Hyperlinks in this section have been revised to reflect up-to- date locations.
Chapter Section Page(s) version 1.20.1 Change Hyperlinks in this section have been revised to reflect up-to- date locations. 4-29 11. Falls A “fall” refers to unintentionally coming to rest on the ground, floor, or other lower level or as a result of an overwhelming external force (e.g., being pushed by another resident). A fall without injury is still a fall. Falls are a leading cause of morbidity and mortality among the elderly, including nursing home residents. Falls may indicate functional decline and/or the development of other serious conditions, such as delirium, adverse medication reactions, dehydration, and infections. A potential fall is an episode in which a resident lost their balance and would have fallen without staff intervention. A “fall” refers to unintentionally coming to rest on the ground, floor, or other lower level or as a result of an overwhelming external force (e.g., being pushed by another resident). A fall without injury is still a fall. Falls are a leading cause of morbidity and mortality among the elderly, including nursing home residents. Falls may indicate functional decline and/or the development of other serious conditions, such as delirium, adverse medication reactions, dehydration, and infections. A potential fall is an episode in which a resident lost their balance and would have fallen without staff intervention. but not A “fall” refers to unintentionally coming to rest on the ground, floor, or other lower level or as a result of an overwhelming external force (e.g., being pushed by another resident). A fall without injury is still a fall. Falls are a leading cause of morbidity and mortality among the elderly, including nursing home residents. Falls may indicate functional decline and/or the development of other serious conditions, such as delirium, adverse medication reactions, dehydration, and infections. A potential fall is an episode in which a resident lost their balance and would have fallen without staff intervention. A “fall” refers to unintentionally coming to rest on the g round, floor, or other lower level or the result of an overwhelming external force (e.g., aresident pushes another resident). App. A
App. A
Track Changes from Appendix A v1.19.1R to Appendix A v1.20.1 Page 2 Chapter Section Page(s) version 1.20.1 Change App. A
Interim Payment Assessment IPA An optional assessment that may be completed by providers in order to report a change in the resident’s PDPM classification. App. A
Non-medication Pain Intervention An intervention, other than medication, used to try to manage pain which may include, but are not limited to: bio-feedback, application of heat/cold, massage, physical therapy, occupational therapy, nerve block, stretching and strengthening exercises, chiropractic, electrical stimulation, radiotherapy, ultrasound, and acupuncture. Non- pharmacological Intervention Approaches that do not involve the use of medication to address a medical condition. Non-Therapy Ancillary NTA One of the five categories used to determine reimbursement under PDPM. NTA accounts for the non-therapy services and treatments a resident may need during their stay, such as medications, medical supplies, and specialized treatments. App. A
Passive Range of Motion PROM Movement within the unrestricted range of motion for a segment, which is provided entirely by an external force. There is no voluntary muscle contraction. This type of range of motion is often used when a resident is not able to perform the movement at all or puts forth no effort . Track Changes from Appendix A v1.19.1R to Appendix A v1.20.1 Page 3 Chapter Section Page(s) version 1.20.1 Change App. A
Physical Therapy Services that are provided or directly supervised by a licensed physical therapist. A qualified physical therapy assistant (PTA) may provide therapy but not supervise others (aides or volunteers) giving therapy. Includes services provided by a qualified physical therapy assistant who is employed by (or under contract to) the nursing facility only if they are under the direction of a licensed physical therapist. Physical therapist and physical therapist assistant are defined in regulation 42 CFR 484.4. Physical therapists (PTs) are licensed health care professionals who diagnose and manage movement dysfunction and enhance physical and functional status for people of all ages. PTs alleviate impairments andactivity limitations and participation restrictions, promote and maintain optimal fitness, physical function, and quality of life, and reduce risk as it relatesto movement and health. Following an evaluation of an individual with impairments, activity limitations, and participation restrictions or other health-related conditions, the physical therapist designs an individualized plan of physicaltherapy care and services for each patient.Physical therapists use a variety of interventions to treat patients. Interventions may include therapeutic exercise, functional training, manual therapy techniques, assistive and adaptivedevices and equipment, physical agents, and electrotherapeutic modalities. App. A
Prior to the Benefit of Services Prior to provision of any care by facility staff that would result in more independent coding. App. A
Qualified Clinicians Healthcare professionals practicing within their scope of practice and consistent with Federal, state, and local laws and regulations. Track Changes from Appendix A v1.19.1R to Appendix A v1.20.1 Page 4 Chapter Section Page(s) version 1.20.1 Change App. A
Quality Measure
Tools that help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include care that is: effective, safe, efficient, patient-centered, equitable, and timely. App. A
Social Security Number SSN A tracking number assigned to an individual by the U.S. Federal government for taxation, benefits, and identification purposes. Track Changes from Appendix A v1.19.1R to Appendix A v1.20.1 Page 5 Chapter Section Page(s) version 1.20.1 Change App. A
Speech- Language Pathology and Audiology Services SLP Services that are provided by a licensed speech-language pathologist and/or audiologist. Rehabilitative treatment addresses physical and/or cognitive deficits/disorders resulting in difficulty with communication and/or swallowing (dysphagia). Communication includes speech, language (both receptive and expressive) and non-verbal communication such as facial expression and gesture. Swallowing problems managed under speech therapy are problems in the oral, laryngeal, and/or pharyngeal stages of swallowing. Depending on the nature and severity of the disorder, common treatments may range from physical strengthening exercises, instructive or repetitive practice and drilling, to the use of audio-visual aids and introduction of strategies to facilitate functional communication. Speech therapy may also include sign language and the use of picture symbols. Speech-language pathologist is defined in regulation 42 CFR 484.4. App. A
Swing Bed SB A rural non-critical access hospital with fewer than 100 beds that participates in the Medicare program that has CMS approval to provide post-hospital SNF care. The hospital may use its beds, as needed, to provide either acute or SNF care. App. A
Total Parenteral Nutrition TPN A method of feeding that bypasses the gastrointestinal tract. A special formula given through a vein provides most of the nutrients the body needs. Track Changes from Appendix A v1.19.1R to Appendix A v1.20.1 Page 6 Chapter Section Page(s) version 1.20.1 Change App. A
Usual Performance A resident’s functional status can be impacted by the environment or situationsencountered at the facility. Observing the resident’s interactions with others in different locations and circumstances is important for a comprehensive understanding of the resident’s functionalstatus. If the resident’s functional status varies, record the resident’s usual ability to perform each activity. Do not record the resident’s best performance and do not record the resident’s worst performance, but rather record the resident’s usual performance. App. A
A/AROM or AAROM Active Assisted Range of Motion App. A
App. A
App. A
App. A
App. A
App. A
App. A
GDR Gradual Dose Reduction App. A
App. A
App. A
App. A
Track Changes from Appendix A v1.19.1R to Appendix A v1.20.1 Page 7 Chapter Section Page(s) version 1.20.1 Change App. A
OBRA ’87 Omnibus Budget Reconciliation Act of 1987 App. A
App. A
PROM Passive Range of Motion App. A
App. A
QIN Quality Improvement Network App. A
SB Swing Bed Track Changes from Appendix B v1.19.1 to Appendix B v1.20.1 Page 1 Chapter Section Page(s) version 1.20.1 Change App. B Hyperlinks in this section have been revised to reflect up-to- date locations. Track Changes from Appendix C v1.19.1R to Appendix C v1.20.1 Page 1 Chapter Section Page(s) version 1.20.1 Change App. C Hyperlinks in this section have been revised to reflect up-to- date locations. App. C
Medications (consultant pharmacist review of medication regimen can be very helpful) • Opioids (N0415H) • Antipsychotics (N0415A) • Antianxiety (N0415B) • Antidepressants (N0415C) • Parkinson’s medications • Hypnotics (N0415D) • Gentamycin (N0415F) • Tobramycin (N0415F) • AspirinAntiplatelet (N0415I) • Other Track Changes from Appendix C v1.19.1R to Appendix C v1.20.1 Page 2 Chapter Section Page(s) version 1.20.1 Change App. C
Health issues that result in reduced activity participation • Indicators of depression or anxiety (D0150, D0160, D0500, D0600) • Use of psychoactive medications (N0415A–N0415D) • Functional/mobility (GG0130, GG0170) or balance problems; physical disability • Cognitive deficits (C0500, C0700– C1000), including stamina, ability to express self (B0700), understand others (B0800), make decisions (C1000) • Unstable acute/chronic health problem (O0110, J0100, J1100, J1400, J1550, J2000, I8000, M1040) • Chronic health conditions, such as incontinence (H0300, H0400) or pain (J0300, J0800) • Embarrassment or unease due to presence of equipment, such as tubes, oxygen tank (O0110C1), or colostomy bag (H0100) • Receives numerous treatments (M1200, O0110, O0390, O0400) that limit available time/energy • Performs tasks slowly due to reduced energy reserves App. C Care Area General Resources
Emerging Solutions in Pain Tools: http://www.emergingsolutionsinpain.com/; Hartford Institute for Geriatric Nursing Access to Important Geriatric Tools: https://consultgeri.org/tools; Hartford Institute for Geriatric Nursing Evidence-Based Geriatric Content: https://consultgeri.org/; Hartford Institute for Geriatric Nursing: https://hign.org/; Improving Nursing Home Culture (CMS Special Study): http://healthcentricadvisors.org/wp- content/uploads/2015/03/INHC_Final-Report_PtI- IV_121505_mam.pdf; Track Changes from Appendix C v1.19.1R to Appendix C v1.20.1 Page 3 Chapter Section Page(s) version 1.20.1 Change App. C Care Area General Resources
Quality Improvement Organizations: University of Missouri’s Geriatric Examination Tool Kit: http://geriatrictoolkit.missouri.edu/; and. U.S. Department of Health and Human Services Agency for Healthcare Research and Quality’s National Guideline Clearinghouse: http://www.guideline.gov/. Track Changes from Appendix E v1.19.1 to Appendix E v1.20.1 Page 1 Chapter Section Page(s) version 1.20.1 Change App. E Scoring Rules: Resident Mood Interview Total Severity Score D0160
The following rules explain how to compute the score that is placed in item D0160. These rules consider the “number of missing items in Column 2”, which is the number of items in Column 2 that are blank (or skipped) or dashed. An item in Column 2 could be blank if the corresponding item in Column 1 was equal to 9, No response or a dash (symptom not assessed). If all of the items in Column 2 have a value of 0, 1, 2, or 3 (i.e., they all contain non-missing values), then item D0160 is equal to the simple sum of those values. If any of the items in Column 2 are blank (or skipped) or dashed, then omit their values when computing the sum. App. E Scoring Rules: Resident Mood Interview Total Severity Score: D0160
In this example, all of the items in Column 2 have non- missing values (i.e., none of the values are blank or dashed). Therefore, the value of D0160 is equal to the simple sum of the values in Column 2, which is 14. Track Changes from Appendix F v1.19.1 to Appendix F v1.20.1 Page 1 Chapter Section Page(s) version 1.20.1 Change App. F Hyperlinks in this section have been revised to reflect up-to- date locations. Track Changes from Appendix G v1.19.1R to Appendix G v1.20.1 Page 1 Chapter Section Page(s) version 1.20.1 Change App. G Hyperlinks in this section have been revised to reflect up-to- date locations. App. G
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, (45th ed.). Washington, DC. American Psychiatric AssociationPublishing, 19942013. App. G
Baker, D.W., Cameron, K.A., Feinglass, J., Georgas, P., Foster, S., Pierce, D., Thompson, J.A., and Hasnain-Wynia, R.: Patients’ attitudes toward health care providers collecting information about their race and ethnicity. J. Gen. Intern. Med. 20:895-900, 2005. App. G
Centers for Medicare & Medicaid Services: Minimum Data Set (MDS) 3.0 Provider User’s Guide. Available from users-guide App. G
Centers for Medicare & Medicaid Services: State Operations Manual (Pub. 100-07). Available from guidance/guidance/manuals/internet-only-manuals-ioms- items/cms1201984. App. G
Centers for Medicare & Medicaid Services: Your Discharge Planning Checklist. CMS Product No. 11376; revised March
201924. Available from https://www.medicare.gov/publications/11376-your- discharge-planning-checklist.pdf.
App. G
National Pressure Injury Advisory Panel: NPIAP Pressure Injury Stages. Retrieved September 29, 2021,Available from https://cdn.ymaws.com/npiap.com/resource/resmgr/NPIAP- Staging-Poster.pdf. Track Changes from Appendix G v1.19.1R to Appendix G v1.20.1 Page 2 Chapter Section Page(s) version 1.20.1 Change App. G
Office of the National Coordinator for Health Information Technology: What is anAre eElectronic hHealth rRecords (EHRs)?. Available from https://www.healthit.gov/faq/what- electronic-health-record- ehrhttps://www.healthit.gov/topic/health-it-and-health- information-exchange-basics/what-are-electronic-health- records-ehrs. App. G
Quality Improvement and Evaluation System (QIES) Technical Support Office: Nursing Home (MDS)/Swing Bed Providers Reference & Manuals. Available from providers/reference-manuals Quality Improvement and Evaluation System (QIES) Technical Support Office: QIES Technical Support Office Website. Retrieved April 2, 2019,Available from App. G
U.S. Department of Health & Human Services, Office of Disease Prevention and Health Promotion: Healthy People
20230. Available from https://www.healthypeople.gov/2020/default https://odphp.health.gov/healthypeople App. G
U.S. Department of Health and Human Services, Office of Minority Health: Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. Available from https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid =53 Track Changes from Appendix H v1.19.1 to Appendix H v1.20.1 Page 1 Chapter Section Page(s) version 1.20.1 Change Appendix H Hyperlinks in this section have been revised to reflect up-to- date locations. Appendix H
PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 1140 (Expires 11/30/2028). This is a mandatory information collection. The time required to complete this information collection is estimated to average 51 minutes (for the NP item set) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Heidi Magladry at Heidi.magladry@cms.hhs.gov.
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