Source anchor
CMS MDS 3.0 RAI Manual v1.20.1 is the governed baseline currently attached to this lookup item.
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Prognosis
Item Rationale
Matrix review
5 matrix group(s) are already attached for review on this item.
Answer coverage
2 governed answer row(s) are attached for this item.
Answer Codes
Code 0
No
if the medical record does not contain physician documentation that the resident is terminally ill and the resident is not receiving hospic...
Code 1
Yes
if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice ser...
What this item is
Item Rationale
When to use it
Use this item when the facility is completing content tied to Section J and needs to stay anchored to v1.20.1.
Reminders
- Current source status: Published.
- Item locator: Manual page J-28
- CMS exact locator: Manual page J-28
- This item has 2 governed answer row(s) attached.
Source awareness
This page is grounded in CMS MDS 3.0 RAI Manual v1.20.1. Review the exact text and locators before treating the item as final reference content.
Source & Review
Manual
CMS MDS 3.0 RAI Manual v1.20.1
Status
Published
Effective start
2025-10-01
Item locator
Manual page J-28
CMS exact locator
Manual page J-28
Full CMS Text
Item Rationale
Health-related Quality of Life
Residents with conditions or diseases that may result in a life expectancy of less than 6 months have special needs and may benefit from palliative or hospice services in the nursing home.
Planning for Care
If life expectancy is less than 6 months, interdisciplinary team care planning should be based on the resident’s preferences for goals and interventions of care whenever possible.
Steps for Assessment
1. Review the medical record for documentation by the
physician that the resident’s condition or chronic disease may result in a life expectancy of less than 6 months, or that they have a terminal illness.
2. If the physician states that the resident’s life expectancy
may be less than 6 months, request that they document this in the medical record. Do not code until there is documentation in the medical record.
3. Review the medical record to determine whether the
resident is receiving hospice services.
DEFINITION
CONDITION OR CHRONIC DISEASE THAT MAY RESULT IN A LIFE EXPECTANCY OF LESS THAN 6 MONTHS In the physician’s judgment, the resident has a diagnosis or combination of clinical conditions that have advanced (or will continue to deteriorate) to a point that the average resident with that level of illness would not be expected to survive more than 6 months. This judgment should be substantiated by a physician note. It can be difficult to pinpoint the exact life expectancy for a single resident. Physician judgment should be based on typical or average life expectancy of residents with similar level of disease burden as this resident.
Coding Instructions
Code 0, no: if the medical record does not contain
physician documentation that the resident is terminally ill and the resident is not receiving hospice services.
Code 1, yes: if the medical record includes physician
documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services.
Examples
1. Resident T has a diagnosis of heart failure. During the past
few months, they have had three hospital admissions for acute heart failure. Their heart has become significantly weaker despite maximum treatment with medications and oxygen. Their physician has discussed their deteriorating condition with them and their family and has documented that their prognosis for survival beyond the next couple of months is poor.
Coding: J1400 would be coded 1, yes.
Rationale: The physician documented that their life
expectancy is likely to be less than 6 months.
2. Resident J was diagnosed with non-small cell lung cancer
that is metastatic to their bone. They are not a candidate for surgical or curative treatment. With their consent, Resident J has been referred to hospice by their physician, who documented that their life expectancy was less than 6 months.
Coding: J1400 would be coded 1, yes.
Rationale: The physician referred the resident to hospice and documented that their life
expectancy is likely to be less than 6 months.
Matrix Applicability
Nursing Home Subsets
NC - Comprehensive
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NQ - Quarterly
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
ND - Discharge
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
NP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Swing Bed Subsets
SP - PPS 5 Day
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
SD - Discharge
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
Program and Policy Use
NHQI Quality Measures
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Stand Alone Assessments
OBRA Admission A=01, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Quarterly A=02, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Annual / Sig Chg A=03, B=99, F=99, G=^, H=0 A= 04, B=99, F=99, G=^, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
OBRA Discharge A=99, B=99, F=10, 11, G=1, 2, H=0
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
D/C Items (Only when A0310F = 10 or 11)
A0310G=1 PDC
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4
A0310G=2 UPD
Marker: x
applies
Locator: MDS Item Matrix v1.20.1 v4