CMS-10387 Interim Payment Assessment (IPA) Item Set

Resident

Identifier

Date

MINIMUM DATA SET (MDS) - Version 3.0.

RESIDENT ASSESSMENT AND CARE SCREENING.
Interim Payment Assessment (IPA) Item Set.
Section A.

Identification Information.

A0050. Type of Record.
Enter Code

1. Add new record
Continue to A0100, Facility Provider Numbers.
2. Modify existing record
Continue to A0100, Facility Provider Numbers.
3. Inactivate existing record
Skip to X0150, Type of Provider.

A0100. Facility Provider Numbers.
A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):

C. State Provider Number:

A0200. Type of Provider.
Enter Code

Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.

A0300. Optional State Assessment.
Complete only if A0200 = 1.
Enter Code

A. Is this assessment for state payment purposes only?
0. No

A0310. Type of Assessment.
Enter Code

Enter Code

Enter Code

Enter Code

A. Federal OBRA Reason for Assessment.
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
B. PPS Assessment.
PPS Scheduled Assessment for a Medicare Part A Stay.
01. 5-day scheduled assessment.
PPS Unscheduled Assessment for a Medicare Part A Stay.
08. IPA - Interim Payment Assessment.
Not PPS Assessment.
99. None of the above.
E. Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
0. No.
1. Yes.
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.

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Resident

Identifier

Section A.

Date

Identification Information.

A0310. Type of Assessment - Continued.
Enter Code

G. Type of discharge - Complete only if A0310F = 10 or 11.
1. Planned.
2. Unplanned.

A0410. Unit Certification or Licensure Designation.
Enter Code

1. Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State.
2. Unit is neither Medicare nor Medicaid certified but MDS data is required by the State.
3. Unit is Medicare and/or Medicaid certified.

A0500. Legal Name of Resident.
A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers.
A. Social Security Number:

_

_

B. Medicare number:

A0700. Medicaid Number - Enter "+" if pending, "N" if not a Medicaid recipient.

A0800. Gender.
Enter Code

1. Male.
2. Female.

A0900. Birth Date.
_
Month

_
Day

Year

A1000. Race/Ethnicity.
Check all that apply.
A. American Indian or Alaska Native.
B. Asian.
C. Black or African American.
D. Hispanic or Latino.
E. Native Hawaiian or Other Pacific Islander.
F. White.

A1100. Language.
Enter Code

A. Does the resident need or want an interpreter to communicate with a doctor or health care staff?
0. No
Skip to A1200, Marital Status.
1. Yes
Specify in A1100B, Preferred language.
9. Unable to determine.
Skip to A1200, Marital Status.
B. Preferred language:

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Resident

Identifier

Section A.

Date

Identification Information.

A1200. Marital Status.
Enter Code

1.
2.
3.
4.
5.

Never married.
Married.
Widowed.
Separated.
Divorced.

A1300. Optional Resident Items.
A. Medical record number:

B. Room number:

C. Name by which resident prefers to be addressed:

D. Lifetime occupation(s) - put "/" between two occupations:

A2300. Assessment Reference Date.
Observation end date:

_
Month

_
Day

Year

A2400. Medicare Stay.
Enter Code

A. Has the resident had a Medicare-covered stay since the most recent entry?
0. No
Skip to B0100, Comatose.
Continue to A2400B, Start date of most recent Medicare stay.
1. Yes
B. Start date of most recent Medicare stay:

_
Month

_
Day

Year

C. End date of most recent Medicare stay - Enter dashes if stay is ongoing:

_
Month

_
Day

Year

Look back period for all items is 7 days unless another time frame is indicated.
Section B.

Hearing, Speech, and Vision.

B0100. Comatose.
Enter Code

Persistent vegetative state/no discernible consciousness.
0. No
Continue to B0700, Makes Self Understood.
1. Yes
Skip to GG0130, Self-Care.

B0700. Makes Self Understood.
Enter Code

Ability to express ideas and wants, consider both verbal and non-verbal expression.
0. Understood.
1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time.
2. Sometimes understood - ability is limited to making concrete requests.
3. Rarely/never understood.

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Resident

Identifier

Section C.

Date

Cognitive Patterns.

C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all residents.
Enter Code

0. No (resident is rarely/never understood)
Skip to and complete C0700-C1000, Staff Assessment for Mental Status.
1. Yes
Continue to C0200, Repetition of Three Words.

Brief Interview for Mental Status (BIMS).
C0200. Repetition of Three Words.
Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
Enter Code

Number of words repeated after first attempt.
0. None.
1. One.
2. Two.
3. Three.
After the resident's first attempt, repeat the words using cues ("sock, something to wear; blue, a color; bed, a piece
of furniture"). You may repeat the words up to two more times.

C0300. Temporal Orientation (orientation to year, month, and day).
Ask resident: "Please tell me what year it is right now."
Enter Code

Enter Code

Enter Code

A. Able to report correct year.
0. Missed by > 5 years or no answer.
1. Missed by 2-5 years.
2. Missed by 1 year.
3. Correct.
Ask resident: "What month are we in right now?"
B. Able to report correct month.
0. Missed by > 1 month or no answer.
1. Missed by 6 days to 1 month.
2. Accurate within 5 days.
Ask resident: "What day of the week is today?"
C. Able to report correct day of the week.
0. Incorrect or no answer.
1. Correct.

C0400. Recall.

Enter Code

Enter Code

Enter Code

Ask resident: "Let's go back to an earlier question. What were those three words that I asked you to repeat?"
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall "sock".
0. No - could not recall.
1. Yes, after cueing ("something to wear").
2. Yes, no cue required.
B. Able to recall "blue".
0. No - could not recall.
1. Yes, after cueing ("a color").
2. Yes, no cue required.
C. Able to recall "bed".
0. No - could not recall.
1. Yes, after cueing ("a piece of furniture").
2. Yes, no cue required.

C0500. BIMS Summary Score.
Enter Score

Add scores for questions C0200-C0400 and fill in total score (00-15).
Enter 99 if the resident was unable to complete the interview.

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Resident

Identifier

Section C.

Date

Cognitive Patterns.

C0600. Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?
Enter Code

0. No (resident was able to complete Brief Interview for Mental Status)
Conducted?
1. Yes (resident was unable to complete Brief Interview for Mental Status)

Skip to D0100, Should Resident Mood Interview be
Continue to C0700, Short-term Memory OK.

Staff Assessment for Mental Status.
Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed.

C0700. Short-term Memory OK.
Enter Code

Seems or appears to recall after 5 minutes.
0. Memory OK.
1. Memory problem.

C1000. Cognitive Skills for Daily Decision Making.
Enter Code

Made decisions regarding tasks of daily life.
0. Independent - decisions consistent/reasonable.
1. Modified independence - some difficulty in new situations only.
2. Moderately impaired - decisions poor; cues/supervision required.
3. Severely impaired - never/rarely made decisions.

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Resident

Identifier

Section D.

Date

Mood.

D0100. Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents.
Enter Code

0. No (resident is rarely/never understood)
Skip to and complete D0500-D0600, Staff Assessment of Resident Mood
(PHQ-9-OV).
1. Yes
Continue to D0200, Resident Mood Interview (PHQ-9©).

D0200. Resident Mood Interview (PHQ-9©).
Say to resident: "Over the last 2 weeks, have you been bothered by any of the following problems?"
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: "About how often have you been bothered by this?"
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).
9. No response (leave column 2
blank).

2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).

1.
Symptom
Presence.

2.
Symptom
Frequency.

Enter Scores in Boxes

A. Little interest or pleasure in doing things.
B. Feeling down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Feeling bad about yourself - or that you are a failure or have let yourself or your family
down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual.
I.

Thoughts that you would be better off dead, or of hurting yourself in some way.

D0300. Total Severity Score.
Enter Score

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more items).

Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.

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Resident

Identifier

Section D.

Date

Mood.

D0500. Staff Assessment of Resident Mood (PHQ-9-OV*).

Do not conduct if Resident Mood Interview (D0200-D0300) was completed.
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
Then move to column 2, Symptom Frequency, and indicate symptom frequency.
1. Symptom Presence.
0. No (enter 0 in column 2).
1. Yes (enter 0-3 in column 2).

2. Symptom Frequency.
0. Never or 1 day.
1. 2-6 days (several days).
2. 7-11 days (half or more of the days).
3. 12-14 days (nearly every day).

1.
Symptom
Presence.

2.
Symptom
Frequency.

Enter Scores in Boxes

A. Little interest or pleasure in doing things.
B. Feeling or appearing down, depressed, or hopeless.
C. Trouble falling or staying asleep, or sleeping too much.
D. Feeling tired or having little energy.
E. Poor appetite or overeating.
F. Indicating that s/he feels bad about self, is a failure, or has let self or family down.
G. Trouble concentrating on things, such as reading the newspaper or watching television.
H. Moving or speaking so slowly that other people have noticed. Or the opposite - being so fidgety
or restless that s/he has been moving around a lot more than usual.
I.

States that life isn't worth living, wishes for death, or attempts to harm self.

J.

Being short-tempered, easily annoyed.

D0600. Total Severity Score.
Enter Score

Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30.

* Copyright © Pfizer Inc. All rights reserved.
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Resident

Identifier

Section E.

Date

Behavior.

E0100. Potential Indicators of Psychosis.
Check all that apply
A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli).
B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality).
Z. None of the above.

Behavioral Symptoms.
E0200. Behavioral Symptom - Presence & Frequency.
Note presence of symptoms and their frequency.
Enter Codes in Boxes.
Coding:
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days,
but less than daily.
3. Behavior of this type occurred daily.

A.

Physical behavioral symptoms directed toward others (e.g., hitting,
kicking, pushing, scratching, grabbing, abusing others sexually).

B.

Verbal behavioral symptoms directed toward others (e.g., threatening
others, screaming at others, cursing at others).

C.

Other behavioral symptoms not directed toward others (e.g., physical
symptoms such as hitting or scratching self, pacing, rummaging, public
sexual acts, disrobing in public, throwing or smearing food or bodily wastes,
or verbal/vocal symptoms like screaming, disruptive sounds).

E0800. Rejection of Care - Presence & Frequency.

Enter Code

Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the
resident's goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care
planning with the resident or family), and determined to be consistent with resident values, preferences, or goals.
0. Behavior not exhibited.
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.

E0900. Wandering - Presence & Frequency.
Enter Code

Has the resident wandered?
0. Behavior not exhibited
1. Behavior of this type occurred 1 to 3 days.
2. Behavior of this type occurred 4 to 6 days, but less than daily.
3. Behavior of this type occurred daily.

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Resident

Section GG.

Identifier

Date

Functional Abilities and Goals - Interim Payment Assessment.

GG0130. Self-Care (Assessment period is the last 3 days).
Code the resident's usual performance for each activity using the 6-point scale. If an activity was not attempted, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
5.
Interim
Performance.
Enter Codes in Boxes

A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the
meal is placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove
dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel
movement. If managing an ostomy, include wiping the opening but not managing equipment..

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Resident

Section GG.

Identifier

Date

Functional Abilities and Goals - Interim Payment Assessment.

GG0170. Mobility (Assessment period is the last 3 days).
Code the resident's usual performance for each activity using the 6-point scale. If an activity was not attempted, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by him/herself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than
half the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half
the effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused.
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints).
88. Not attempted due to medical condition or safety concerns.
5.
Interim
Performance.
Enter Codes in Boxes

B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed with feet flat on
the floor, and with no back support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed..
E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F. Toilet transfer: The ability to get on and off a toilet or commode.
I. Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space.
Skip to H0100, Appliances.
If interim performance is coded 07, 09, 10, or 88
J. Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

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Resident

Identifier

Section H.

Date

Bladder and Bowel.

H0100. Appliances.
Check all that apply.
C. Ostomy (including urostomy, ileostomy, and colostomy).
D. Intermittent catheterization.
Z. None of the above.

H0200. Urinary Toileting Program.
Enter Code

C. Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) currently
being used to manage the resident's urinary continence?
0. No...
1. Yes.

H0500. Bowel Toileting Program.
Enter Code

Is a toileting program currently being used to manage the resident's bowel continence?
0. No...
1. Yes.

Section I.

Active Diagnoses.

I0020. Indicate the resident’s primary medical condition category.
Enter Code

Indicate the resident's primary medical condition category that best describes the primary reason for admission
01.
02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.
13.

Stroke.
Non-Traumatic Brain Dysfunction.
Traumatic Brain Dysfunction.
Non-Traumatic Spinal Cord Dysfunction.
Traumatic Spinal Cord Dysfunction.
Progressive Neurological Conditions.
Other Neurological Conditions.
Amputation
Hip and Knee Replacement.
Fractures and Other Multiple Trauma.
Other Orthopedic Conditions.
Debility, Cardiorespiratory Conditions.
Medically Complex Conditions.

I0020B. ICD Code

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Resident

Identifier

Section I.

Date

Active Diagnoses.

Active Diagnoses in the last 7 days - Check all that apply.
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists.
Gastrointestinal.
I1300. Ulcerative Colitis, Crohn's Disease, or Inflammatory Bowel Disease.
Infections.
I1700. Multidrug-Resistant Organism (MDRO).
I2000. Pneumonia.
I2100. Septicemia.
I2500. Wound Infection (other than foot).
Metabolic.
I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy).
Neurological.
I4300. Aphasia.
I4400. Cerebral Palsy.
I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke.
I4900. Hemiplegia or Hemiparesis.
I5100. Quadriplegia.
I5200. Multiple Sclerosis (MS).
I5300. Parkinson's Disease.
I5500. Traumatic Brain Injury (TBI).
Nutritional.
I5600. Malnutrition (protein or calorie) or at risk for malnutrition.
Pulmonary.
I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung
diseases such as asbestosis).
I6300. Respiratory Failure
None of Above.
I7900. None of the above active diagnoses within the last 7 days.
Other.
I8000. Additional active diagnoses.
Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box.

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.

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Resident

Identifier

Section J.

Date

Health Conditions.

Other Health Conditions.
J1100. Shortness of Breath (dyspnea).
Check all that apply.
C. Shortness of breath or trouble breathing when lying flat.
Z. None of the above.

J1550. Problem Conditions.
Check all that apply.
A. Fever.
B. Vomiting.
Z. None of the above.

J2100. Recent Surgery Requiring Active SNF Care.
Enter Code

Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay?
0. No.
1. Yes.
8. Unknown.

Surgical Procedures - Complete only if J2100 = 1.
Check all that apply.
Major Joint Replacement.
J2300. Knee Replacement - partial or total.
J2310. Hip Replacement - partial or total.
J2320. Ankle Replacement - partial or total.
J2330. Shoulder Replacement - partial or total.
Spinal Surgery.
J2400. Involving the spinal cord or major spinal nerves.
J2410. Involving fusion of spinal bones.
J2420. Involving Iamina, discs, or facets .
J2499. Other major spinal surgery.
Other Orthopedic Surgery.
J2500. Repair fractures of the shoulder (including clavicle and scapula) or arm (but not hand).
J2510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot).
J2520. Repair but not replace joints.
J2530. Repair other bones (such as hand, foot, jaw).
J2599. Other major orthopedic surgery.
Neurological Surgery.
J2600. Involving the brain, surrounding tissue or blood vessels (excludes skull and skin but includes cranial nerves).
J2610. Involving the peripheral or autonomic nervous system - open or percutaneous.
J2620. Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices .
J2699. Other major neurological surgery.
Cardiopulmonary Surgery.
J2700. Involving the heart or major blood vessels - open or percutaneous procedures.
J2710. Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords - open or endoscopic.
J2799. Other major cardiopulmonary surgery .
Genitourinary Surgery.
J2800. Involving male or female organs (such as prostate, testes, ovaries, uterus, vagina, external genitalia).
J2810. Involving the kidneys, ureters, adrenal glands, or bladder - open or laparoscopic (includes creation or removal of
nephrostomies or urostomies).
J2899. Other major genitourinary surgery.

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Resident

Identifier

Section J.

Date

Health Conditions.

Surgical Procedures - Continued.
Check all that apply.
Other Major Surgery.
J2900. Involving tendons, ligaments, or muscles.
J2910. Involving the gastrointestinal tract or abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver,
pancreas, or spleen - open or laparoscopic (including creation or removal of ostomies or percutaneous feeding tubes, or hernia repair).
J2920. Involving the endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, or thymus - open.
J2930. Involving the breast.
J2940. Repair of deep ulcers, internal brachytherapy, bone marrow or stem cell harvest or transplant.
J5000. Other major surgery not listed above .

Section K.

Swallowing/Nutritional Status.

K0100. Swallowing Disorder.
Signs and symptoms of possible swallowing disorder.
Check all that apply.
A. Loss of liquids/solids from mouth when eating or drinking.
B. Holding food in mouth/cheeks or residual food in mouth after meals.
C. Coughing or choking during meals or when swallowing medications.
D. Complaints of difficulty or pain with swallowing.
Z. None of the above.

K0300. Weight Loss.
Enter Code

Loss of 5% or more in the last month or loss of 10% or more in last 6 months.
0. No or unknown.
1. Yes, on physician-prescribed weight-loss regimen.
2. Yes, not on physician-prescribed weight-loss regimen.

K0510. Nutritional Approaches.
Check all of the following nutritional approaches that were performed during the last 7 days.
1. While NOT a Resident.
Performed while NOT a resident of this facility and within the last 7 days. Only check column 1 if
resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days
ago, leave column 1 blank.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.

1.
While NOT a
Resident.

2.
While a
Resident.

Check all that apply

A. Parenteral/IV feeding.
B. Feeding tube - nasogastric or abdominal (PEG).
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed food,
thickened liquids).
Z. None of the above.

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Resident

Identifier

Section K.

Date

Swallowing/Nutritional Status.

K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 2 is checked for K0510A and/or K0510B.
2. While a Resident.
Performed while a resident of this facility and within the last 7 days.
3. During Entire 7 Days.
Performed during the entire last 7 days.

2.
While a
Resident.

3.
During Entire
7 Days.
Enter Codes

A. Proportion of total calories the resident received through parenteral or tube feeding.
1. 25% or less.
2. 26-50%.
3. 51% or more.
B. Average fluid intake per day by IV or tube feeding.
1. 500 cc/day or less.
2. 501 cc/day or more.

Section M.

Skin Conditions.
Report based on highest stage of existing ulcers/injuries at their worst;
do not "reverse" stage.

M0210. Unhealed Pressure Ulcers/Injuries.
Enter Code

Does this resident have one or more unhealed pressure ulcers/injuries?
Skip to M1030, Number of Venous and Arterial Ulcers.
0. No
1. Yes
Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.

M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.
B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also
present as an intact or open/ruptured blister.
Enter Number

1. Number of Stage 2 pressure ulcers.
C. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be
present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Enter Number

1. Number of Stage 3 pressure ulcers .
D. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the
wound bed. Often includes undermining and tunneling.
Enter Number

1. Number of Stage 4 pressure ulcers.
F. Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar.
Enter Number

1. Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar.

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Resident

Identifier

Section M.

Date

Skin Conditions.

M1030. Number of Venous and Arterial Ulcers.
Enter Number

Enter the total number of venous and arterial ulcers present.

M1040. Other Ulcers, Wounds and Skin Problems.
Check all that apply.
Foot Problems.
A. Infection of the foot (e.g., cellulitis, purulent drainage).
B. Diabetic foot ulcer(s).
C. Other open lesion(s) on the foot.
Other Problems.
D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion).
E. Surgical wound(s).
F. Burn(s) (second or third degree).
None of the Above.
Z. None of the above were present.

M1200. Skin and Ulcer/Injury Treatments.
Check all that apply.
A. Pressure reducing device for chair.
B. Pressure reducing device for bed.
C. Turning/repositioning program.
D. Nutrition or hydration intervention to manage skin problems.
E. Pressure ulcer/injury care.
F. Surgical wound care.
G. Application of nonsurgical dressings (with or without topical medications) other than to feet.
H. Applications of ointments/medications other than to feet.
I. Application of dressings to feet (with or without topical medications).
Z. None of the above were provided.

Section N.

Medications.

N0350. Insulin.
Enter Days

A. Insulin injections - Record the number of days that insulin injections were received during the last 7 days or since admission/entry
or reentry if less than 7 days.

Enter Days

B. Orders for insulin - Record the number of days the physician (or authorized assistant or practitioner) changed the resident's
insulin orders during the last 7 days or since admission/entry or reentry if less than 7 days.

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Resident

Identifier

Section O.

Date

Special Treatments, Procedures, and Programs.

O0100. Special Treatments, Procedures, and Programs.
Check all of the following treatments, procedures, and programs that were performed during the last 14 days.
2. While a Resident.
Performed while a resident of this facility and within the last 14 days.

2.
While a
Resident.
Check all that apply

Cancer Treatments.
A. Chemotherapy.
B. Radiation.
Respiratory Treatments.
C. Oxygen therapy.
D. Suctioning.
E. Tracheostomy care.
F. Invasive Mechanical Ventilator (ventilator or respirator).
Other.
H. IV medications.
I. Transfusions.
J. Dialysis.
M. Isolation or quarantine for active infectious disease (does not include standard body/fluid precautions).
None of the Above.
Z. None of the above.

O0400. Therapies.
D. Respiratory Therapy.
Enter Number of Days

2. Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days.

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Resident

Identifier

Section O.

Date

Special Treatments, Procedures, and Programs.

O0500. Restorative Nursing Programs.
Record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days
(enter 0 if none or less than 15 minutes daily).
Number
of Days.

Technique.
A. Range of motion (passive).
B. Range of motion (active).
C. Splint or brace assistance.

Number
of Days.

Training and Skill Practice In:
D. Bed mobility.
E. Transfer.
F. Walking.
G. Dressing and/or grooming.
H. Eating and/or swallowing.
I. Amputation/prostheses care.
J. Communication.

Section X.

Correction Request.

Complete Section X only if A0050 = 2 or 3.
Identification of Record to be Modified/Inactivated - The following items identify the existing assessment record that is in error. In this
section, reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect.
This information is necessary to locate the existing record in the National MDS Database.
X0150. Type of Provider (A0200 on existing record to be modified/inactivated).
Enter Code

Type of provider.
1. Nursing home (SNF/NF).
2. Swing Bed.

X0200. Name of Resident (A0500 on existing record to be modified/inactivated).
A. First name:

C. Last name:

X0300. Gender (A0800 on existing record to be modified/inactivated).
Enter Code

1. Male
2. Female

X0400. Birth Date (A0900 on existing record to be modified/inactivated).
_
Month

_
Day

Year

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Resident

Identifier

Section X.

Date

Correction Request.

X0500. Social Security Number (A0600A on existing record to be modified/inactivated).
_

_

X0570. Optional State Assessment (A0300A on existing record to be modified/inactivated).
Enter Code

A. Is this assessment for state payment purposes only?.
0. No.
1. Yes.

X0600. Type of Assessment (A0310 on existing record to be modified/inactivated).
Enter Code

Enter Code

Enter Code

A. Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14).
02. Quarterly review assessment.
03. Annual assessment.
04. Significant change in status assessment.
05. Significant correction to prior comprehensive assessment.
06. Significant correction to prior quarterly assessment.
99. None of the above.
B. PPS Assessment.
PPS Scheduled Assessment for a Medicare Part A Stay.
01. 5-day scheduled assessment..
PPS Unscheduled Assessment for a Medicare Part A Stay.
08. IPA - Interim Payment Assessment.
Not PPS Assessment.
99. None of the above.
F. Entry/discharge reporting
01. Entry tracking record.
10. Discharge assessment-return not anticipated.
11. Discharge assessment-return anticipated.
12. Death in facility tracking record.
99. None of the above.

X0700. Date on existing record to be modified/inactivated.
A. Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600B = 08.

_
Month

_
Day

Year

Correction Attestation Section.- Complete this section to explain and attest to the modification/inactivation request.
X0800. Correction Number.
Enter Number

Enter the number of correction requests to modify/inactivate the existing record, including the present one.

X0900. Reasons for Modification.- Complete only if Type of Record is to modify a record in error (A0050 = 2).
Check all that apply.
A. Transcription error.
B. Data entry error.
C. Software product error.
D. Item coding error.
Z. Other error requiring modification.
If "Other" checked, please specify:

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Resident

Identifier

Section X.

Date

Correction Request.

X1050. Reasons for Inactivation.- Complete only if Type of Record is to inactivate a record in error (A0050 = 3).
Check all that apply.
A. Event did not occur.
Z. Other error requiring inactivation.
If "Other" checked, please specify:

X1100. RN Assessment Coordinator Attestation of Completion.
A. Attesting individual's first name:

B. Attesting individual's last name:

C. Attesting individual's title:
D. Signature.
E. Attestation date.

_
Month

Section Z.

_
Day

Year

Assessment Administration.

Z0100. Medicare Part A Billing.
A. Medicare Part A HIPPS code:

B. Version code:

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Resident

Section Z.

Identifier

Date

Assessment Administration.

Z0400. Signature of Persons Completing the Assessment or Entry/Death Reporting.
I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated
collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable
Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive appropriate and quality
care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and continued participation in the
government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and that I may be personally subject to
or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false information. I also certify that I am
authorized to submit this information by this facility on its behalf.
Date Section
Signature
Title
Sections
Completed

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion.
A. Signature:

B. Date RN Assessment Coordinator signed
assessment as complete:

_
Month

_
Day

Year

Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and interRAI. This work may be freely used and
distributed solely within the United States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the
copyright for the PHQ-9; Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted
from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Both Pfizer Inc. and the Hospital Elder Life Program, LLC have granted
permission to use these instruments in association with the MDS 3.0.
MDS 3.0 Interim Payment Assessment (IPA) Version 1.17.1 Effective 10/01/2019

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