CMS-10387 Long-Term Care Facility Resident Assessment Instrument (

Minimum 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 QRP (CMS-10387)

Draft_MDS-3.0-RAI-Manual-v1.19.1_October_2024

OMB: 0938-1140

Document [pdf]

Download: pdf | pdf

Centers for Medicare &
Medicaid Services

Long-Term Care
Facility Resident
Assessment
Instrument 3.0
User’s Manual
Version 1.19.1
October 2024

Centers for Medicare & Medicaid Services’
Long-Term Care Facility
Resident Assessment Instrument (RAI)
User’s Manual
October 2024
For Use Effective October 1, 2024

The Long-Term Care Facility Resident Assessment Instrument User’s Manual for Version 3.0
is published by the Centers for Medicare & Medicaid Services (CMS) and is a public
document. It may be copied freely, as our goal is to disseminate information broadly to
facilitate accurate and effective resident assessment practices in long-term care facilities.

TABLE OF CONTENTS
Chapter 1: Resident Assessment Instrument (RAI)
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8

Overview ............................................................................................................ 1-2
Content of the RAI for Nursing Homes ................................................................ 1-3
Completion of the RAI......................................................................................... 1-4
Problem Identification Using the RAI .................................................................. 1-6
MDS 3.0 ............................................................................................................. 1-8
Components of the MDS..................................................................................... 1-10
Layout of the RAI Manual ................................................................................... 1-10
Protecting the Privacy of the MDS Data .............................................................. 1-12

Chapter 2: Assessments for the Resident Assessment Instrument (RAI)
Introduction to the Requirements for the RAI ...................................................... 2-1
CMS Designation of the RAI for Nursing Homes ................................................. 2-2
Responsibilities of Nursing Homes for Completing Assessments........................ 2-2
Responsibilities of Nursing Homes for Reproducing and Maintaining
Assessments ...................................................................................................... 2-7
Assessment Types and Definitions ..................................................................... 2-8
Required OBRA Assessments for the MDS ........................................................ 2-16
The Care Area Assessment (CAA) Process and Care Plan Completion ............. 2-43
Skilled Nursing Facility Prospective Payment System Assessment Schedule ..... 2-44
MDS PPS Assessments for SNFs ...................................................................... 2-47
Combining PPS Assessments and OBRA Assessments..................................... 2-48
PPS and OBRA Assessment Combinations........................................................ 2-50
Factors Impacting SNF PPS Assessment Scheduling ........................................ 2-52
Expected Order of MDS Records........................................................................ 2-54
Determining the Item Set for an MDS Record ..................................................... 2-57

2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14

2.1
2.2
2.3
2.4

Chapter 3: Overview to the Item-by-Item Guide to the MDS 3.0
3.1
3.2
3.3

Using this Chapter .............................................................................................. 3-1
Becoming Familiar with the MDS-recommended Approach ................................ 3-2
Coding Conventions ........................................................................................... 3-3

October 2024

Identification Information........................................................................... A-1
Hearing, Speech, and Vision .................................................................... B-1
Cognitive Patterns .................................................................................... C-1
Mood ........................................................................................................ D-1
Behavior ................................................................................................... E-1
Preferences for Customary Routine and Activities .................................... F-1
Functional Abilities .................................................................................... GG-1
Bladder and Bowel ................................................................................... H-1
Active Diagnoses ...................................................................................... I-1
Health Conditions ..................................................................................... J-1
Swallowing/Nutritional Status.................................................................... K-1
Oral/Dental Status .................................................................................... L-1
Skin Conditions......................................................................................... M-1
Medications .............................................................................................. N-1
Special Treatments, Procedures, and Programs....................................... O-1
Restraints and Alarms .............................................................................. P-1
Participation in Assessment and Goal Setting .......................................... Q-1
(Reserved)................................................................................................ S-1
Care Area Assessment (CAA) Summary .................................................. V-1

Section A
Section B
Section C
Section D
Section E
Section F
Section GG
Section H
Section I
Section J
Section K
Section L
Section M
Section N
Section O
Section P
Section Q
Section S
Section V

Page i

Section X
Section Z

Correction Request................................................................................... X-1
Assessment Administration ...................................................................... Z-1

Chapter 4: Care Area Assessment (CAA) Process and Care Planning
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
4.11

Background and Rationale.................................................................................. 4-1
Overview of the Resident Assessment Instrument (RAI) and Care Area
Assessments (CAAs) .......................................................................................... 4-1
What Are the Care Area Assessments (CAAs)? ................................................. 4-2
What Does the CAA Process Involve? ................................................................ 4-3
Other Considerations Regarding Use of the CAAs.............................................. 4-6
When Is the RAI Not Enough? ............................................................................ 4-7
The RAI and Care Planning ................................................................................ 4-8
CAA Tips and Clarifications ................................................................................ 4-11
Using the Care Area Assessment (CAA) Resources........................................... 4-12
The Twenty Care Areas ...................................................................................... 4-16
(Reserved) .......................................................................................................... 4-41

Chapter 5: Submission and Correction of the MDS Assessments
5.1
5.2
5.3
5.4

5.7
5.8

5.5
5.6

Transmitting MDS Data ...................................................................................... 5-1
Timeliness Criteria .............................................................................................. 5-2
Validation Edits ................................................................................................... 5-4
Additional Medicare Submission Requirements that Impact Billing Under the
SNF PPS ............................................................................................................ 5-5
MDS Correction Policy ........................................................................................ 5-6
Correcting Errors in MDS Records That Have Not Yet Been Accepted Into
iQIES .................................................................................................................. 5-7
Correcting Errors in MDS Records That Have Been Accepted Into iQIES .......... 5-9
Special Manual Record Correction Request ....................................................... 5-13

Chapter 6: Medicare Skilled Nursing Facility Prospective Payment System
(SNF PPS)
Background ........................................................................................................ 6-1
Using the MDS in the Medicare Prospective Payment System ........................... 6-1
Patient Driven Payment Model (PDPM) .............................................................. 6-2
Relationship between the Assessment and the Claim ......................................... 6-2
SNF PPS Eligibility Criteria ................................................................................. 6-10
PDPM Calculation Worksheet for SNFs .............................................................. 6-11
SNF PPS Policies ............................................................................................... 6-50
Non-compliance with the SNF PPS Assessment Schedule................................. 6-52

Appendices
Appendix A:
Appendix B:
Appendix C
Appendix D:
Appendix E:
Appendix F:
Appendix G:
Appendix H:

October 2024

6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8

Glossary and Common Acronyms ............................................................... A-1
State Agency and CMS Locations RAI/MDS Contacts................................. B-1
Care Area Assessment (CAA) Resources ................................................... C-1
Interviewing to Increase Resident Voice in MDS Assessments ................... D-1
Patient Health Questionnaire (PHQ) Scoring Rules and
Instruction for BIMS (When Administered In Writing) ................................... E-1
MDS Item Matrix .......................................................................................... F-1
References .................................................................................................. G-1
MDS 3.0 Forms ........................................................................................... H-1

Page ii

CMS’s RAI Version 3.0 Manual

Acknowledgements

CMS ACKNOWLEDGEMENTS
The collective hard work and dedication of so many people, over the years in the development,
testing, writing, formatting, and ongoing review and maintenance of the MDS 3.0 RAI Manual,
MDS 3.0 Data Item Set, and MDS 3.0 Data Specifications are too numerous to list, but their
dedication has resulted in an RAI process that increases clinical relevancy, data accuracy, clarity,
and notably adds more of the resident voice to the assessment process. CMS acknowledges and
thanks the many people, organizations, and stakeholders that have contributed to making these
updates and enhancements possible. Thank you for the work you do to promote the care and
services to individuals in nursing homes.

Questions regarding information presented in this Manual should be directed to your State’s RAI
Coordinator. Please continue to check our web site for more information at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html.

October 2024

Page 1-1

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

CHAPTER 1: RESIDENT ASSESSMENT INSTRUMENT
(RAI)
1.1 Overview

The purpose of this manual is to offer clear guidance about how to use the Resident Assessment
Instrument (RAI) correctly and effectively to help provide appropriate care. Providing care to
residents with post-hospital and long-term care needs is complex and challenging work. Clinical
competence, observational, interviewing and critical thinking skills, and assessment expertise
from all disciplines are required to develop individualized care plans. The RAI helps nursing
home staff gather definitive information on a resident’s strengths and needs, which must be
addressed in an individualized care plan. It also assists staff with evaluating goal achievement
and revising care plans accordingly by enabling the nursing home to track changes in the
resident’s status. As the process of problem identification is integrated with sound clinical
interventions, the care plan becomes each resident’s unique path toward achieving or maintaining
their highest practical level of well-being.

The RAI helps nursing home staff look at residents holistically—as individuals for whom quality
of life and quality of care are mutually significant and necessary. Interdisciplinary use of the RAI
promotes this emphasis on quality of care and quality of life. Nursing homes have found that
involving disciplines such as dietary, social work, physical therapy, occupational therapy, speech
language pathology, pharmacy, and activities/recreational therapy in the RAI process has
fostered a more holistic approach to resident care and strengthened team communication. This
interdisciplinary process also helps to support the spheres of influence on the resident’s
experience of care, including: workplace practices, the nursing home’s cultural and physical
environment, staff satisfaction, clinical and care practice delivery, shared leadership, family and
community relationships, and Federal/State/local government regulations. 1

Persons generally enter a nursing home because of problems with functional status caused by
physical deterioration, cognitive decline, the onset or exacerbation of an acute illness or
condition, or other related factors. Sometimes, the individual’s ability to manage independently
has been limited to the extent that skilled nursing, medical treatment, and/or rehabilitation is
needed for the resident to maintain and/or restore function or to live safely from day to day.
While there are often unavoidable declines, particularly in the last stages of life, all necessary
resources and disciplines must be used to ensure that residents achieve the highest level of
functioning possible (quality of care) and maintain their sense of individuality (quality of life).
This is true for both long-term residents and residents in a rehabilitative program anticipating
return to their previous environment or another environment of their choice.

October 2024

Page 1-2

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

1.2 Content of the RAI for Nursing Homes
The RAI consists of three basic components: The Minimum Data Set (MDS) Version 3.0, the
Care Area Assessment (CAA) process and the RAI Utilization Guidelines. The utilization of the
three components of the RAI yields information about a resident’s functional status, strengths,
weaknesses, and preferences, as well as offering guidance on further assessment once problems
have been identified. Each component flows naturally into the next as follows:
•

Minimum Data Set (MDS). A core set of screening, clinical, and functional status data
elements, including common definitions and coding categories, which form the
foundation of a comprehensive assessment for all residents of nursing homes certified to
participate in Medicare or Medicaid. The data elements (also referred to as “items”) in the
MDS standardize communication about resident problems and conditions within nursing
homes, between nursing homes, and between nursing homes and outside agencies. The
required subsets of data elements for each MDS assessment and tracking document (e.g.,
Comprehensive, Quarterly, OBRA Discharge, Entry Tracking, PPS item sets) can be
found on CMS’s website at https://www.cms.gov/Medicare/Quality/Nursing-HomeImprovement/Resident-Assessment-Instrument-Manual.

•

Care Area Assessment (CAA) Process. This process is designed to assist the assessor to
systematically interpret the information recorded on the MDS. Once a care area has been
identified or “triggered,” nursing home providers use current, evidence-based clinical
resources to conduct an assessment of the potential problem and determine whether or not
to care plan for it. The CAA process helps the clinician to focus on key issues identified
during the assessment process so that decisions as to whether and how to intervene can be
explored with the resident. The CAA process is explained in detail in Chapter 4. Specific
components of the CAA process include:
— Care Area Triggers (CATs) are specific coding responses for one or a combination
of MDS data elements. The triggers identify residents who have or are at risk for
developing specific problems and require further assessment.

— Care Area Assessment is the further investigation of triggered areas, to determine if
the care area triggers require interventions and care planning. The CAA resources are
provided as a courtesy to facilities in Appendix C. These resources include a
compilation of checklists and Web links that may be helpful in performing the
assessment of a triggered care area. The use of these resources is not mandatory and
the list of Web links is neither all-inclusive nor government endorsed.
— CAA Summary (Section V of the MDS 3.0) provides a location for documentation
of the care area(s) that have triggered from the MDS and the decisions made during
the CAA process regarding whether or not to proceed to care planning.
•

Utilization Guidelines. The Utilization Guidelines provide instructions for when and
how to use the RAI. The Utilization Guidelines, also known as the Long-Term Care
Facility Resident Assessment Instrument 3.0 User’s Manual, includes instructions for
completion of the RAI as well as structured frameworks for synthesizing MDS and other
clinical information (available from https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual).

October 2024

Page 1-3

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

1.3 Completion of the RAI
Over time, the various uses of the MDS have expanded. While its primary purpose as an
assessment instrument is to identify resident care problems that are addressed in an
individualized care plan, data collected from MDS assessments are also used for the Skilled
Nursing Facility Prospective Payment System (SNF PPS) Medicare reimbursement system,
many State Medicaid reimbursement systems, and monitoring the quality of care provided to
nursing home residents. The MDS has also been adapted for use by non-critical access hospitals
(non-CAHs) with a swing bed (SB) agreement. Non-CAH SBs are required to complete the MDS
for reimbursement under the SNF PPS.
•

Medicare and Medicaid Payment Systems. The MDS contains data elements that
reflect the acuity level of the resident, including diagnoses, treatments, and an evaluation
of the resident’s functional status. The MDS is used as a data collection instrument to
classify Medicare residents into PDPM components. The PDPM classification system is
used in the SNF PPS for skilled nursing facilities and non-CAH SB programs. States may
use PDPM, a Resource Utilization Group (RUG)-based system, or an alternate system to
group residents into similar resource use categories for the purposes of Medicaid
reimbursement. More detailed information on the SNF PPS is provided in Chapters 2 and
6. Please refer to the Medicare Internet-Only Manuals, including the Medicare Benefit
Policy Manual, located at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/index.html for comprehensive information on SNF PPS,
including, but not limited to, SNF coverage, SNF policies, and claims processing.
Monitoring the Quality of Care. MDS assessment data are also used to monitor the
quality of care in the nation’s nursing homes. MDS-based quality measures (QMs), which
are derived from data collected on the MDS, were developed by researchers to assist: (1)
State Survey and Certification staff in identifying potential care problems in a nursing
home; (2) nursing home providers with quality improvement activities/efforts; (3) nursing
home consumers in understanding the quality of care provided by a nursing home; and
(4) CMS with long-term quality monitoring and program planning. CMS continuously
evaluates the QMs for opportunities to improve their effectiveness, reliability, and
validity.

•

Consumer Access to Nursing Home Information. Consumers are also able to access
information about every Medicare- and/or Medicaid-certified nursing home in the
country. The Medicare Care Compare tool (https://www.medicare.gov/care-compare/)
provides public access to information about a variety of health care providers, including
nursing homes. Information available regarding nursing homes includes their
characteristics, staffing data, and quality of care measures for certified nursing homes.

•

The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20
(b)(1)(xviii), (g), and (h) require that
(1) the assessment accurately reflects the resident’s status
(2) a registered nurse conducts or coordinates each assessment with the appropriate
participation of health professionals
October 2024

Page 1-4

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

(3) the assessment process includes direct observation, as well as communication with the
resident and direct care staff on all shifts.
Nursing homes are left to determine
(1) who should participate in the assessment process,
(2) how the assessment process is completed, and
(3) how the assessment information is documented while remaining in compliance with the
requirements of the Federal regulations and the instructions contained within this
manual.

Given the requirements of participation of appropriate health professionals and direct care staff,
completion of the RAI is best accomplished by an interdisciplinary team (IDT) that includes
nursing home staff with varied clinical backgrounds, including nursing staff and the resident’s
physician. Such a team brings their combined experience and knowledge to the table in providing
an understanding of the strengths, needs and preferences of a resident to ensure the best possible
quality of care and quality of life. It is important to note that even nursing homes that have been
granted an RN waiver under 42 CFR 483.35(e) must provide an RN to conduct or coordinate the
assessment and sign off the assessment as complete.

In addition, an accurate assessment requires collecting information from multiple sources, some
of which are mandated by regulations. Those sources must include the resident and direct care
staff on all shifts, and should also include the resident’s medical record, physician, and family,
guardian and/or other legally authorized representative, or significant other as appropriate or
acceptable. It is important to note here that information obtained should cover the same
observation period as specified by the MDS items on the assessment, and should be validated for
accuracy (what the resident’s actual status was during that observation period) by the IDT
completing the assessment. As such, nursing homes are responsible for ensuring that all
participants in the assessment process have the requisite knowledge to complete an accurate
assessment.

While CMS does not impose specific documentation procedures on nursing homes in completing
the RAI, documentation that contributes to identification and communication of a resident’s
problems, needs, and strengths, that monitors their condition on an on-going basis, and that
records treatment and response to treatment, is a matter of good clinical practice and an
expectation of trained and licensed health care professionals. Good clinical practice is an
expectation of CMS. As such, it is important to note that completion of the MDS does not
remove a nursing home’s responsibility to document a more detailed assessment of particular
issues relevant for a resident. In addition, documentation must substantiate a resident’s need for
Part A SNF-level services and the response to those services for the Medicare SNF PPS.

October 2024

Page 1-5

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

1.4 Problem Identification Using the RAI
Clinicians are generally taught a problem identification process as part of their professional
education. For example, the nursing profession’s problem identification model is called the
nursing process, which consists of assessment, diagnosis, outcome identification, planning,
implementation, and evaluation. All good problem identification models have similar steps to
those of the nursing process.
The RAI simply provides a structured, standardized approach for applying a problem
identification process in nursing homes. The RAI should not be, nor was it ever meant to be, an
additional burden for nursing home staff.
The completion of the RAI can be conceptualized using the nursing process as follows:

a. Assessment—Taking stock of all observations, information, and knowledge about a resident
from all available sources (e.g., medical records, the resident, resident’s family, and/or
guardian or other legally authorized representative).

b. Decision Making—Determining with the resident (resident’s family and/or guardian or other
legally authorized representative), the resident’s physician and the interdisciplinary team, the
severity, functional impact, and scope of a resident’s clinical issues and needs. Decision
making should be guided by a review of the assessment information, in-depth understanding
of the resident’s diagnoses and co-morbidities, and the careful consideration of the triggered
areas in the CAA process. Understanding the causes and relationships between a resident’s
clinical issues and needs and discovering the “whats” and “whys” of the resident’s clinical
issues and needs; finding out who the resident is and consideration for incorporating their
needs, interests, and lifestyle choices into the delivery of care, is key to this step of the
process.

c. Identification of Outcomes—Determining the expected outcomes forms the basis for
evaluating resident-specific goals and interventions that are designed to help residents
achieve those goals. This also assists the interdisciplinary team in determining who needs to
be involved to support the expected resident outcomes. Outcomes identification reinforces
individualized care tenets by promoting the resident’s active participation in the process.
d. Care Planning—Establishing a course of action with input from the resident (resident’s
family and/or guardian or other legally authorized representative), resident’s physician and
interdisciplinary team that moves a resident toward resident-specific goals utilizing
individual resident strengths and interdisciplinary expertise; crafting the “how” of resident
care.

e. Implementation—Putting that course of action (specific interventions derived through
interdisciplinary individualized care planning) into motion by staff knowledgeable about the
resident’s care goals and approaches; carrying out the “how” and “when” of resident care.
f. Evaluation—Critically reviewing individualized care plan goals, interventions and
implementation in terms of achieved resident outcomes as identified and assessing the need
to modify the care plan (i.e., change interventions) to adjust to changes in the resident’s
status, goals, or improvement or decline.

October 2024

Page 1-6

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

The following pathway illustrates a problem identification process flowing from MDS (and other
assessments), to the CAA decision-making process, care plan development, care plan
implementation, and finally to evaluation. This manual will refer to this process throughout
several chapter discussions.

If you look at the RAI process as a solution oriented and dynamic process, it becomes a richly
practical means of helping nursing home staff gather and analyze information in order to
improve a resident’s quality of care and quality of life. The RAI offers a clear path toward using
all members of the interdisciplinary team in a proactive process. There is absolutely no reason to
insert the RAI process as an added task or view it as another “layer” of labor.

The key to successfully using the RAI process is to understand that its structure is designed to
enhance resident care, increase a resident’s active participation in care, and promote the quality
of a resident’s life. This occurs not only because it follows an interdisciplinary problem-solving
model, but also because staff (across all shifts), residents and families (and/or guardian or other
legally authorized representative) and physicians (or other authorized healthcare professionals as
allowable under state law) are all involved in its “hands on” approach. The result is a process that
flows smoothly and allows for good communication and tracking of resident care. In short, it
works.
Since the RAI has been implemented, nursing home staff who have applied the RAI process in
the manner we have discussed have discovered that it works in the following ways:
Residents Respond to Individualized Care. While we will discuss other positive
responses to the RAI below, there is none more persuasive or powerful than good resident
outcomes both in terms of a resident’s quality of care and enhanced quality of life.
Nursing home providers have found that when residents actively participate in their care,
and care plans reflect appropriate resident-specific approaches to care based on careful
consideration of individual problems and causes, linked with input from residents,
residents’ families (and/or guardian or other legally authorized representative), and the
interdisciplinary team, residents have experienced goal achievement and either their level
of functioning has improved or has deteriorated at a slower rate. Nursing home staff
report that, as individualized attention increases, resident satisfaction with quality of life
also increases.

•

Staff Communication Has Become More Effective. When staff members are involved
in a resident’s ongoing assessment and have input into the determination and
development of a resident’s care plan, the commitment to and the understanding of that
care plan is enhanced. All levels of staff, including nursing assistants, have a stake in the
process. Knowledge gained from careful examination of possible causes and solutions of
resident problems (i.e., from performing the CAAs) challenges staff to hone the
professional skills of their discipline as well as focus on the individuality of the resident
and holistically consider how that individuality is accommodated in the care plan.

October 2024

•

Page 1-7

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

•

Resident and Family Involvement in Care Has Increased. There has been a dramatic
increase in the frequency and nature of resident and family involvement in the care
planning process. Input has been provided on individual resident goals, needs, interests,
strengths, problems, preferences, and lifestyle choices. When considering all of this
information, staff members have a much better picture of the resident, and residents and
families have a better understanding of the goals and processes of care.

•

Increased Clarity of Documentation. When the approaches to achieving a specific goal
are understood and distinct, the need for voluminous documentation diminishes.
Likewise, when staff members are communicating effectively among themselves with
respect to resident care, repetitive documentation is not necessary and contradictory notes
do not occur. In addition, new staff, consultants, or others who review records have found
that the increased clarity of the information documented about a resident makes tracking
care and outcomes easier to accomplish.

The purpose of this manual is to offer clear guidance, through instruction and example, for the
effective use of the RAI, and thereby help nursing home staff achieve the benefits listed above.

In keeping with objectives set forth in the Institute of Medicine (IOM) study completed in 1986
(Committee on Nursing Home Regulation, IOM) that made recommendations to improve the
quality of care in nursing homes, the RAI provides each resident with a standardized,
comprehensive and reproducible assessment. This tool assesses a resident’s ability to perform
daily life functions, identifies significant impairments in a resident’s functional capacity, and
provides opportunities for direct resident interview. In essence, with an accurate RAI completed
periodically, caregivers have a genuine and consistent recorded “look” at the resident and can
attend to that resident’s needs with realistic goals in hand.
Furthermore, with the consistent application of item definitions, the RAI ensures standardized
communication both within the nursing home and between facilities (e.g., other long-term care
facilities or hospitals). Basically, when everyone is speaking the same language, the opportunity
for misunderstanding or error is diminished considerably.

1.5 MDS 3.0

In response to changes in nursing home care, resident characteristics, advances in resident
assessment methods, and provider and consumer concerns about the performance of the MDS
2.0, the Centers for Medicare & Medicaid Services (CMS) contracted with the RAND
Corporation and Harvard University to draft revisions and nationally test the MDS Version 3.0.
Following is a synopsis of the goals and key findings as reported in the Development &
Validation of a Revised Nursing Home Assessment Tool: MDS 3.0 final report (Saliba and
Buchanan, 2008; available at https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/NursingHomeQualityInits/downloads/MDS30FinalReport.pdf).

October 2024

Page 1-8

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

Goals
The goals of the MDS 3.0 revision were to introduce advances in assessment measures, increase
the clinical relevance of data elements, improve the accuracy and validity of the assessment
instrument, increase user satisfaction, and increase the resident’s voice by introducing more
resident interview items. Providers, consumers, and other technical experts in nursing home care
requested that MDS 3.0 revisions focus on improving the instrument’s clinical utility, clarity, and
accuracy. CMS also wanted to increase the usability of the instrument while maintaining the
ability to use MDS data for quality measure reporting and Medicare SNF PPS reimbursement
(via Patient Driven Payment Model [PDPM] classification).

In addition to improving the content and structure of the MDS, the RAND/Harvard team also
aimed to improve user satisfaction. User attitudes are key determinants of quality improvement
implementation. Negative user attitudes toward the MDS are often cited as a reason that nursing
homes have not fully implemented the information from the MDS into targeted care planning.

Methods

To address many of the issues and challenges previously identified and to provide an empirical
foundation for examining revisions to the MDS before they were implemented, the
RAND/Harvard team engaged in a careful iterative process that incorporated provider and
consumer input, expert consultation, scientific advances in clinical knowledge about screening
and assessment, CMS experience, and intensive item development and testing by a national
Veterans Health Administration (VHA) consortium. This process allowed the final national
testing of MDS 3.0 to include well-developed and tested items.

Key Findings for MDS 3.0

The national validation and evaluation of the MDS 3.0 included 71 community nursing homes
(3,822 residents) and 19 VHA nursing homes (764 residents), regionally distributed throughout
the United States. The evaluation was designed to test and analyze inter-rater agreement
(reliability) between gold-standard (research) nurses and between nursing home and goldstandard nurses, validity of key sections, response rates for interview items, anonymous feedback
on changes from participating nurses, and time to complete the MDS assessment. In addition, the
national test design allowed comparison of item distributions between MDS 3.0 and MDS 2.0
and thus facilitated mapping into payment cells (Saliba and Buchanan, 2008).

•

Improved Resident Input

•

Improved Accuracy and Reliability

•

Increased Efficiency

•

Improved Staff Satisfaction and Perception of Clinical Utility

Improvements incorporated in MDS 3.0 produce a more efficient assessment instrument: better
quality information was obtained in less time. Such gains should improve identification of
resident needs and enhance resident-focused care planning. In addition, inclusion of items
recognized in other care settings is likely to enhance communication among providers. These
significant gains reflect the cumulative effect of changes across the tool, including:
October 2024

Page 1-9

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

•

use of more valid items,

•

direct inclusion of resident reports, and

•

improved clarity of retained items.

1.6 Components of the MDS
The MDS is completed for all residents in Medicare- or Medicaid-certified nursing homes and
residents in a Medicare Part A SNF PPS stay in non-critical access hospitals with Medicare
swing bed agreements. The mandated assessment schedule is discussed in Chapter 2. States may
also establish additional MDS requirements. For specific information on State requirements,
please contact your State RAI Coordinator (see Appendix B).

1.7 Layout of the RAI Manual

D
The layout of the RAI manual is as follows:

Chapter 1: Resident Assessment Instrument (RAI)

•

Chapter 2: Assessments for the Resident Assessment Instrument (RAI)

•

Chapter 3: Overview to the Item-by-Item Guide to the MDS 3.0

•

Chapter 4: Care Area Assessment (CAA) Process and Care Planning

•

Chapter 5: Submission and Correction of the MDS Assessments

•

Chapter 6: Medicare Skilled Nursing Facility Prospective Payment System (SNF PPS)

•

Appendices

Appendix A: Glossary and Common Acronyms

•

Appendix B: State Agency and CMS Locations RAI/MDS Contacts

•

Appendix C: Care Area Assessment (CAA) Resources

•

Appendix D: Interviewing to Increase Resident Voice in MDS Assessments

•

Appendix E: Patient Health Questionnaire (PHQ)-Scoring Rules and Instruction for
BIMS (When Administered in Writing)

•

Appendix F: MDS Item Matrix

•

Appendix G: References

•

Appendix H: MDS 3.0 Forms

October 2024

•

Page 1-10

CMS’s RAI Version 3.0 Manual

Section

CH 1: Resident Assessment Instrument (RAI)

Title

Intent

Identification Information

Obtain key demographic information to uniquely identify each resident,
administrative information, nursing home in which they reside, reason
for assessment, and potential care needs, including access to
transportation.

Hearing, Speech, and
Vision

Document whether the resident is comatose, the resident’s ability to
hear, understand, and communicate with others and the resident’s
ability to see objects nearby in their environment.

Cognitive Patterns

Determine the resident’s attention, orientation, and ability to register
and recall information, and whether the resident has signs and
symptoms of delirium.

Mood

Identify signs and symptoms of mood distress and social isolation.

Behavior

Identify behavioral symptoms that may cause distress or are
potentially harmful to the resident, or may be distressing or disruptive
to facility residents, staff members or the care environment.

Preferences for Customary
Routine and Activities

Obtain information regarding the resident’s preferences for their daily
routine and activities.

Functional Abilities

Assess the need for assistance with self-care and mobility activities,
prior function, admission performance, discharge performance,
functional limitations in range of motion, and current and prior device
use.

Bladder and Bowel

Gather information on the use of bowel and bladder appliances, the
use of and response to urinary toileting programs, urinary and bowel
continence, bowel training programs, and bowel patterns.

Active Diagnoses

Code diseases that have a direct relationship to the resident’s current
functional, cognitive, mood or behavior status, medical treatments,
nursing monitoring, or risk of death.

Health Conditions

Document health conditions that impact the resident’s functional status
and quality of life.

Swallowing/Nutritional
Status

Assess conditions that could affect the resident’s ability to maintain
adequate nutrition and hydration.

Oral/Dental Status

Record any oral or dental problems present.

Skin Conditions

Document the risk, presence, appearance, and change of pressure
ulcers as well as other skin ulcers, wounds or lesions. Also includes
treatment categories related to skin injury or avoiding injury.

Medications

Record the number of days that any type of injection, insulin, and/or
select medications was received by the resident. Also includes use
and indication of high-risk drug classes, antipsychotic use and drug
regimen review to identify potentially significant medication issues.

Special Treatments,
Procedures, and Programs

Identify any special treatments, procedures, and programs that the
resident received or performed during the specified time periods.

Restraints and Alarms

Record the frequency that the resident was restrained by any of the
listed devices or an alarm was used at any time during the day or
night.

Participation in Assessment
and Goal Setting

Record the participation and expectations of the resident, family
and/or significant others in the assessment, and to understand the
resident’s overall goals.

Care Area Assessment
(CAA) Summary

Document triggered care areas, whether or not a care plan has been
developed for each triggered area, and the location of care area
assessment documentation.

Correction Request

To identify an MDS record already present in iQIES system for
modification or inactivation.

October 2024

Page 1-11

CMS’s RAI Version 3.0 Manual

Section
Z

CH 1: Resident Assessment Instrument (RAI)

Title

Intent

Assessment Administration

Provide billing information and signatures of persons completing and
attesting to the accuracy of the assessment, as well as the signature
and date by the RN Assessment Coordinator verifying the assessment
is complete.

1.8 Protecting the Privacy of the MDS Data

MDS assessment data is personal information about nursing facility residents that facilities are
required to collect and keep confidential in accordance with federal law. The 42 CFR Part 483.20
requires Medicare and Medicaid certified nursing facility providers to collect the resident
assessment data that comprises the MDS. This data is considered part of the resident’s medical
record and is protected from improper disclosure by Medicare and Medicaid certified facilities by
regulation at CFR 483.70(i) and 483.75(i)(4), release of information from the resident’s clinical
record is permissible only when required by:
1. transfer to another health care institution,
2. law (both State and Federal), and/or

3. the resident.

Otherwise, providers cannot release MDS data in individual level format or in the aggregate.
Nursing facility providers are also required under CFR 483.20 to transmit MDS data to a Federal
data repository. Any personal data maintained and retrieved by the Federal government is subject
to the requirements of the Privacy Act of 1974. The Privacy Act specifically protects the
confidentiality of personal identifiable information and safeguards against its misuse.
Information regarding The Privacy Act can be found at https://www.cms.gov/ResearchStatistics-Data-and-Systems/Computer-Data-and-Systems/Privacy/PrivacyActof1974.html.

The Privacy Act requires by regulation that all individuals whose data are collected and
maintained in a federal database must receive notice. Therefore, residents in nursing facilities
must be informed that the MDS data is being collected and submitted to the national system,
Internet Quality Improvement Evaluation System (iQIES). The notice shown on page 1-14 of this
section meets the requirements of the Privacy Act of 1974 for nursing facilities. The form is a
notice and not a consent to release or use MDS data for health care information. Each resident or
family member must be given the notice containing submission information at the time of
admission. It is important to remember that resident consent is not required to complete and
submit MDS assessments that are required under Omnibus Budget Reconciliation Act of 1987
(OBRA ’87) or for Medicare payment purposes.

October 2024

Page 1-12

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

Contractual Agreements
Providers who are part of a multi-facility corporation may release data to their corporate office or
parent company but not to other providers within the multi-facility corporation. The parent
company is required to “act” in the same manner as the facility and is permitted to use data only
to the extent the facility is permitted to do so (as described in 42 CFR at 483.10(h)(3)(i)).

In the case where a facility submits MDS data to CMS through a contractor or through its
corporate office, the contractor or corporate office has the same rights and restrictions as the
facility does under the Federal and State regulations with respect to maintaining resident data,
keeping such data confidential, and making disclosures of such data. This means that a contractor
may maintain a database, but must abide by the same rules and regulations as the facility.
Moreover, the fact that there may have been a change of ownership of a facility that has been
transferring data through a contractor should not alter the contractor's rights and responsibilities;
presumably, the new owner has assumed existing contractual rights and obligations, including
those under the contract for submitting MDS information. All contractual agreements, regardless
of their type, involving the MDS data should not violate the requirements of participation in the
Medicare and/or Medicaid program, the Privacy Act of 1974 or any applicable State laws.

October 2024

Page 1-13

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

PRIVACY ACT STATEMENT – HEALTH CARE RECORDS
Long Term Care-Minimum Data Set (MDS) System of Records revised 04/28/2007
(Issued: 9-6-12, Implementation/Effective Date: 6-17-13)
THIS FORM PROVIDES YOU THE ADVICE REQUIRED BY THE PRIVACY ACT OF
1974 (5 USC 552a). THIS FORM IS NOT A CONSENT FORM TO RELEASE OR USE
HEALTH CARE INFORMATION PERTAINING TO YOU.
1. AUTHORITY FOR COLLECTION OF INFORMATION, INCLUDING SOCIAL
SECURITY NUMBER AND WHETHER DISCLOSURE IS MANDATORY OR
VOLUNTARY. Authority for maintenance of the system is given under Sections 1102(a),
1819(b)(3)(A), 1819(f), 1919(b)(3)(A), 1919(f) and 1864 of the Social Security Act.

The system contains information on all residents of long-term care (LTC) facilities that are
Medicare and/or Medicaid certified, including private pay individuals and not limited to
Medicare enrollment and entitlement, and Medicare Secondary Payer data containing other
party liability insurance information necessary for appropriate Medicare claim payment.

Medicare and Medicaid participating LTC facilities are required to conduct comprehensive,
accurate, standardized and reproducible assessments of each resident's functional capacity and
health status. To implement this requirement, the facility must obtain information from every
resident. This information is also used by the Centers for Medicare & Medicaid Services
(CMS) to ensure that the facility meets quality standards and provides appropriate care to all
residents. 42 CFR §483.20, requires LTC facilities to establish a database, the Minimum Data
Set (MDS), of resident assessment information. The MDS data are required to be
electronically transmitted to the CMS National Repository.
Because the law requires disclosure of this information to Federal and State sources as
discussed above, a resident does not have the right to refuse consent to these disclosures.
These data are protected under the requirements of the Federal Privacy Act of 1974 and the
MDS LTC System of Records.

2. PRINCIPAL PURPOSES OF THE SYSTEM FOR WHICH INFORMATION IS
INTENDED TO BE USED. The primary purpose of the system is to aid in the
administration of the survey and certification, and payment of Medicare/Medicaid LTC
services which include skilled nursing facilities (SNFs), nursing facilities (NFs) and noncritical access hospitals with a swing bed agreement.

Information in this system is also used to study and improve the effectiveness and quality of
care given in these facilities. This system will only collect the minimum amount of personal
data necessary to achieve the purposes of the MDS, reimbursement, policy and research
functions.

October 2024

Page 1-14

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

3. ROUTINE USES OF RECORDS MAINTAINED IN THE SYSTEM. The information
collected will be entered into the LTC MDS System of Records, System No. 09-70-0528.
This system will only disclose the minimum amount of personal data necessary to
accomplish the purposes of the disclosure. Information from this system may be disclosed
to the following entities under specific circumstances (routine uses), which include:
(1) To support Agency contractors, consultants, or grantees who have been contracted by
the Agency to assist in accomplishment of a CMS function relating to the purposes for
this system and who need to have access to the records in order to assist CMS;

(2) To assist another Federal or state agency, agency of a state government, an agency
established by state law, or its fiscal agent for purposes of contributing to the accuracy
of CMS’ proper payment of Medicare benefits and to enable such agencies to fulfill a
requirement of a Federal statute or regulation that implements a health benefits
program funded in whole or in part with Federal funds and for the purposes of
determining, evaluating and/or assessing overall or aggregate cost, effectiveness,
and/or quality of health care services provided in the State, and determine Medicare
and/or Medicaid eligibility;

(3) To assist Quality Improvement Organizations (QIOs) in connection with review of
claims, or in connection with studies or other review activities, conducted pursuant to
Title XI or Title XVIII of the Social Security Act and in performing affirmative
outreach activities to individuals for the purpose of establishing and maintaining their
entitlement to Medicare benefits or health insurance plans;

(4) To assist insurers and other entities or organizations that process individual insurance
claims or oversees administration of health care services for coordination of benefits
with the Medicare program and for evaluating and monitoring Medicare claims
information of beneficiaries including proper reimbursement for services provided;

(5) To support an individual or organization to facilitate research, evaluation, or
epidemiological projects related to effectiveness, quality of care, prevention of disease
or disability, the restoration or maintenance of health, or payment related projects;
(6) To support litigation involving the agency, this information may be disclosed to The
Department of Justice, courts or adjudicatory bodies;

(7) To support a national accrediting organization whose accredited facilities meet certain
Medicare requirements for inpatient hospital (including swing beds) services;

(8) To assist a CMS contractor (including but not limited to fiscal intermediaries and
carriers) that assists in the administration of a CMS-administered health benefits
program, or to a grantee of a CMS-administered grant program to combat fraud, waste
and abuse in certain health benefit programs; and

October 2024

Page 1-15

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

(9) To assist another Federal agency or to an instrumentality of any governmental
jurisdiction within or under the control of the United States (including any state or
local governmental agency), that administers, or that has the authority to investigate
potential fraud, waste and abuse in a health benefits program funded in whole or in
part by Federal funds.
4. EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION. The
information contained in the LTC MDS System of Records is generally necessary for the
facility to provide appropriate and effective care to each resident.
If a resident fails to provide such information, e.g. thorough medical history, inappropriate
and potentially harmful care may result. Moreover, payment for services by Medicare,
Medicaid and third parties, may not be available unless the facility has sufficient information
to identify the individual and support a claim for payment.

NOTE: Residents or their representative must be supplied with a copy of the notice. This
notice may be included in the admission packet for all new nursing home admissions, or
distributed in other ways to residents or their representative(s). Although signature of receipt
is NOT required, providers may request to have the Resident or his or her Representative sign
a copy of this notice as a means to document that notice was provided and merely
acknowledges that they have been provided with this information.

Your signature merely acknowledges that you have been advised of the foregoing. If
requested, a copy of this form will be furnished to you.
___________________________________________
Signature of Resident or Sponsor

______________________
Date

NOTE: Providers may request to have the Resident or his or her Representative sign a copy of
this notice as a means to document that notice was provided. Signature is NOT required. If the
Resident or his or her Representative agrees to sign the form it merely acknowledges that they
have been advised of the foregoing information. Residents or their Representative must be
supplied with a copy of the notice. This notice may be included in the admission packet for all
new nursing home admissions.

October 2024

Page 1-16

CMS’s RAI Version 3.0 Manual

CH 1: Resident Assessment Instrument (RAI)

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 and license protections:
• Patient Health Questionnaire (PHQ)©: Copyright Pfizer Inc. All rights reserved.
Reproduced with permission.
• Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Confusion
Assessment Method. Copyright 2003, Hospital Elder Life Program, LLC. Not to be
reproduced without permission.
• Health Literacy: The Single Item Literacy Screener is licensed under a Creative
Commons Attribution-NonCommercial 4.0 International License.
• Transportation © 2019. National Association of Community Health Centers, Inc.,
Association of Asian Pacific Community Health Organizations, Oregon Primary Care
Association. PRAPARE and its resources are proprietary information of NACHC and its
partners, intended for use by NACHC, its partners, and authorized recipients. Do not
publish, copy, or distribute this information in part or whole without written consent from
NACHC.
All copyright and license holders have granted permission to use these instruments and data
elements in association with the MDS 3.0.

October 2024

Page 1-17

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

CHAPTER 2: ASSESSMENTS FOR THE RESIDENT
ASSESSMENT INSTRUMENT (RAI)
This chapter presents the assessment types and instructions for the completion (including timing
and scheduling) of the mandated OBRA and Prospective Payment System (PPS) assessments in
nursing homes and the mandated PPS assessments in non-critical access hospitals with a swing
bed agreement.

2.1 Introduction to the Requirements for the RAI

The statutory authority for the RAI is found in Section 1819(f)(6)(A-B) for Medicare, and 1919
(f)(6)(A-B) for Medicaid, of the Social Security Act (SSA), as amended by the Omnibus Budget
Reconciliation Act of 1987 (OBRA 1987). These sections of the SSA require the Secretary of the
Department of Health and Human Services (the Secretary) to specify a Minimum Data Set
(MDS) of core elements for use in conducting assessments of nursing home residents. It
furthermore requires the Secretary to designate one or more resident assessment instruments
based on the MDS.

The OBRA regulations require nursing homes that are Medicare certified, Medicaid certified or
both, to conduct initial and periodic assessments for all their residents. The Resident Assessment
Instrument (RAI) process is the basis for the accurate assessment of each resident. The MDS 3.0
is part of that assessment process and is required by CMS. The OBRA-required assessments will
be described in detail in Section 2.6.

MDS assessments are also required to be completed and submitted to the iQIES system for
Medicare payment (Skilled Nursing Facility (SNF) PPS) purposes under Medicare Part A
(described in detail in Section 2.9) or for the SNF Quality Reporting Program (QRP) required
under the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act).
Other payors (e.g., Medicare Advantage Plans) may require Health Insurance Prospective
Payment System (HIPPS) codes or other MDS data for billing purposes. However, facilities must
not code assessments done for these purposes as PPS assessments in A0310B and A0310H or
submit these assessments to iQIES.
It is important to note that, in most cases, when the OBRA and PPS assessment time frames
coincide, one assessment may be used to satisfy both requirements. In such cases, the most
stringent requirement for MDS completion must be met. Therefore, it is imperative that nursing
home staff fully understand the requirements for both types of assessments in order to avoid
unnecessary duplication of effort and to remain in compliance with both OBRA and PPS
requirements. (Refer to Sections 2.10 and 2.11 for combining OBRA and PPS assessments).

October 2024

Page 2-1

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

2.2 CMS Designation of the RAI for Nursing Homes
Federal regulatory requirements at 42 CFR 483.20(b)(1) and 483.20(c) require facilities to use an
RAI that has been specified by CMS. The Federal requirement also mandates facilities to encode
and electronically transmit MDS 3.0 data. (Detailed submission requirements are located in
Chapter 5.)
While states must use all Federally required MDS 3.0 items, they have some flexibility in adding
optional Section S items.
•

CMS’ specified RAI covers the core items included on the instrument, the wording and
sequencing of those items, and all definitions and instructions for the RAI.

•

CMS’ specified RAI does not include characteristics related to formatting (e.g., print type,
color coding, or changes such as printing triggers on the assessment form).

All comprehensive RAIs specified by CMS must include at least the CMS MDS Version
3.0 (with or without optional Section S) and use of the Care Area Assessment (CAA)
process (including Care Area Triggers (CATs) and the CAA Summary (Section V).

•

If allowed by the State, facilities may have some flexibility in form design (e.g., print
type, color, shading, integrating triggers) or use a computer-generated printout of the RAI
as long as the State can ensure that the facility’s RAI in the resident’s record accurately
and completely represents the CMS-specified RAI in accordance with 42 CFR 483.20(b).
This applies to either pre-printed forms or computer-generated printouts.

•

Facility assessment systems must always be based on the MDS (i.e., both item
terminology and definitions). However, facilities may insert additional items within
automated assessment programs, but must be able to “extract” and print the MDS in a
manner that replicates CMS’ specified RAI (i.e., using the exact wording and sequencing
of items as is found on the RAI specified by CMS).

•

Additional information about CMS specification of the RAI and variations in format can be
found in Sections 4145.1–4145.7 of the CMS State Operations Manual (SOM) which can be
found here: https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107c04.pdf. For more information about your
State’s assessment requirements, contact your State RAI Coordinator (see Appendix B).

2.3 Responsibilities of Nursing Homes for Completing
Assessments

The requirements for the RAI are found at 42 CFR 483.20 and are applicable to all residents in
Medicare and/or Medicaid certified long-term care facilities. The requirements are applicable
regardless of age, diagnosis, length of stay, payment source or payer source. Federal RAI
requirements are not applicable to individuals residing in non-certified units of long-term care
facilities or licensed-only facilities. This does not preclude a State from mandating the RAI for
residents who live in these units. Please contact your State RAI Coordinator for State
requirements.

October 2024

Page 2-2

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

An RAI (MDS, CAA process, and Utilization Guidelines) must be completed for any resident
residing in the facility, including:
All residents of Medicare (Title 18) skilled nursing facilities (SNFs) or Medicaid (Title
19) nursing facilities (NFs). This includes certified SNFs or NFs in hospitals, regardless
of payment source.

•

Hospice residents: When a SNF or NF is the hospice resident’s residence for purposes of
the hospice benefit, the facility must comply with the Medicare or Medicaid participation
requirements, meaning the resident must be assessed using the RAI, have a care plan and
be provided with the services required under the plan of care. This can be achieved
through cooperation of both the hospice and long-term care facility staff (including
participation in completing the RAI and care planning) with the consent of the resident.

•

Short-term or respite residents: An RAI must be completed for any individual residing
more than 14 days on a unit of a facility that is certified as a long-term care facility for
participation in the Medicare or Medicaid programs. If the respite resident is in a certified
bed, the OBRA assessment schedule and tracking document requirements must be
followed. If the respite resident is in the facility for fewer than 14 days, an OBRA
Admission assessment is not required; however, an OBRA Discharge assessment is
required:

•

— Given the nature of a short-term or respite resident, staff members may not have
access to all information required to complete some MDS items prior to the resident’s
discharge. In that case, the “not assessed/no information” coding convention should
be used (“-”) (See Chapter 3 for more information).
— Regardless of the resident’s length of stay, the facility must still have a process in
place to identify the resident’s needs and must initiate a plan of care to meet those
needs upon admission.
— If the resident is eligible for Medicare Part A benefits, a Medicare assessment will
still be required to support payment under the SNF PPS.
Special population residents (e.g., pediatric or residents with a psychiatric
diagnosis): Certified facilities are required to complete an RAI for all residents who
reside in the facility, regardless of age or diagnosis.

•

Swing bed facilities: SNF-level services of non-critical access hospital (non-CAH)
swing bed (SB) facilities were phased into the SNF PPS on July 1, 2002 (referred to as
swing beds in this manual). Swing bed facilities must assess the clinical condition of
Medicare beneficiaries by completing certain MDS assessments for each Medicare
resident receiving Medicare Part A SNF level of care in order to be reimbursed under the
SNF PPS Patient Driven Payment Model. CMS began collecting MDS data for quality
monitoring purposes of non-CAH SB facilities effective October 1, 2010. Therefore, SB
providers must complete these assessments: Swing Bed PPS (SP) and Swing Bed
Discharge (SD) assessments, and Entry Tracking and Death in Facility records. Swing
bed facilities may also choose to complete an Interim Payment Assessment (IPA) at any
time during the resident’s stay in the facility. Swing bed providers must adhere to the
same assessment requirements including, but not limited to, completion date, encoding

October 2024

•

Page 2-3

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

requirements, submission time frame, and RN signature. Swing bed facilities must use
the instructions in this manual when completing MDS assessments.
Skilled Nursing Facility Quality Reporting Program: The IMPACT Act of 2014 established
the SNF QRP. Amending Section 1888(e) of the Social Security Act, the IMPACT Act mandates
that SNFs are to collect and report on standardized resident assessment data. Failure to report
such data results in a 2 percent reduction in the SNF’s market basket percentage for the
applicable fiscal year. Data collected for the SNF QRP is submitted through the Internet Quality
Improvement Evaluation System (iQIES) as it currently is for other MDS assessments.
•

Additional information regarding the IMPACT Act and associated quality measures may
be found on CMS’s website at: https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of2014/IMPACT-Act-of-2014-Data-Standardization-and-Cross-Setting-Measures.

The RAI process must be used with residents in facilities with different certification
situations, including:
•

Newly Certified Nursing Homes:

— Nursing homes must admit residents and operate in compliance with certification
requirements before a certification survey can be conducted.

— Nursing homes must meet specific requirements, 42 Code of Federal Regulations,
Part 483 (Requirements for States and Long Term Care Facilities, Subpart B), in
order to participate in the Medicare and/or Medicaid programs.
— The completion and submission of OBRA and/or PPS assessments are a requirement
for Medicare and/or Medicaid long-term care facilities. However, even though OBRA
does not apply until the provider is certified, facilities are required to conduct and
complete resident assessments prior to certification as if the beds were already
certified.*

— Prior to certification, although the facility is conducting and completing assessments,
these assessments are not technically OBRA required, but are required to demonstrate
compliance with certification requirements. Since the data on these pre-certification
assessments was collected and completed with an ARD/target date prior to the
certification date of the facility, CMS does not have the authority to receive this into
iQIES. Therefore, these assessments cannot be submitted to iQIES.
— Assuming a survey is completed where the nursing home has been determined to be
in substantial compliance, the facility will be certified effective the last day of the
survey and can begin to submit OBRA and PPS required assessments to iQIES.

o For OBRA assessments, the assessment schedule is determined from the
resident’s actual date of admission. Please note, if a facility completes an
Admission assessment prior to the certification date, there is no need to do
another Admission assessment. The facility will simply continue with the next
expected assessment according to the OBRA schedule, using the actual admission
date as Day 1. Since the first assessment submitted will not be an Entry or OBRA
Admission assessment, but a Quarterly, OBRA Discharge, etc., the facility may

October 2024

Page 2-4

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

receive a sequencing warning message, but should still submit the required
assessment.
o For PPS assessments, please note that Medicare cannot be billed for any care
provided prior to the certification date. Therefore, the facility must use the
certification date as Day 1 of the covered Part A stay when establishing the
Assessment Reference Date (ARD) for the Medicare Part A SNF PPS
assessments.
— *NOTE: Even in situations where the facility’s certification date is delayed due to the
need for a resurvey, the facility must continue conducting and completing resident
assessments according to the original schedule.
•

Adding Certified Beds:

— If the nursing home is already certified and is just adding additional certified beds, the
procedure for changing the number of certified beds is different from that of the
initial certification.
— Medicare and Medicaid residents should not be placed in one of these additional beds
until the facility has been notified that the beds have been certified.

•

Change in Ownership: There are two types of change in ownership transactions:

— 1) Assumption of Assets and Liabilities: This is the most common situation and
requires the new owner to assume the assets and liabilities of the prior owner and
retain the current CMS Certification Number (CCN). In this case:
○ The assessment schedule for existing residents continues, and the facility
continues to use the existing provider number.
○ Staff with iQIES user IDs continue to use the same iQIES user IDs.

○ Example: if the Admission assessment was done 10 days prior to the change in
ownership, the next OBRA assessment would be due no later than 92 days after
the ARD (A2300) of the Admission assessment and would be submitted using the
existing provider number. If the resident is in a Part A stay, and the 5-Day PPS
assessment was combined with the OBRA Admission assessment, the next PPS
assessment could be an Interim Payment Assessment (IPA), if the provider
chooses to complete one, and would also be submitted under the existing provider
number.
— 2) No Assumption of Assets or Liabilities: There are situations where the new owner
does not assume the assets and liabilities of the previous owner. In these cases:
○ The beds are no longer certified.

○ There are no links to the prior provider, including sanctions, deficiencies, resident
assessments, Quality Measures, debts, CMS Certification Number (CCN), etc.
○ The previous owner would complete an OBRA Discharge assessment - return not
anticipated, thus code A0310F = 10, A2000 = date of ownership change, and
A2105 = 02 or 03 for those residents who will remain in the facility. Refer to
Chapter 3, Section A for additional guidance regarding A1805.

October 2024

Page 2-5

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

○ The new owner would complete an Admission assessment and Entry tracking
record for all residents, thus code A0310F = 01, A1600 = date of ownership
change, A1700 = 1 (admission), and A1805 = 02 or 03. Refer to Chapter 3,
Section A for additional guidance regarding A1805.
○ Staff who worked for the previous owner must update their iQIES role to submit
data for the CCN associated with the new owner.
○ Compliance with OBRA regulations, including the MDS requirements, is
expected at the time of survey for certification of the facility with a new owner.
See information above regarding newly certified nursing homes.
•

Resident Transfers:

— When transferring a resident, the transferring facility must provide the new facility
with necessary medical records, including appropriate MDS assessments, to support
the continuity of resident care.
— When admitting a resident from another nursing home, regardless of whether or not it
is a transfer within the same chain, a new Admission assessment must be done within
14 days. The MDS schedule then starts with the new Admission assessment and, if
applicable, a 5-Day assessment.
— The admitting facility should look at the previous facility’s assessment in the same way
they would review other incoming documentation about the resident for the purpose of
understanding the resident’s history and promoting continuity of care. However, the
admitting facility must perform a new Admission assessment for the purpose of
planning care within that facility to which the resident has been transferred.
— When there has been a transfer of residents as a result of a natural disaster(s) (e.g.,
flood, earthquake, fire) with an anticipated return to the facility, the evacuating
facility should contact their CMS Location (formerly known as Regional Office),
State Agency, and Medicare Administrative Contractor (MAC) for guidance.
— When there has been a transfer as a result of a natural disaster(s) (e.g., flood,
earthquake, fire) and it has been determined that the resident will not return to the
evacuating facility, the evacuating provider will discharge the resident return not
anticipated and the receiving facility will admit the resident, with the MDS cycle
beginning as of the admission date to the receiving facility. For questions related to
this type of situation, providers should contact their CMS Location, State Agency,
and MAC for guidance.
— More information on emergency preparedness can be found at:
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/SurveyCertEmergPrep/index.html.

October 2024

Page 2-6

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

2.4 Responsibilities of Nursing Homes for Reproducing and
Maintaining Assessments
The Federal regulatory requirement at 42 CFR 483.20(d) requires nursing homes to maintain all
resident assessments completed within the previous 15 months in the resident’s active clinical
record. This requirement applies to all MDS assessment types regardless of the form of storage
(i.e., electronic or hard copy).
•

The 15-month period for maintaining assessment data may not restart with each
readmission to the facility:

— When a resident is discharged return anticipated and the resident returns to the
facility within 30 days, the facility must copy the previous RAI and transfer that
copy to the new record. The15-month requirement for maintenance of the RAI data
must be adhered to.
— When a resident is discharged return anticipated and does not return within 30
days or discharged return not anticipated, facilities may develop their own specific
policies regarding how to handle return situations, whether or not to copy the
previous RAI to the new record.

— In cases where the resident returns to the facility after a long break in care (i.e., 15
months or longer), staff may want to review the older record and familiarize
themselves with the resident history and care needs. However, the decision on
retaining the prior stay record in the active clinical record is a matter of facility policy
and is not a CMS requirement.
After the 15-month period, RAI information may be thinned from the active clinical
record and stored in the medical records department, provided that it is easily retrievable
if requested by clinical staff, State Agency surveyors, CMS, or others as authorized by
law. The exception is that demographic information (items A0500-A1600) from the most
recent Admission assessment must be maintained in the active clinical record until the
resident is discharged return not anticipated or is discharged return anticipated but does
not return within 30 days.

•

Nursing homes may use electronic signatures for clinical record documentation, including
the MDS, when permitted to do so by State and local law and when authorized by the
facility’s policy. Use of electronic signatures for the MDS does not require that the entire
clinical record be maintained electronically. Facilities must have written policies in place
to ensure proper security measures are in place to protect the use of an electronic
signature by anyone other than the person to whom the electronic signature belongs.

•

Nursing homes also have the option for a resident’s clinical record to be maintained
electronically rather than in hard copy. This also applies to portions of the clinical record
such as the MDS. Maintenance of the MDS electronically does not require that the entire
clinical record also be maintained electronically, nor does it require the use of electronic
signatures.

•

In cases where the MDS is maintained electronically without the use of electronic
signatures, nursing homes must maintain, at a minimum, hard copies of signed and dated

•

October 2024

Page 2-7

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

CAA(s) completion (items V0200B-C), correction completion (items X1100A-E), and
assessment completion (items Z0400-Z0500) data that is resident-identifiable in the
resident’s active clinical record.
Nursing homes must ensure that proper security measures are implemented via facility
policy to ensure the privacy and integrity of the record.

•

Nursing homes must also ensure that clinical records, regardless of form, are maintained
in a centralized location as deemed by facility policy and procedure (e.g., a facility with
five units may maintain all records in one location or by unit or a facility may maintain
the MDS assessments and care plans in a separate binder). Nursing homes must also
ensure that clinical records, regardless of form, are easily and readily accessible to staff
(including consultants), State agencies (including surveyors), CMS, and others who are
authorized by law and need to review the information in order to provide care to the
resident. Resident specific information must also be available to the individual resident.

•

Nursing homes that are not capable of maintenance of the MDS electronically must
adhere to the current requirement that either a handwritten or a computer-generated copy
be maintained in the active clinical record for 15 months following the final completion
date for all assessments and correction requests. This includes all MDS records, including
the CAA Summary, Quarterly assessment records, Identification Information, Entry and
Death in Facility tracking records and MDS Correction Requests (including signed
attestation).

•

All State licensure and State practice regulations continue to apply to Medicare and/or
Medicaid certified facilities. Where State law is more restrictive than Federal
requirements, the provider needs to apply the State law standard.

•

In the future, facilities may be required to conform to a CMS electronic signature
standard should CMS adopt one.

•

2.5 Assessment Types and Definitions

In order to understand the requirements for conducting assessments of nursing home residents, it
is first important to understand some of the concepts and definitions associated with MDS
assessments. Concepts and definitions for assessments are only introduced in this section.
Detailed instructions are provided throughout the rest of this chapter.

Admission refers to the date a person enters the facility and is admitted as a resident. A day
begins at 12:00 a.m. and ends at 11:59 p.m. Regardless of whether admission occurs at 12:00
a.m. or 11:59 p.m., this date is considered the 1st day of admission. Completion of an OBRA
Admission assessment must occur in any of the following admission situations:
•

when the resident has never been admitted to this facility before; OR

•

when the resident has been in this facility previously and was discharged return not
anticipated; OR

October 2024

Page 2-8

CMS’s RAI Version 3.0 Manual

•

CH 2: Assessments for the RAI

when the resident has been in this facility previously and was discharged return
anticipated and did not return within 30 days of discharge (see Discharge assessment
below).

Assessment Combination refers to the use of one assessment to satisfy both OBRA and

PPS assessment requirements when the time frames coincide for both required assessments. In
such cases, the most stringent requirement of the two assessments for MDS completion must be
met. Therefore, it is imperative that nursing home staff fully understand the requirements for
both types of assessments in order to avoid unnecessary duplication of effort and to remain in
compliance with both OBRA and PPS requirements. Sections 2.10 and 2.11 provide more
detailed information on combining PPS and OBRA assessments. In addition, when all
requirements for both are met, one assessment may satisfy two OBRA assessment requirements,
such as Admission and OBRA Discharge assessment.

Assessment Completion refers to the date that all information needed has been collected and
recorded for a particular assessment type and staff have signed and dated that the assessment is
complete.

For OBRA-required Comprehensive assessments, assessment completion is defined as
completion of the CAA process in addition to the MDS items, meaning that the RN
assessment coordinator has signed and dated both the MDS (item Z0500) and CAA(s)
(item V0200B) completion attestations. Since a Comprehensive assessment includes
completion of both the MDS and the CAA process, the assessment timing requirements
for a comprehensive assessment apply to both the completion of the MDS and the CAA
process.

•

For non-comprehensive and Discharge assessments, assessment completion is defined as
completion of the MDS only, meaning that the RN assessment coordinator has signed and
dated the MDS (item Z0500) completion attestation.

•

Completion requirements are dependent on the assessment type and timing requirements.
Completion specifics by assessment type are discussed in Section 2.6 for OBRA assessments and
Section 2.9 for PPS assessments.

Assessment Reference Date (ARD) refers to the specific endpoint for the observation (or

“look-back”) periods in the MDS assessment process. The facility is required to set the ARD on
the MDS Item Set or in the facility software within the required time frame of the assessment
type being completed. This concept of setting the ARD is used for all assessment types (OBRA
and PPS) and varies by assessment type and facility determination. Most of the MDS 3.0 items
have a 7-day look-back period. If a resident has an ARD of July 1, 2011, then all pertinent
information starting at 12:00 a.m. on June 25th and ending on July 1st at 11:59 p.m. should be
included for MDS 3.0 coding.

Assessment Scheduling refers to the period of time during which assessments take place,

setting the ARD, timing, completion, submission, and the observation periods required to
complete the MDS items.

October 2024

Page 2-9

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Assessment Submission refers to electronic MDS data being in record and file formats that
conform to standard record layouts and data dictionaries, and passes standardized edits defined
by CMS and the State. Chapter 5, CFR 483.20(f)(2), and the MDS 3.0 Data Submission
Specifications on the CMS MDS 3.0 web site provide more detailed information.

Assessment Timing refers to when and how often assessments must be conducted, based

upon the resident’s length of stay and the length of time between ARDs. The table in Section 2.6
describes the assessment timing schedule for OBRA-required assessments, while information on
the PPS assessment timing schedule is provided in Section 2.8.
•

•

For OBRA-required assessments, regulatory requirements for each assessment type
dictate assessment timing, the schedule for which is established with the Admission
(comprehensive) assessment when the ARD is set by the RN assessment coordinator and
the Interdisciplinary Team (IDT).
Assuming the resident did not experience a significant change in status, was not
discharged, and did not have a Significant Correction to Prior Comprehensive assessment
(SCPA) completed, assessment scheduling would then move through a cycle of three
Quarterly assessments followed by an Annual (comprehensive) assessment.
This cycle (Comprehensive assessment – Quarterly assessment – Quarterly assessment –
Quarterly assessment – Comprehensive assessment) would repeat itself annually for the
resident who: 1) the IDT determines the criteria for a Significant Change in Status
Assessment (SCSA) has not occurred, 2) an uncorrected significant error in prior
comprehensive or Quarterly assessment was not determined, and 3) was not discharged
with return not anticipated.
OBRA assessments may be scheduled early if a nursing home wants to stagger due dates
for assessments. As a result, more than three OBRA Quarterly assessments may be
completed on a particular resident in a given year, or the Annual may be completed early
to ensure that regulatory time frames between assessments are met. However, States may
have more stringent restrictions.
When a resident does have an SCSA or SCPA completed, the assessment resets the
assessment timing/scheduling. The next Quarterly assessment would be scheduled within
92 days after the ARD of the SCSA or SCPA, and the next comprehensive assessment
would be scheduled within 366 days after the ARD of the SCSA or SCPA.

Assessment Transmission refers to the electronic transmission of submission files to iQIES.
Chapter 5 and the CMS MDS 3.0 web site provide more detailed information.
Comprehensive MDS assessments include both the completion of the MDS as well as

completion of the CAA process and care planning. Comprehensive MDSs include Admission,
Annual, SCSA, and SCPA.

Death in Facility refers to when the resident dies in the facility or dies while on a leave of

absence (LOA) (see LOA definition). The facility must complete a Death in Facility tracking
record. No Discharge assessment is required.

October 2024

Page 2-10

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Discharge refers to the date a resident leaves the facility or the date the resident’s Medicare

Part A stay ends but the resident remains in the facility. A day begins at 12:00 a.m. and ends at
11:59 p.m. Regardless of whether discharge occurs at 12:00 a.m. or 11:59 p.m., this date is
considered the actual date of discharge. There are three types of discharges: two are OBRA
required—return anticipated and return not anticipated; the third is Medicare required—Part A
PPS Discharge. A Discharge assessment is required with all three types of discharges. Section
2.6 provides detailed instructions regarding return anticipated and return not anticipated types,
and Section 2.8 provides detailed instructions regarding the Part A PPS Discharge type. Any of
the following situations warrant a Discharge assessment, regardless of facility policies regarding
opening and closing clinical records and bed holds:
•
•

Resident is discharged from the facility to a private residence (as opposed to going on an
LOA);
Resident is admitted to a hospital or other care setting (regardless of whether the nursing
home discharges or formally closes the record);
Resident has a hospital observation stay greater than 24 hours, regardless of whether the
hospital admits the resident.
Resident is transferred from a Medicare- and/or Medicaid-certified bed to a non-certified
bed.
Resident’s Medicare Part A stay ends, but the resident remains in the facility.

•

Discharge Assessment refers to an assessment required on resident discharge from the

facility, or when a resident’s Medicare Part A stay ends, but the resident remains in the facility
(unless it is an instance of an interrupted stay, as defined below). This assessment includes
clinical items for quality monitoring as well as discharge tracking information.

Entry is a term used for both an admission and a reentry and requires completion of an Entry
tracking record.

Entry and Discharge Reporting MDS assessments and tracking records that include a
select number of items from the MDS used to track residents and gather important quality data at
transition points, such as when they enter a nursing home, leave a nursing home, or when a
resident’s Medicare Part A stay ends, but the resident remains in the facility. Entry/Discharge
reporting includes Entry tracking record, OBRA Discharge assessments, Part A PPS Discharge
assessment, and Death in Facility tracking record.
Interdisciplinary Team (IDT 1) is a group of professional disciplines that combine
knowledge, skills, and resources to provide the greatest benefit to the resident.

42 CFR 483.21(b)(2) A comprehensive care plan must be (ii) Prepared by an interdisciplinary team, that includes
but is not limited to - the attending physician, a registered nurse with responsibility for the resident, a nurse aide
with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or
professionals in disciplines as determined by the resident’s needs or as requested by the resident, and, to the
extent practicable, the participation of the resident and the resident’s representative(s).

October 2024

Page 2-11

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Interrupted Stay is a Medicare Part A SNF stay in which a resident is discharged from SNF
care (i.e., the resident is discharged from a Medicare Part A-covered stay) and subsequently
resumes SNF care in the same SNF for a Medicare Part A-covered stay during the interruption
window.
Interruption Window is a 3-day period, starting with the calendar day of Part A discharge

and including the 2 immediately following calendar days. In other words, if a resident in a
Medicare Part A SNF stay is discharged from Part A, the resident must resume Part A services,
or return to the same SNF (if physically discharged) to resume Part A services, by 11:59 p.m. at
the end of the third calendar day after their Part A-covered stay ended. The interruption window
begins with the first non-covered day following a Part A-covered stay and ends at 11:59 p.m. on
the third consecutive non-covered day following a Part A-covered SNF stay. If these conditions
are met, the subsequent stay is considered a continuation of the previous Medicare Part Acovered stay for the purposes of both the variable per diem schedule and PPS assessment
completion.
Examples of when there is an Interrupted Stay:
If a resident is discharged from Part A, remains in the facility, and resumes Part A
within the 3-day interruption window, this is an interrupted stay and no Part A PPS
Discharge or OBRA Discharge is completed, nor is a 5-Day or Entry Tracking record
required when Part A resumes.

•

If a resident is discharged from Part A, leaves the facility, and resumes Part A within
the 3-day interruption window, this is an interrupted stay and only an OBRA Discharge
is required. An Entry Tracking record is required on reentry, but no 5-Day is required.

•

Examples of when there is no Interrupted Stay:

If a resident is discharged from Part A, remains in the facility, and does not resume
Part A within the 3-day interruption window, it is not an interrupted stay. Therefore, a
Part A PPS Discharge and a 5-Day assessment are both required (as long as resumption
of Part A occurs within the 30-day window allowed by Medicare).

•

If a resident is discharged from Part A, leaves the facility, and does not resume Part A
within the 3-day interruption window, it is not an interrupted stay and the Part A PPS
Discharge and OBRA Discharge are both required and must be combined if the Medicare
Part A stay ends on the day of, or one day before, the resident’s Discharge Date (A2000)
(see Part A PPS Discharge assessment in Section 2.5). Any return to the facility in this
instance would be considered a new entry—that means that an Entry Tracking record,
OBRA admission and/or 5-Day assessment would be required.

October 2024

•

Page 2-12

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Item Set refers to the MDS items that are active on a particular assessment type or tracking
form. There are 9 different item subsets for nursing homes and 5 for swing bed providers as
follows:
•

Nursing Home
— Comprehensive (NC) 2 Item Set. This is the set of items active on an OBRA
Comprehensive assessment (Admission, Annual, SCSA, and SCPA). This item set is
used whether the OBRA Comprehensive assessment is standalone or combined with
any other assessment (PPS assessment and/or Discharge assessment).
— Quarterly (NQ) Item Set. This is the set of items active on an OBRA Quarterly
assessment (including Significant Correction of Prior Quarterly assessment [SCQA]).
This item set is used for a standalone Quarterly assessment or a Quarterly assessment
combined with any type of PPS assessment and/or Discharge assessment.

— PPS (NP) Item Set. This is the set of items active on a 5-Day PPS assessment.
— Interim Payment Assessment (IPA) Item Set. This is the set of items active on an
Interim Payment Assessment and used for PPS payment purposes. This is a
standalone assessment.

— Discharge (ND) Item Set. This is the set of items active on a standalone OBRA
Discharge assessment (either return anticipated or not anticipated) to be used when a
resident is physically discharged from the facility.

— Part A PPS Discharge (NPE) Item Set. This is the set of items active on a
standalone nursing home Part A PPS Discharge assessment for the purposes of the
SNF QRP. It is completed when the resident’s Medicare Part A stay ends, but the
resident remains in the facility.
— Tracking (NT) Item Set. This is the set of items active on an Entry Tracking Record
or a Death in Facility Tracking Record.

•

Swing Beds

— Inactivation Request (XX) Item Set. This is the set of items active on a request to
inactivate a record in iQIES.
— PPS (SP) Item Set. This is the set of items active on a 5-Day PPS assessment.

— Discharge (SD) Item Set. This is the set of items active on a standalone Swing Bed
Discharge assessment (either return anticipated or not anticipated).
— Interim Payment Assessment (IPA) Item Set. This is the set of items active on an
Interim Payment Assessment and used for PPS payment purposes. This is a
standalone assessment.

— Tracking (ST) Item Set. This is the set of items active on an Entry Tracking Record
or a Death in Facility Tracking Record.

The codes in parentheses are the item set codes (ISCs) used in the data submission specifications.

October 2024

Page 2-13

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

— Inactivation (XX) Item Set. This is the set of items active on a request to inactivate a
record in iQIES.
Printed layouts for the item sets are available in Appendix H of this manual.
The item set for a particular MDS record is completely determined by the Type of Provider, item
A0200 (indicating nursing home or swing bed), and the reason for assessment items (A0310A,
A0310B, A0310F, and A0310H). Item set determination is complicated and standard MDS
software from CMS and private vendors will automatically make this determination. Section 2.14
of this chapter provides manual lookup tables for determining the item set when automated
software is unavailable.

Item Set Codes are those values that correspond to the OBRA-required and PPS assessments

represented in items A0310A, A0310B, A0310F, and A0310H of the MDS 3.0. They will be
used to reference assessment types throughout the rest of this chapter.

Leave of Absence (LOA), which does not require completion of either a Discharge
assessment or an Entry tracking record, occurs when a resident has a:

• Temporary home visit of at least one night; or
• Therapeutic leave of at least one night; or
• Hospital observation stay less than 24 hours and the hospital does not admit the resident.
Providers should refer to Chapter 6 and their State LOA policy for further information, if
applicable.

Upon return of the resident to the facility, providers should make appropriate documentation in
the medical record regarding any changes in the resident’s status. If significant changes in status
are noted after an LOA, a Significant Change in Status Assessment (SCSA) may be necessary
(see Section 2.6).

Non-Comprehensive MDS assessments include a select number of items from the MDS used

to track the resident’s status between comprehensive assessments and to ensure monitoring of
critical indicators of the gradual onset of significant changes in resident status. They do not
include completion of the CAA process and care planning. Non-comprehensive assessments
include Quarterly assessments and SCQAs.

Observation (Look-Back, Assessment) Period is the time period over which the

resident’s condition or status is captured by the MDS assessment. When the resident is first
admitted to the nursing home, the RN assessment coordinator and the IDT will set the ARD. For
subsequent assessments, the observation period for a particular assessment for a particular
resident will be chosen based upon the regulatory requirements concerning timing and the ARDs
of previous assessments. Most MDS items themselves require an observation period, such as 7 or
14 days, depending on the item. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the
observation period must also cover this time period. When completing the MDS, only those
occurrences during the look-back period will be captured. In other words, if it did not occur
during the look-back period, it is not coded on the MDS.

October 2024

Page 2-14

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

OBRA-Required Tracking Records and Assessments are Federally mandated, and

therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing
homes. These assessments are coded on the MDS 3.0 in items A0310A (Federal OBRA Reason
for Assessment) and A0310F (Entry/discharge reporting). They include:
Tracking records
•
•

Entry
Death in facility

Assessments
Admission (comprehensive)
Quarterly
Annual (comprehensive)
SCSA (comprehensive)
SCPA (comprehensive)
SCQA
Discharge (return not anticipated or return anticipated)

•
•
•
•
•
•
•

PPS Assessments provide information about the clinical condition of beneficiaries receiving

•
•
•

Part A SNF-level care in order to be reimbursed under the SNF PPS for both SNFs and Swing
Bed providers. These assessments are coded on the MDS 3.0 in items A0310B (PPS Assessment)
and A0310H (Is this a Part A PPS Discharge Assessment?). They include:
5-Day assessment
Interim Payment Assessment (IPA)
Part A PPS Discharge Assessment

Reentry refers to the situation when all three of the following occurred prior to this entry: the
resident was previously in this facility and was discharged return anticipated and returned within
30 days of discharge. Upon the resident’s return to the facility, the facility is required to complete
an Entry tracking record. In determining if the resident returned to the facility within 30 days, the
day of discharge from the facility is not counted in the 30 days. For example, a resident who is
discharged return anticipated on December 1 would need to return to the facility by December 31
to meet the “within 30 days” requirement.
Respite refers to short-term, temporary care provided to a resident to allow family members to

take a break from the daily routine of care giving. The nursing home is required to complete an
Entry tracking record and an OBRA Discharge assessment for all respite residents. If the respite
stay is 14 days or longer, the facility must have completed an OBRA Admission.

October 2024

Page 2-15

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

2.6 Required OBRA Assessments for the MDS
If the assessment is being used for OBRA requirements, the OBRA reason for assessment must
be coded in items A0310A and A0310F (Entry/discharge reporting). PPS reasons for assessment
are described later in this chapter (Section 2.9) while the OBRA reasons for assessment are
described below.
The table provides a summary of the assessment types and requirements for the OBRA-required
assessments, the details of which will be discussed throughout the remainder of this chapter.

D
October 2024

Page 2-16

Assessment
Type/Item Set
Admission
(Comprehensive)

MDS
Assessment
Code (A0310A
or A0310F)

7-day
Observation
Period
(Look-Back)
Consists Of

A0310A = 03

ARD of previous
OBRA
comprehensive
assessment + 366
calendar days
AND
ARD of previous
OBRA Quarterly
assessment + 92
calendar days

ARD + 6
previous
calendar days

Significant Change A0310A = 04
in Status (SCSA)
(Comprehensive)

14th calendar day
after
determination
that significant
change in
resident’s status
occurred
(determination
date + 14
calendar days)

ARD + 6
previous
calendar days

ARD + 13
previous
calendar days

ARD +13
previous
calendar days

MDS
Completion
Date (Item
Z0500B)
No Later
Than

CAA(s)
Completion
Date (Item
V0200B2)
No Later
Than

Care Plan
Completion
Date (Item Transmission
Date
V0200C2)
No Later
No Later
Than
Than

Assessment
Combination

14th calendar
day of the
resident’s
admission
(admission date
+ 13 calendar
days)

CAA(s)
Completion
Date + 7
calendar
days

Care Plan
Completion
Date + 14
calendar
days

42 CFR 483.20
(Initial)
42 CFR 483.20
(b)(2)(i) (by
the 14th day)

May be
combined
with any
OBRA
assessment;
5-Day or Part
A PPS
Discharge
Assessment

ARD + 14
calendar days

CAA(s)
Completion
Date + 7
calendar
days

Care Plan
Completion
Date + 14
calendar
days

42 CFR 483.20
(b)(2)(iii)
(every 12
months)

May be
combined
with any
OBRA or
5-Day or Part
A PPS
Discharge
Assessment

CAA(s)
Completion
Date + 7
calendar
days

Care Plan
Completion
Date + 14
calendar
days

42 CFR 483.20
(b)(2)(ii)
(within 14
days)

May be
combined
with any
OBRA or
5-Day or Part
A PPS
Discharge
Assessment

ra
ARD + 13
previous
calendar days

Regulatory
Requirement

14th calendar
day after
determination
that significant
change in
resident’s
status occurred
(determination
date + 14
calendar days)

Page 2-17

14th calendar
day after
determination
that significant
change in
resident’s status
occurred
(determination
date + 14
calendar days)

(continued)

CH 2: Assessments for the RAI

ARD + 6
previous
calendar days

14-day
Observation
Period
(Look-Back)
Consists Of

14th calendar day
of the resident’s
admission
(admission date +
13 calendar days)

Annual
(Comprehensive)

A0310A = 01

Assessment
Reference Date
(ARD)
(Item A2300)
No Later Than

CMS՚s RAI Version 3.0 Manual

October 2024

RAI OBRA-required Assessment Summary

Assessment
Type/Item Set

Significant
Correction to
Prior Quarterly
(SCQA) (NonComprehensive)

14th calendar day
after
determination
that significant
error in prior
comprehensive
assessment
occurred
(determination
date + 14
calendar days)

ARD + 6
previous
calendar days

ARD + 13
previous
calendar days

A0310A = 02

ARD of previous
OBRA
assessment of
any type + 92
calendar days

ARD + 6
previous
calendar days

A0310A = 06

14th day after
determination
that significant
error in prior
quarterly
assessment
occurred
(determination
date + 14
calendar days)

ARD + 6
previous
calendar days

MDS
Assessment
Code (A0310A
or A0310F)
A0310A = 05

MDS Completion
Date (Item
Z0500B)
No Later
Than

CAA(s)
Completion
Date (Item
V0200B2)
No Later
Than

Care Plan
Completion
Date (Item Transmission
Date
V0200C2)
No Later
No Later
Than
Than

Regulatory
Requirement

Assessment
Combination

14th calendar
day after
determination
that significant
error in prior
comprehensive
assessment
occurred
(determination
date + 14
calendar days)

CAA(s)
Completion
Date + 7
calendar
days

Care Plan
Completion
Date + 14
calendar
days

42 CFR
483.20(f)
(3)(iv)

May be
combined
with any
OBRA or
5-Day or Part
A PPS
Discharge
Assessment

ARD + 13
previous
calendar days

ARD + 14
calendar days

N/A

MDS
Completion
Date + 14
calendar
days

42 CFR
483.20(c)
(every 3
months)

May be
combined
with any
OBRA or
5-Day or Part
A PPS
Discharge
Assessment

ARD + 13
previous
calendar days

14th day after
determination
that significant
error in prior
quarterly
assessment
occurred
(determination
date + 14
calendar days)

N/A

MDS
Completion
Date + 14
calendar
days

42 CFR
483.20(f)
(3)(v)

May be
combined
with any
OBRA or
5-Day or Part
A PPS
Discharge
Assessment

N/A

Page 2-18

(continued)

CH 2: Assessments for the RAI

14-day
Observation
Period
(Look-Back)
Consists Of

Quarterly (NonComprehensive)

7-day
Observation
Period
(Look-Back)
Consists Of

Significant
Correction to Prior
Comprehensive
(SCPA)
(Comprehensive)

Assessment
Reference Date
(ARD)
(Item A2300)
No Later Than

CMS՚s RAI Version 3.0 Manual

October 2024

RAI OBRA-required Assessment Summary (cont.)

Assessment
Type/Item Set

N/A

14-day
Observation
Period
(Look-Back)
Consists Of
N/A

A0310F = 11

N/A

MDS Completion
Date (Item
Z0500B)
No Later
Than
Discharge Date
+ 14 calendar
days

CAA(s)
Completion
Date (Item
V0200B2)
No Later
Than
N/A

Care Plan
Completion
Date (Item Transmission
Date
V0200C2)
No Later
No Later
Than
Than
N/A

N/A

Discharge Date
+ 14 calendar
days

N/A

Regulatory
Requirement

Assessment
Combination
May be
combined
with any
OBRA or
5-Day and
must be
combined
with a
Part A PPS
Discharge if
the Medicare
Part A stay
ends on the
day of, or one
day before,
the resident’s
Discharge
Date (A2000)

MDS
Completion
Date + 14
calendar
days

May be
combined
with any
OBRA or
5-Day and
must be
combined
with a
Part A PPS
Discharge if
the Medicare
Part A stay
ends on the
day of, or one
day before,
the resident’s
Discharge
Date (A2000)

Page 2-19

MDS
Completion
Date + 14
calendar
days

(continued)

CH 2: Assessments for the RAI

Discharge
Assessment –
return anticipated
(NonComprehensive)

A0310F = 10

7-day
Observation
Period
(Look-Back)
Consists Of

Discharge
Assessment –
return not
anticipated (NonComprehensive)

MDS
Assessment
Code (A0310A
or A0310F)

Assessment
Reference Date
(ARD)
(Item A2300)
No Later Than

CMS՚s RAI Version 3.0 Manual

October 2024

RAI OBRA-required Assessment Summary (cont.)

Assessment
Type/Item Set
Entry tracking
record

A0310F = 01

N/A

7-day
Observation
Period
(Look-Back)
Consists Of
N/A

14-day
Observation
Period
(Look-Back)
Consists Of
N/A

A0310F = 12

N/A

MDS Completion
Date (Item
Z0500B)
No Later
Than

CAA(s)
Completion
Date (Item
V0200B2)
No Later
Than

Care Plan
Completion
Date (Item Transmission
Date
V0200C2)
No Later
No Later
Than
Than

Entry Date + 7
calendar days

Death in facility
tracking record

MDS
Assessment
Code (A0310A
or A0310F)

Assessment
Reference Date
(ARD)
(Item A2300)
No Later Than

Discharge
(death) Date + 7
calendar days

N/A

Regulatory
Requirement

Assessment
Combination

Entry Date
+ 14
calendar
days

May not be
combined
with another
assessment

Discharge
(death) Date
+14
calendar
days

May not be
combined
with another
assessment

CMS՚s RAI Version 3.0 Manual

October 2024

RAI OBRA-required Assessment Summary (cont.)

CH 2: Assessments for the RAI

ra
Page 2-20

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Comprehensive Assessments
OBRA-required comprehensive assessments include the completion of both the MDS and the
CAA process, as well as care planning. Comprehensive assessments are completed upon
admission, annually, and when a significant change in a resident’s status has occurred or a
significant correction to a prior comprehensive assessment is required. They consist of:
•

Admission Assessment

•

Annual Assessment

•

Significant Change in Status Assessment

•

Significant Correction to Prior Comprehensive Assessment

Each of these assessment types will be discussed in detail in this section. They are not required
for residents in swing bed facilities.
Assessment Management Requirements and Tips for Comprehensive Assessments:
The ARD (item A2300) is the last day of the observation/look-back period, and day 1 for
purposes of counting back to determine the beginning of observation/look-back periods.
For example, if the ARD is set for day 14 of a resident’s admission, then the beginning of
the observation period for MDS items requiring a 7-day observation period would be day
8 of admission (ARD + 6 previous calendar days), while the beginning of the observation
period for MDS items requiring a 14-day observation period would be day 1 of admission
(ARD + 13 previous calendar days).

•

The nursing home may not complete a Significant Change in Status Assessment until
after an OBRA Admission assessment has been completed.

•

If a resident had an OBRA Admission assessment completed and then goes to the
hospital (discharge return anticipated and returns within 30 days) and returns during an
assessment period and most of the assessment was completed prior to the hospitalization,
then the nursing home may wish to continue with the original assessment, provided the
resident does not meet the criteria for an SCSA. In this case, the ARD remains the same
and the assessment must be completed by the completion dates required of the assessment
type based on the time frame in which the assessment was started. Otherwise, the
assessment should be reinitiated with a new ARD and completed within 14 days after reentry from the hospital. The portion of the resident’s assessment that was previously
completed should be stored on the resident’s record with a notation that the assessment
was reinitiated because the resident was hospitalized.

•

If a resident is discharged prior to the completion deadline for the assessment, completion
of the assessment is not required. Whatever portions of the RAI that have been completed
must be maintained in the resident’s medical record. 3 In closing the record, the nursing
home should note why the RAI was not completed.

•

The RAI is considered part of the resident’s clinical record and is treated as such by the RAI Utilization
Guidelines, e.g., portions of the RAI that are “started” must be saved.

October 2024

Page 2-21

CMS’s RAI Version 3.0 Manual

•

•
•
•

CH 2: Assessments for the RAI

•

•
•
•

If a resident dies prior to the completion deadline for the assessment, completion of the
assessment is not required. Whatever portions of the RAI that have been completed must
be maintained in the resident’s medical record. 4 In closing the record, the nursing home
should note why the RAI was not completed.
If a significant change in status is identified in the process of completing any OBRA
assessment except Admission and SCSAs, code and complete the assessment as a
comprehensive SCSA instead.
The nursing home may combine a comprehensive assessment with a Discharge
assessment.
In the process of completing any OBRA comprehensive assessment except an Admission
and an SCPA, if it is identified that an uncorrected significant error occurred in a previous
assessment that has already been submitted and accepted into iQIES, and has not already
been corrected in a subsequent comprehensive assessment, code and complete the
assessment as a comprehensive SCPA instead. A correction request for the erroneous
assessment should also be completed and submitted. See the section on SCPAs for
detailed information on completing an SCPA, and Chapter 5 for detailed information on
processing corrections.
In the process of completing any assessment except an Admission, if it is identified that a
non-significant (minor) error occurred in a previous assessment, continue with
completion of the assessment in progress and also submit a correction request for the
erroneous assessment as per the instructions in Chapter 5.
The MDS must be transmitted (submitted and accepted into iQIES) electronically no later
than 14 calendar days after the care plan completion date (V0200C2 + 14 calendar days).
The ARD of an assessment drives the due date of the next assessment. The next
comprehensive assessment is due within 366 days after the ARD of the most recent
comprehensive assessment.
May be combined with a 5-Day assessment or SNF Part A PPS Discharge assessment (see
Sections 2.10 and 2.11 for details) or any Discharge assessment type.

OBRA-required comprehensive assessments include the following types, which are numbered
according to their MDS 3.0 assessment code (item A0310A).
01. Admission Assessment (A0310A = 01)

The Admission assessment is a comprehensive assessment for a new resident and, under some
circumstances, a returning resident that must be completed by the end of day 14, counting the
date of admission to the nursing home as day 1 if:

The RAI is considered part of the resident’s clinical record and is treated as such by the RAI Utilization
Guidelines, e.g., portions of the RAI that are “started” must be saved.

October 2024

Page 2-22

CMS’s RAI Version 3.0 Manual

•
•
•

CH 2: Assessments for the RAI

this is the resident’s first time in this facility, OR
the resident has been admitted to this facility and was discharged return not anticipated,
OR
the resident has been admitted to this facility and was discharged return anticipated and
did not return within 30 days of discharge.

Assessment Management Requirements and Tips for Admission Assessments:
•
•

•

•
•
•

•

Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the actual date of admission,
regardless of whether admission occurs at 12:00 a.m. or 11:59 p.m., is considered day “1”
of admission.
The ARD (item A2300) must be set no later than day 14, counting the date of admission
as day 1. Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the ARD must also
cover this time period. For example, if a resident is admitted at 8:30 a.m. on Wednesday
(day 1), a completed RAI is required by the end of the day Tuesday (day 14).
Federal statute and regulations require that residents are assessed promptly upon
admission (but no later than day 14) and the results are used in planning and providing
appropriate care to attain or maintain the highest practicable well-being. This means it is
imperative for nursing homes to assess a resident upon the individual’s admission. The
IDT may choose to start and complete the Admission comprehensive assessment at any
time prior to the end of day 14. Nursing homes may find early completion of the MDS
and CAA(s) beneficial to providing appropriate care, particularly for individuals with
short lengths of stay when the assessment and care planning process is often accelerated.
The MDS completion date (item Z0500B) must be no later than day 14. This date may be
earlier than or the same as the CAA(s) completion date, but not later than.
The CAA(s) completion date (item V0200B2) must be no later than day 14.
The care plan completion date (item V0200C2) must be no later than 7 calendar days
after the CAA(s) completion date (item V0200B2) (CAA(s) completion date + 7 calendar
days).
For a resident who goes in and out of the facility on a relatively frequent basis and return
is expected within the next 30 days, the resident may be discharged with return
anticipated. This status requires an Entry tracking record each time the resident returns
to the facility and an OBRA Discharge assessment each time the resident is discharged.
The nursing home may combine the Admission assessment with a Discharge assessment
when applicable.

02. Annual Assessment (A0310A = 03)

The Annual assessment is a comprehensive assessment for a resident that must be completed on
an annual basis (at least every 366 days) unless an SCSA or an SCPA has been completed since
the most recent comprehensive assessment was completed. Its completion dates
(MDS/CAA(s)/care plan) depend on the most recent comprehensive and past assessments’ ARDs
and completion dates.

October 2024

Page 2-23

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Assessment Management Requirements and Tips for Annual Assessments:
The ARD (item A2300) must be set within 366 days after the ARD of the previous
OBRA comprehensive assessment (ARD of previous comprehensive assessment + 366
calendar days) AND within 92 days since the ARD of the previous OBRA Quarterly or
SCQA (ARD of previous OBRA Quarterly assessment + 92 calendar days).

•

The MDS completion date (item Z0500B) must be no later than 14 days after the ARD
(ARD + 14 calendar days). This date may be earlier than or the same as the CAA(s)
completion date, but not later than.

•

The CAA(s) completion date (item V0200B2) must be no later than 14 days after the
ARD (ARD + 14 calendar days). This date may be the same as the MDS completion date,
but not earlier than.

•

The care plan completion date (item V0200C2) must be no later than 7 calendar days
after the CAA(s) completion date (item V0200B2) (CAA(s) completion date + 7 calendar
days).

•

03. Significant Change in Status Assessment (SCSA) (A0310A = 04)

The SCSA is a comprehensive assessment for a resident that must be completed when the IDT
has determined that a resident meets the significant change guidelines for either major
improvement or decline. It can be performed at any time after the completion of an Admission
assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT’s
determination was made that the resident had a significant change.
A “significant change” is a major decline or improvement in a resident’s status that:
1. Will not normally resolve itself without intervention by staff or by implementing
standard disease-related clinical interventions, the decline is not considered “selflimiting”;

2. Impacts more than one area of the resident’s health status; and

3. Requires interdisciplinary review and/or revision of the care plan.

A significant change differs from a significant error because it reflects an actual significant
change in the resident’s health status and NOT incorrect coding of the MDS.
A significant change may require referral for a Preadmission Screening and Resident
Review (PASRR) evaluation if a mental illness, intellectual disability (ID), or related
condition is present or is suspected to be present.

Assessment Management Requirements and Tips for Significant Change in Status
Assessments:
•

When a resident’s status changes and it is not clear whether the resident meets the SCSA
guidelines, the nursing home may take up to 14 days to determine whether the criteria are
met.

October 2024

Page 2-24

CMS’s RAI Version 3.0 Manual

•
•

CH 2: Assessments for the RAI

•
•

•

October 2024

•

After the IDT has determined that a resident meets the significant change guidelines, the
nursing home should document the initial identification of a significant change in the
resident’s status in the clinical record.
An SCSA is appropriate when:
— There is a determination that a significant change (either improvement or decline) in a
resident’s condition from their baseline has occurred as indicated by comparison of
the resident’s current status to the most recent comprehensive assessment and any
subsequent Quarterly assessments; and
— The resident’s condition is not expected to return to baseline within two weeks.
— For a resident who goes in and out of the facility on a relatively frequent basis and
reentry is expected within the next 30 days, the resident may be discharged with
return anticipated. This status requires an Entry tracking record each time the resident
returns to the facility and an OBRA Discharge assessment each time the resident is
discharged. However, if the IDT determines that the resident would benefit from an
SCSA during the intervening period, the staff must complete an SCSA. This is only
allowed when the resident has had an OBRA Admission assessment completed and
submitted prior to discharge return anticipated (and resident returns within 30 days) or
when the OBRA Admission assessment is combined with the discharge return
anticipated assessment (and resident returns within 30 days).
An SCSA may not be completed prior to an OBRA Admission assessment.
An SCSA is required to be performed when a terminally ill resident enrolls in a hospice
program (Medicare-certified or State-licensed hospice provider) or changes hospice
providers and remains a resident at the nursing home. The ARD must be within 14 days
from the effective date of the hospice election (which can be the same or later than the
date of the hospice election statement, but not earlier than). An SCSA must be performed
regardless of whether an assessment was recently conducted on the resident. This is to
ensure a coordinated plan of care between the hospice and nursing home is in place. A
Medicare-certified hospice must conduct an assessment at the initiation of its services.
This is an appropriate time for the nursing home to evaluate the MDS information to
determine if it reflects the current condition of the resident, since the nursing home
remains responsible for providing necessary care and services to assist the resident in
achieving their highest practicable well-being at whatever stage of the disease process the
resident is experiencing.
If a resident is admitted on the hospice benefit (i.e., the resident is coming into the facility
having already elected hospice), or elects hospice on or prior to the ARD of the
Admission assessment, the facility should complete the Admission assessment, checking
the Hospice Care item, O0110K1. Completing an Admission assessment followed by an
SCSA is not required. Where hospice election occurs after the Admission assessment
ARD but prior to its completion, facilities may choose to adjust the ARD to the date of
hospice election so that only the Admission assessment is required. In such situations, an
SCSA is not required.
An SCSA is required to be performed when a resident is receiving hospice services and
then decides to discontinue those services (known as revoking of hospice care). The ARD
must be within 14 days from one of the following: 1) the effective date of the hospice

Page 2-25

CMS’s RAI Version 3.0 Manual

•

election revocation (which can be the same or later than the date of the hospice election
revocation statement, but not earlier than); 2) the expiration date of the certification of
terminal illness; or 3) the date of the physician’s or medical director’s order stating the
resident is no longer terminally ill.
If a resident is admitted on the hospice benefit but decides to discontinue it prior to the
ARD of the Admission assessment, the facility should complete the Admission
assessment, checking the Hospice Care item, O0110K1. Completing an Admission
assessment followed by an SCSA is not required. Where hospice revocation occurs after
the Admission assessment ARD but prior to its completion, facilities may choose to
adjust the ARD to the date of hospice revocation so that only the Admission assessment
is required. In such situations, an SCSA is not required.
The ARD must be less than or equal to 14 days after the IDT’s determination that the
criteria for an SCSA are met (determination date + 14 calendar days).
The MDS completion date (item Z0500B) must be no later than 14 days from the ARD
(ARD + 14 calendar days) and no later than 14 days after the determination that the
criteria for an SCSA were met. This date may be earlier than or the same as the CAA(s)
completion date, but not later than.
When an SCSA is completed, the nursing home must review all triggered care areas
compared to the resident’s previous status. If the CAA process indicates no change in a
care area, then the prior documentation for the particular care area may be carried
forward, and the nursing home should specify where the supporting documentation can
be located in the medical record.
The CAA(s) completion date (item V0200B2) must be no later than 14 days after the
ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the
criteria for an SCSA were met. This date may be the same as the MDS completion date,
but not earlier than MDS completion.
The care plan completion date (item V0200C2) must be no later than 7 calendar days
after the CAA(s) completion date (item V0200B2) (CAA(s) completion date + 7 calendar
days).

•

CH 2: Assessments for the RAI

Guidelines for Determining a Significant Change in a Resident’s Status:
Note: this is not an exhaustive list

The final decision regarding what constitutes a significant change in status must be based upon
the judgment of the IDT. MDS assessments are not required for minor or temporary variations in
resident status - in these cases, the resident’s condition is expected to return to baseline within 2
weeks. However, staff must note these transient changes in the resident’s status in the resident’s
record and implement necessary assessment, care planning, and clinical interventions, even
though an MDS assessment is not required.
Some Guidelines to Assist in Deciding If a Change Is Significant or Not:
•

A condition is defined as “self-limiting” when the condition will normally resolve itself
without further intervention or by staff implementing standard disease-related clinical
interventions. If the condition has not resolved within 2 weeks, staff should begin an
SCSA. This time frame may vary depending on clinical judgment and resident needs. For

October 2024

Page 2-26

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

example, a 5% weight loss for a resident with the flu would not normally meet the
requirements for an SCSA. In general, a 5% weight loss may be an expected outcome for
a resident with the flu who experienced nausea and diarrhea for a week. In this situation,
staff should monitor the resident’s status and attempt various interventions to rectify the
immediate weight loss. If the resident did not become dehydrated and started to regain
weight after the symptoms subsided, a comprehensive assessment would not be required.
•

An SCSA is appropriate if there are either two or more areas of decline or two or more
areas of improvement. In this example, a resident with a 5% weight loss in 30 days would
not generally require an SCSA unless a second area of decline accompanies it. Note that
this assumes that the care plan has already been modified to actively treat the weight loss
as opposed to continuing with the original problem, “potential for weight loss.” This
situation should be documented in the resident’s clinical record along with the plan for
subsequent monitoring and, if the problem persists or worsens, an SCSA may be
warranted.

D
•

•

If there is only one change, staff may still decide that the resident would benefit from an
SCSA. It is important to remember that each resident’s situation is unique, and the IDT
must make the decision as to whether or not the resident will benefit from an SCSA.
Nursing homes must document a rationale, in the resident’s medical record, for
completing an SCSA that does not meet the criteria for completion.
An SCSA is also appropriate if there is a consistent pattern of changes, with either two or
more areas of decline or two or more areas of improvement. This may include two
changes within a particular domain (e.g., two areas of ADL decline or improvement).
An SCSA would not be appropriate in situations where the resident has stabilized but is
expected to be discharged in the immediate future. The nursing home has engaged in
discharge planning with the resident and family, and a comprehensive reassessment is not
necessary to facilitate discharge planning.
Decline in two or more of the following:
— Resident’s decision-making ability has changed;
— Presence of a resident mood item not previously reported by the resident or staff
and/or an increase in the symptom frequency (PHQ-2 to 9©), e.g., increase in the
number of areas where behavioral symptoms are coded as being present and/or the
frequency of a symptom increases for items in Section E (Behavior);
— Changes in frequency or severity of behavioral symptoms of dementia that indicate
progression of the disease process since the last assessment;
— Any decline in an ADL physical functioning area (e.g., self-care or mobility) (at least
1) where a resident is newly coded as partial/moderate assistance,
substantial/maximal assistance, dependent, resident refused, or the activity was not
attempted since last assessment and does not reflect normal fluctuations in that
individual’s functioning;
— Resident’s incontinence pattern changes or there was placement of an indwelling
catheter;
— Emergence of unplanned weight loss problem (5% change in 30 days or 10% change
in 180 days);

October 2024

Page 2-27

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

— Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure
ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status;
— Resident begins to use a restraint of any type when it was not used before; and/or
— Emergence of a condition/disease in which a resident is judged to be unstable.
•

Improvement in two or more of the following:
— Any improvement in an ADL physical functioning area (at least 1) where a resident is
newly coded as Independent, setup or clean-up assistance, or supervision or touching
assistance since last assessment and does not reflect normal fluctuations in that
individual’s functioning;
— Decrease in the number of areas where Behavioral symptoms are coded as being
present and/or the frequency of a symptom decreases;
— Resident’s decision making improves;

— Resident’s incontinence pattern improves.

Examples (SCSA):

1. Resident T no longer responds to verbal requests to alter their screaming behavior. It now
occurs daily and has neither lessened on its own nor responded to treatment. They are also
starting to resist their daily care, pushing staff away from themself as the staff members
attempt to assist with their ADLs. This is a significant change, and an SCSA is required,
since there has been deterioration in the behavioral symptoms to the point where it is
occurring daily and new approaches are needed to alter the behavior. Resident T’s behavioral
symptoms could have many causes, and an SCSA will provide an opportunity for staff to
consider illness, medication reactions, environmental stress, and other possible sources of
Resident T’s disruptive behavior.

2. Resident T required supervision with ADLs. They fractured their hip and upon return to the
facility require maximal assistance with all ADLs. Rehab has started and staff is hopeful they
will return to their prior level of function in 4–6 weeks.
3. Resident G has been in the nursing home for 5 weeks following an 8-week acute
hospitalization. On admission they were very frail, had trouble thinking, were confused, and
had many behavioral complications. The course of treatment led to steady improvement and
they are now stable. They are no longer confused or exhibiting inappropriate behaviors. The
resident, their family, and staff agree that they have made remarkable progress. An SCSA is
required at this time. The resident is not the person they were at admission - their initial
problems have resolved and they will be remaining in the facility. An SCSA will permit the
interdisciplinary team to review their needs and plan a new course of care for the future.
Guidelines for When a Change in Resident Status Is Not Significant:
Note: this is not an exhaustive list
•

Discrete and easily reversible cause(s) documented in the resident’s record and for which
the IDT can initiate corrective action (e.g., an anticipated side effect of introducing a

October 2024

Page 2-28

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

psychoactive medication while attempting to establish a clinically effective dose level.
Tapering and monitoring of dosage would not require an SCSA).
Short-term acute illness, such as a mild fever secondary to a cold from which the IDT
expects the resident to fully recover.

•

Well-established, predictable cyclical patterns of clinical signs and symptoms associated
with previously diagnosed conditions (e.g., depressive symptoms in a resident previously
diagnosed with bipolar disease would not precipitate an SCSA).

•

Instances in which the resident continues to make steady progress under the current
course of care. Reassessment is required only when the condition has stabilized.

•

Instances in which the resident has stabilized but is expected to be discharged in the
immediate future. The facility has engaged in discharge planning with the resident and
family, and a comprehensive reassessment is not necessary to facilitate discharge
planning.

•

Guidelines for Determining the Need for an SCSA for Residents with Terminal
Conditions:
Note: this is not an exhaustive list

The key in determining if an SCSA is required for individuals with a terminal condition is
whether or not the change in condition is an expected, well-defined part of the disease course and
is consequently being addressed as part of the overall plan of care for the individual.
•

If a terminally ill resident experiences a new onset of symptoms or a condition that is not
part of the expected course of deterioration and the criteria are met for an SCSA, an
SCSA is required.

•

If a resident elects the Medicare Hospice program, it is important that the two separate
entities (nursing home and hospice program staff) coordinate their responsibilities and
develop a care plan reflecting the interventions required by both entities. The nursing
home and hospice plans of care should be reflective of the current status of the resident.

Examples (SCSA):

1. Resident M has been in this nursing home for two and one-half years. They have been a
favorite of staff and other residents, and their child has been an active volunteer on the unit.
Resident M is now in the end stage of their course of chronic dementia, diagnosed as
probable Alzheimer’s. They experience recurrent pneumonias and swallowing difficulties,
their prognosis is guarded, and family members are fully aware of their status. They are on a
special dementia unit, staff has detailed palliative care protocols for all such end stage
residents, and there has been active involvement of their child in the care planning process.
As changes have occurred, staff has responded in a timely, appropriate manner. In this case,
Resident M’s care is of a high quality, and as their physical state has declined, there is no
need for staff to complete a new MDS assessment for this bedfast, highly dependent terminal
resident.

October 2024

Page 2-29

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

2. Resident K came into the nursing home with identifiable problems and has steadily
responded to treatment. Their condition has improved over time and has recently hit a
plateau. They will be discharged within 5 days. The initial RAI helped to set goals and start
their care. The course of care provided to Resident K was modified as necessary to ensure
continued improvement. The IDT’s treatment response reversed the causes of the resident’s
condition. An assessment need not be completed in view of the imminent discharge.
Remember, facilities have 14 days to complete an assessment once the resident’s condition
has stabilized, and if Resident K is discharged within this period, a new assessment is not
required. If the resident’s discharge plans change, or if they are not discharged, an SCSA is
required by the end of the allotted 14-day period.

3. Resident P, too, has responded to care. Unlike Resident K, however, they continue to
improve. Their discharge date has not been specified. They are benefiting from their care and
full restoration of their functional abilities seems possible. In this case, treatment is focused
appropriately, progress is being made, staff is on top of the situation, and there is nothing to
be gained by requiring an SCSA at this time. However, if their condition were to stabilize
and their discharge was not imminent, an SCSA would be in order.
Guidelines for Determining When a Significant Change Should Result in Referral for a
Preadmission Screening and Resident Review (PASRR) Level II Evaluation:
•

•

If an SCSA occurs for an individual known or suspected to have a mental illness,
intellectual disability, or related condition (as defined by 42 CFR 483.102), a referral to
the State Mental Health or Intellectual Disability/Developmental Disabilities
Administration authority (SMH/ID/DDA) for a possible Level II PASRR evaluation must
promptly occur as required by Section 1919(e)(7)(B)(iii) of the Social Security Act.5
PASRR is not a requirement of the resident assessment process but is an OBRA provision
that is required to be coordinated with the resident assessment process. This guideline is
intended to help facilities coordinate PASRR with the SCSA — the guideline does not
require any actions to be taken in completing the SCSA itself.
Facilities should look to their state PASRR program requirements for specific procedures.
PASRR contact information for the SMH/ID/DDA authorities and the State Medicaid
Agency is available at http://www.cms.gov/.
The nursing facility must provide the SMH/ID/DDA authority with referrals as described
below, independent of the findings of the SCSA. PASRR Level II is to function as an
independent assessment process for this population with special needs, in parallel with
the facility’s assessment process. Nursing facilities should have a low threshold for
referral to the SMH/ID/DDA, so that these authorities may exercise their expert judgment
about when a Level II evaluation is needed.
Referral should be made as soon as the criteria indicating such are evident — the facility
should not wait until the SCSA is complete.

The statute may also be referenced as 42 U.S.C. 1396r(e)(7)(B)(iii). Note that as of this revision date the statute
supersedes Federal regulations at 42 CFR 483.114(c), which still reads as requiring annual resident review. The
regulation has not yet been updated to reflect the statutory change to resident review upon significant change in
condition.

October 2024

Page 2-30

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Referral for Level II Resident Review Evaluations Is Required for Individuals Previously
Identified by PASRR to Have Mental Illness, Intellectual Disability/Developmental
Disability, or a Related Condition in the Following Circumstances:
Note: this is not an exhaustive list
•
•
•
•

•

A resident who demonstrates increased behavioral, psychiatric, or mood-related
symptoms.
A resident with behavioral, psychiatric, or mood related symptoms that have not
responded to ongoing treatment.
A resident who experiences an improved medical condition—such that the resident’s plan
of care or placement recommendations may require modifications.
A resident whose significant change is physical, but with behavioral, psychiatric, or
mood-related symptoms, or cognitive abilities, that may influence adjustment to an
altered pattern of daily living.
A resident who indicates a preference (may be communicated verbally or through other
forms of communication, including behavior) to leave the facility.
A resident whose condition or treatment is or will be significantly different than
described in the resident’s most recent PASRR Level II evaluation and determination.
(Note that a referral for a possible new Level II PASRR evaluation is required whenever
such a disparity is discovered, whether or not associated with an SCSA.)

•

Example (PASRR & SCSA):

1. Resident L has a diagnosis of serious mental illness, but their primary reason for admission
was rehabilitation following a hip fracture. Once the hip fracture resolves and they become
ambulatory, even if other conditions exist for which Resident L receives medical care, they
should be referred for a PASRR evaluation to determine whether a change in their placement
or services is needed.

•
•
•

Referral for Level II Resident Review Evaluations Is Also Required for Individuals Who
May Not Have Previously Been Identified by PASRR to Have Mental Illness, Intellectual
Disability/Developmental Disability, or a Related Condition in the Following
Circumstances:
Note: this is not an exhaustive list
A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting
the presence of a diagnosis of mental illness as defined under 42 CFR 483.100 (where
dementia is not the primary diagnosis).
A resident whose intellectual disability as defined under 42 CFR 483.100, or related
condition as defined under 42 CFR 435.1010 was not previously identified and evaluated
through PASRR.
A resident transferred, admitted, or readmitted to a NF following an inpatient psychiatric
stay or equally intensive treatment.

October 2024

Page 2-31

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

04. Significant Correction to Prior Comprehensive Assessment (SCPA)
(A0310A = 05)
The SCPA is a comprehensive assessment for an existing resident that must be completed when
the IDT determines that a resident’s prior comprehensive assessment contains a significant error.
It can be performed at any time after the completion of an Admission assessment, and its ARD
and completion dates (MDS/CAA(s)/care plan) depend on the date the determination was made
that the significant error exists in a comprehensive assessment.
A “significant error” is an error in an assessment where:

1. The resident’s overall clinical status is not accurately represented (i.e., miscoded) on
the erroneous assessment and/or results in an inappropriate plan of care; and
2. The error has not been corrected via submission of a more recent assessment.
A significant error differs from a significant change because it reflects incorrect coding of
the MDS and NOT an actual significant change in the resident’s health status.

Assessment Management Requirements and Tips for Significant Correction to Prior
Comprehensive Assessments:
Nursing homes should document the initial identification of a significant error in an
assessment in the clinical record.

•

An SCPA is appropriate when:

•

— the erroneous comprehensive assessment has been completed and
transmitted/submitted into iQIES; and
— there is not a more current assessment in progress or completed that includes a
correction to the item(s) in error.
The ARD must be within 14 days after the determination that a significant error in the
prior comprehensive assessment occurred (determination date + 14 calendar days).

•

The MDS completion date (item Z0500B) must be no later than 14 days after the ARD
(ARD + 14 calendar days) and no later than 14 days after the determination was made
that a significant error occurred. This date may be earlier than or the same as the CAA(s)
completion date, but not later than the CAA(s) completion date.

•

The CAA(s) completion date (item V0200B2) must be no later than 14 days after the
ARD (ARD + 14 calendar days) and no more than 14 days after the determination was
made that a significant error occurred. This date may be the same as the MDS completion
date, but not earlier than the MDS completion date.

•

The care plan completion date (item V0200C2) must be no later than 7 calendar days
after the CAA(s) completion date (item V0200B2) (CAA(s) completion date + 7 calendar
days).

•

October 2024

Page 2-32

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Non-Comprehensive Assessments and Entry and Discharge
Reporting
OBRA-required non-comprehensive MDS assessments include a select number of MDS items,
but not completion of the CAA process and care planning. The OBRA non-comprehensive
assessments include:
•

Quarterly Assessment

•

Significant Correction to Prior Quarterly Assessment

•

Discharge Assessment – Return not Anticipated

•

Discharge Assessment – Return Anticipated

The Quarterly assessments, OBRA Discharge assessments and SCQAs are not required for
Swing Bed residents. However, Swing Bed providers are required to complete the Swing Bed
Discharge item set (SD).

Tracking records include a select number of MDS items and are required for all residents in the
nursing home and swing bed facility. They include:
• Entry Tracking Record
• Death in Facility Tracking Record
Assessment Management Requirements and Tips for Non-Comprehensive Assessments:
•

For example:

•

The ARD is considered the last day of the observation/look-back period, therefore it is
day 1 for purposes of counting back to determine the beginning of observation/lookback periods. For example, if the ARD is set for March 14, then the beginning of the
observation period for MDS items requiring a 7-day observation period would be
March 8 (ARD + 6 previous calendar days), while the beginning of the observation
period for MDS items requiring a 14-day observation period would be March 1 (ARD +
13 previous calendar days).
If a resident goes to the hospital (discharge return anticipated and returns within 30 days)
and returns during the assessment period and most of the assessment was completed prior
to the hospitalization, then the nursing home may wish to continue with the original
assessment, provided the resident does not meet the criteria for an SCSA.
— Resident A has a Quarterly assessment with an ARD of March 20th. The facility staff
finished most of the assessment. The resident is discharged (return anticipated) to the
hospital on March 23rd and returns on March 25th. Review of the information from
the discharging hospital reveals that there is not any significant change in status for
the resident. Therefore, the facility staff continues with the assessment that was not
fully completed before discharge and may complete the assessment by April 3rd
(which is day 14 after the ARD).
— Resident B also has a Quarterly assessment with an ARD of March 20th. They go to
the hospital on March 20th and returns March 30th. While there is no significant

October 2024

Page 2-33

CMS’s RAI Version 3.0 Manual

•
•

CH 2: Assessments for the RAI

•

In the process of completing any assessment except an Admission, if it is identified that a
non-significant (minor) error occurred in a previous assessment, continue with
completion of the assessment in progress and also submit a correction request for the
erroneous assessment as per the instructions in Chapter 5.

•

The ARD of an assessment drives the due date of the next assessment. The next noncomprehensive assessment is due within 92 days after the ARD of the most recent OBRA
assessment (ARD of previous OBRA assessment - Admission, Annual, Quarterly,
Significant Change in Status, or Significant Correction assessment - + 92 calendar days).

•

While the CAA process is not required with a non-comprehensive assessment (Quarterly,
SCQA), nursing homes are still required to review the information from these
assessments, and review and revise the resident’s care plan.

•

The MDS must be transmitted (submitted and accepted into iQIES) electronically no later
than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days).

•

Non-comprehensive assessments may be combined with a 5-Day assessment or SNF Part
A PPS Discharge Assessment (see Sections 2.10 and 2.11 for details).

change the facility decides to start a new assessment and sets the ARD for April 2nd
and completes the assessment.
If a resident is discharged during this assessment process, then whatever portions of the
RAI that have been completed must be maintained in the resident’s discharge record. 6 In
closing the record, the nursing home should note why the RAI was not completed.
If a resident dies during this assessment process, completion of the assessment is not
required. Whatever portions of the RAI that have been completed must be maintained in
the resident’s medical record.6 When closing the record, the nursing home should
document why the RAI was not completed.
If a significant change in status is identified in the process of completing any assessment
except Admission and SCSAs, code and complete the assessment as a comprehensive
SCSA instead.
In the process of completing any assessment except an Admission and an SCPA, if it is
identified that a significant error occurred in a previous comprehensive assessment that
has already been submitted and accepted into iQIES and has not already been corrected in
a subsequent comprehensive assessment, code and complete the assessment as a
comprehensive SCPA instead. A correction request for the erroneous comprehensive
assessment should also be completed and submitted. See the section on SCPAs for
detailed information on completing an SCPA, and Chapter 5 for detailed information on
processing corrections.

The RAI is considered part of the resident’s clinical record and is treated as such by the RAI Utilization
Guidelines, e.g., portions of the RAI that are “started” must be saved.

October 2024

Page 2-34

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

05. Quarterly Assessment (A0310A = 02)
The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that must be
completed at least every 92 days following the previous OBRA assessment of any type. It is used
to track a resident’s status between comprehensive assessments to ensure critical indicators of
gradual change in a resident’s status are monitored. As such, not all MDS items appear on the
Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the
most recent OBRA assessment of any type.
Assessment Management Requirements and Tips:
•

Federal requirements dictate that, at a minimum, three Quarterly assessments be
completed in each 12-month period. Assuming the resident does not have an SCSA or
SCPA completed and was not discharged from the nursing home, a typical 12-month
OBRA schedule would look like this:

•

OBRA assessments may be scheduled early if a nursing home wants to stagger due dates
for assessments. As a result, more than three OBRA Quarterly assessments may be
completed on a particular resident in a given year, or the Annual assessment may be
completed early to ensure that the regulatory time frames are met. However, States may
have more stringent restrictions.

•

The ARD must be within 92 days after the ARD of the previous OBRA assessment
(Quarterly, Admission, SCSA, SCPA, SCQA, or Annual assessment + 92 calendar days).

•

The MDS completion date (item Z0500B) must be no later than 14 days after the ARD
(ARD + 14 calendar days).

October 2024

Page 2-35

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

06. Significant Correction to Prior Quarterly Assessment (SCQA) (A0310A = 06)
The SCQA is an OBRA non-comprehensive assessment that must be completed when the IDT
determines that a resident’s prior Quarterly assessment contains a significant error. It can be
performed at any time after the completion of a Quarterly assessment, and the ARD (item
A2300) and completion dates (item Z0500B) depend on the date the determination was made that
there is a significant error in a previous Quarterly assessment.
A “significant error” is an error in an assessment where:
1. The resident’s overall clinical status is not accurately represented (i.e., miscoded) on
the erroneous assessment; and
2. The error has not been corrected via submission of a more recent assessment.

A significant error differs from a significant change because it reflects incorrect coding of
the MDS and NOT an actual significant change in the resident’s health status.

Assessment Management Requirements and Tips:
Nursing homes should document the initial identification of a significant error in an
assessment in the clinical record.

•

An SCQA is appropriate when:

•

— the erroneous Quarterly assessment has been completed (MDS completion date, item
Z0500B) and transmitted/submitted into iQIES; and
— there is not a more current assessment in progress or completed that includes a
correction to the item(s) in error.
•

The ARD must be less than or equal to 14 days after the determination that a significant
error in the prior Quarterly has occurred (determination date + 14 calendar days). The
MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD
+ 14 calendar days) and no later than 14 days after determining that the significant error
occurred.

Tracking Records and Discharge Assessments (A0310F)

OBRA-required tracking records and assessments consist of the Entry tracking record, the
Discharge assessments, and the Death in Facility tracking record. These include the completion
of a select number of MDS items in order to track residents when they enter or leave a facility.
They do not include completion of the CAA process and care planning. The Discharge
assessments include items for quality monitoring. Entry and discharge reporting is required for
residents in Swing Beds or those in respite care.

If the resident has one or more admissions to the hospital before the Admission assessment is
completed, the nursing home should continue to submit OBRA Discharge assessments and Entry
tracking records every time until the resident is in the nursing home long enough to complete the
comprehensive Admission assessment.
October 2024

Page 2-36

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

OBRA-required Tracking Records and Discharge Assessments include the following types (item
A0310F):
07. Entry Tracking Record (Item A0310F = 01)
There are two types of entries – admission and reentry.
Admission (Item A1700 = 1)
•

Entry tracking record is coded an Admission every time a resident:
— is admitted for the first time to this facility; or
— is readmitted after a discharge return not anticipated; or

— is readmitted after a discharge return anticipated when return was not within 30 days
of discharge.

Example (Admission):

1. Resident S. was admitted to the nursing home on February 5, 2011 following a stroke. They
regained most of their function and returned to their home on March 29, 2011. They were
discharged return not anticipated. Five months later, Resident S. underwent surgery for a total
knee replacement. They returned to the nursing home for rehabilitation therapy on August 27,
2011. Code the Entry tracking record for the August 27, 2011 return as follows:
A0310F = 01
A1600 = 08-27-2011
A1700 = 1

Reentry (Item A1700 = 2)
•

Entry tracking record is coded Reentry every time a person:

Example (Reentry):

— is readmitted to this facility, and was discharged return anticipated from this facility,
and returned within 30 days of discharge. See Section 2.5, Reentry, for greater detail.

1. Resident W. was admitted to the nursing home on April 11, 2011. Four weeks later they
became very short of breath during lunch. The nurse assessed them and noted their lung
sounds were not clear. Their breathing became very labored. They were discharged return
anticipated and admitted to the hospital on May 9, 2011. On May 18, 2011, Resident W.
returned to the facility. Code the Entry tracking record for the May 18, 2011 return, as
follows:
A0310F = 01
A1600 = 05-18-2011
A1700 = 2

October 2024

Page 2-37

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Assessment Management Requirements and Tips for Entry Tracking Records:
The Entry tracking record is the first item set completed for all residents.

•

Must be completed every time a resident is admitted (admission) or readmitted (reentry)
into a nursing home (or swing bed facility), including upon return if a resident in a
Medicare Part A stay is discharged from the facility and does not resume Part A within
the same facility within the 3-day interruption window (see Interrupted Stay in Section
2.5, Assessment Types and Definitions above).

•

Must be completed for a respite resident every time the resident enters the facility.

•

Must be completed within 7 days after the admission/reentry.

•

Must be submitted no later than the 14th calendar day after the entry (entry date (A1600)
+ 14 calendar days).

•

Required in addition to the initial Admission assessment or other OBRA or PPS
assessments that might be required.
Contains administrative and demographic information.
Is a standalone tracking record.

•

•
•
•

May not be combined with an assessment.

•
•
•
•
•

08. Death in Facility Tracking Record (A0310F = 12)

Must be completed when the resident dies in the facility or when on LOA.
Must be completed within 7 days after the resident’s death, which is recorded in item
A2000, Discharge Date (A2000 + 7 calendar days).
Must be submitted within 14 days after the resident’s death, which is recorded in item
A2000, Discharge Date (A2000 + 14 calendar days).
Consists of demographic and administrative items.
May not be combined with any type of assessment.

Example (Death in Facility):

1. Resident W. was admitted to the nursing home for hospice care due to a terminal illness on
September 9, 2011. They passed away on November 13, 2011. Code the November 13, 2011
Death in Facility tracking record as follows:
A0310F = 12
A2000 = 11-13-2011
A2105 = 13

OBRA Discharge Assessments (A0310F)
OBRA Discharge assessments consist of discharge return anticipated and discharge return not
anticipated.

October 2024

Page 2-38

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

09. Discharge Assessment–Return Not Anticipated (A0310F = 10)
•
•
•
•
•

Must be completed when the resident is discharged from the facility and the resident is
not expected to return to the facility within 30 days.
Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14
calendar days).
Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar
days).
Consists of demographic, administrative, and clinical items.
If the resident returns, the Entry tracking record will be coded A1700 = 1, Admission.
The OBRA schedule for assessments will start with a new Admission assessment. If the
resident’s stay will be covered by Medicare Part A, the provider must determine whether
the interrupted stay policy applies. Refer to Section 2.9 for instructions on the PPS
assessments.

Examples (Discharge-return not anticipated):
1. Resident S. was admitted to the nursing home on February 5, 2011 following a stroke. They
regained most of their function and were discharged return not anticipated to their home on
March 29, 2011. Code the March 29, 2011 OBRA Discharge assessment as follows:

A0310F = 10
A2000 = 03-29-2011
A2105 = 01

2. Resident K. was transferred from a Medicare-certified bed to a non-certified bed on
December 12, 2013 and plans to remain long term in the facility. Code the December 12,
2013 Discharge assessment as follows:

A0310F = 10
A2000 = 12-12-2013
A2105 = 02

10. OBRA Discharge Assessment–Return Anticipated (A0310F = 11)
•

Must be completed when the resident is discharged from the facility and the resident is
expected to return to the facility within 30 days.

•

For a resident discharged to a hospital or other setting (such as a respite resident) who
comes in and out of the facility on a relatively frequent basis and reentry can be expected,
the resident is discharged return anticipated unless it is known on discharge that they will
not return within 30 days. This status requires an Entry tracking record each time the
resident returns to the facility and an OBRA Discharge assessment each time the resident
is discharged.

•

Must be completed (item Z0500B) within 14 days after the discharge date (item A2000)
(i.e., discharge date (A2000) + 14 calendar days).

October 2024

Page 2-39

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

•

Must be submitted within 14 days after the MDS completion date (item Z0500B) (i.e.,
MDS completion date (Z0500B) + 14 calendar days).

•

Consists of demographic, administrative, and clinical items.

•

When the resident returns to the nursing home, the IDT must determine if criteria are met
for an SCSA (only when the OBRA Admission assessment was completed prior to
discharge).
— If criteria are met, complete an SCSA.
— If criteria are not met, continue with the OBRA schedule as established prior to the
resident’s discharge.
If an interrupted stay occurs, an SCSA should be completed if clinically indicated.

•

If an SCSA is not indicated and an OBRA assessment was due while the resident was in
the hospital, the facility has 13 days after reentry to complete the assessment (this does
not apply to Admission assessment).

•

When a resident had a prior OBRA Discharge assessment completed indicating that the
resident was expected to return (A0310F = 11) to the facility, but later learned that the
resident will not be returning to the facility, there is no Federal requirement to inactivate
the resident's record nor to complete another OBRA Discharge assessment. Please contact
your State RAI Coordinator for specific State requirements.

Example (Discharge-return anticipated):

1. Resident C. was admitted to the nursing home on May 22, 2011. They tripped while at a
restaurant with their child. They were discharged return anticipated and admitted to the
hospital on May 31, 2011. Code the May 31, 2011 OBRA Discharge assessment as follows:
A0310F = 11
A2000 = 05-31-2011
A2105 = 04

Assessment Management Requirements and Tips for OBRA Discharge
Assessments:
•
•
•
•
•
•

Must be completed when the resident is discharged from the facility (see definition of
Discharge in Section 2.5, Assessment Types and Definitions).
Must be completed when the resident is admitted to an acute care hospital.
Must be completed when the resident has a hospital observation stay greater than 24 hours.
Must be completed if a resident in a Medicare Part A stay is discharged from the facility
regardless of whether the resident resumes Part A within the 3-day interruption window
(see Interrupted Stay, Section 2.5, Assessment Types and Definitions above).
Must be completed on a respite resident every time the resident is discharged from the
facility.
May be combined with another OBRA-required assessment when requirements for all
assessments are met.

October 2024

Page 2-40

CMS’s RAI Version 3.0 Manual

•
•

•

May be combined with any OBRA or 5-Day and must be combined with a Part A PPS
Discharge if the Medicare Part A stay ends on the day of, or one day before, the resident’s
Discharge Date (A2000).
For an OBRA Discharge assessment, the ARD (item A2300) is not set prospectively as
with other assessments. The ARD (item A2300) for an OBRA Discharge assessment is
always equal to the Discharge date (item A2000) and may be coded on the assessment
any time during the OBRA Discharge assessment completion period (i.e., Discharge date
(A2000) + 14 calendar days).
The use of the dash, “-”, is appropriate when the staff are unable to determine the
response to an item, including the interview items. In some cases, the facility may have
already completed some items of the assessment and should record those responses or
may be in the process of completing an assessment. The facility may combine the OBRA
Discharge assessment with another assessment(s) when requirements for all assessments
are met.
For unplanned discharges, the facility should complete the OBRA Discharge
assessment to the best of its abilities.
— An unplanned discharge includes, for example:
○ Acute-care transfer of the resident to a hospital or an emergency department in
order to either stabilize a condition or determine if an acute-care admission is
required based on emergency department evaluation; or
○ Resident unexpectedly leaving the facility against medical advice; or
○ Resident unexpectedly deciding to go home or to another setting (e.g., due to the
resident deciding to complete treatment in an alternate setting).
Nursing home bed hold status and opening and closing of the medical record have no
effect on these requirements.

•

CH 2: Assessments for the RAI

The following chart details the sequencing and coding of Tracking records and OBRA Discharge
assessments.

ft
October 2024

Page 2-41

CH 2: Assessments for the RAI

Page 2-42

CMS՚s RAI Version 3.0 Manual

October 2024

Entry, OBRA Discharge, and Reentry Algorithms

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

2.7 The Care Area Assessment (CAA) Process and Care
Plan Completion
Federal statute and regulations require nursing homes to conduct initial and periodic assessments
for all their residents. The assessment information is used to develop, review, and revise the
resident’s plans of care that will be used to provide services to attain or maintain the resident’s
highest practicable physical, mental, and psychosocial well-being.

The RAI process, which includes the Federally mandated MDS, is the basis for an accurate
assessment of nursing home residents. The MDS information and the CAA process provide the
foundation upon which the care plan is formulated. There are 20 problem-oriented CAAs, each
of which includes MDS-based “trigger” conditions that signal the need for additional assessment
and review of the triggered care area. Detailed information regarding each care area and the CAA
process, including definitions and triggers, appear in Chapter 4 of this manual. Chapter 4 also
contains detailed information on care planning development utilizing the RAI and CAA process.

CAA(s) Completion

Is required for OBRA-required comprehensive assessments. They are not required for
non-comprehensive assessments, PPS assessments, Discharge assessments, or Tracking
records.

•

After completing the MDS portion of the comprehensive assessment, the next step is to
further identify and evaluate the resident’s strengths, problems, and needs through use of
the CAA process (described in detail in Chapter 3, Section V, and Chapter 4 of this
manual) and through further investigation of any resident-specific issues not addressed in
the RAI/CAA process.

•

The CAA(s) completion date (item V0200B2) must be either later than or the same date
as the MDS completion date (item Z0500B). In no event should either date be later than
the established time frames as described in Section 2.6.

•

It is important to note that for an Admission assessment, the resident enters the nursing
home with a set of physician-based treatment orders. Nursing home staff should review
these orders and begin to assess the resident and to identify potential care issues/
problems. Within 48 hours of admission to the facility, the facility must develop and
implement a Baseline Care Plan for the resident that includes the instructions needed to
provide effective and person-centered care of the resident that meets professional
standards of care (42 CFR §483.21(a)). In many cases, interventions to meet the
resident’s needs will already have been implemented to address priority issues prior to
completion of the final care plan. At this time, many of the resident’s problems in the 20
care areas will have been identified, causes will have been considered, and a baseline care
plan initiated. However, a final CAA(s) review and associated documentation are still
required no later than the 14th calendar day of admission (admission date plus 13 calendar
days).

•

Detailed information regarding each CAA and the CAA process appears in Chapter 4 of
this manual.

•

October 2024

Page 2-43

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Care Plan Completion
Care plan completion based on the CAA process is required for OBRA-required
comprehensive assessments. It is not required for non-comprehensive assessments
(Quarterly, SCQA), PPS assessments, Discharge assessments, or Tracking records.
However, the resident’s care plan must be reviewed after each assessment, as required by
§483.20, except discharge assessments, and revised based on changing goals, preferences
and needs of the resident and in response to current interventions.

•

After completing the MDS and CAA portions of the comprehensive assessment, the next
step is to evaluate the information gained through both assessment processes in order to
identify problems, causes, contributing factors, and risk factors related to the problems.
Subsequently, the IDT must evaluate the information gained to develop a care plan that
addresses those findings in the context of the resident’s goals, preferences, strengths,
problems, and needs (described in detail in Chapter 4 of this manual).

•

The care plan completion date (item V0200C2) must be either later than or the same date
as the CAA completion date (item V0200B2), but no later than 7 calendar days after the
CAA completion date. The MDS completion date (item Z0500B) must be earlier than or
the same date as the care plan completion date. In no event should either date be later
than the established time frames as described in Section 2.6.

•

For Annual assessments, SCSAs, and SCPAs, the process is basically the same as that
described with an Admission assessment. In these cases, however, the care plan will
already be in place. Review of the CAA(s) when the MDS is complete for these
assessment types should raise questions about the need to modify or continue services
and result in either the continuance or revision of the existing care plan. A new care plan
does not need to be developed after each Annual assessment, SCSA, or SCPA.

•

Residents’ preferences and goals may change throughout their stay, so facilities should
have ongoing discussions with the resident and resident representative, if applicable, so
that changes can be reflected in the comprehensive care plan.

•

Detailed information regarding the care planning process appears in Chapter 4 of this
manual.

•

2.8 Skilled Nursing Facility Prospective Payment System
Assessment Schedule

SNFs must assess the clinical condition of beneficiaries by completing the MDS assessment for
each Medicare resident receiving Part A SNF-level care for reimbursement under the SNF PPS.
In addition to the PPS assessments, the SNF must also complete the OBRA assessments. All
requirements for the OBRA assessments apply to the PPS assessments, such as completion and
submission time frames.

Assessment Window
The PPS 5-Day assessment has defined days within which the Assessment Reference Date
(ARD) must be set. The ARD must be a day within the prescribed window of Days 1 through 8

October 2024

Page 2-44

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

of the Part A stay and must be set on the MDS form itself or in the facility software before this
window has passed.
The first day of Medicare Part A coverage for the current stay is considered day 1 for PPS
assessment scheduling purposes and for purposes of the variable per diem adjustment, as
discussed in Chapter 6, Section 6.7. In most cases, the first day of Medicare Part A coverage is
the date of admission. However, there are situations in which the Medicare beneficiary may
qualify for Part A services at a later date. See Chapter 6, Section 6.7, for more detailed
information.

Scheduled PPS Assessment
The PPS-required standard assessment is the 5-Day assessment, which has a predetermined time
period for setting the ARD. The SNF provider must set the ARD on days 1–8 to assure
compliance with the SNF PPS PDPM requirements.

D
Unscheduled PPS Assessments

There are situations when a SNF provider may complete an assessment after the 5-Day
assessment. This assessment is an unscheduled assessment called the Interim Payment
Assessment (IPA). When deemed appropriate by the provider, this assessment may be completed
to capture changes in the resident’s status and condition.

Tracking Records and Discharge Assessments Reporting
Tracking records and Discharge assessments reporting are required on all residents in the SNF
and swing bed facilities. Tracking records and standalone Discharge assessments do not impact
payment.
Part A PPS Discharge Assessment (A0310H)

•

The Part A PPS Discharge assessment contains data elements used to calculate current and future
SNF QRP quality measures under the IMPACT Act. The IMPACT Act directs the Secretary to
specify quality measures on which Post-Acute Care (PAC) providers (which includes SNFs) are
required to submit standardized resident assessment data. Section 1899B(2)(b)(1)(A)(B) of the
Act delineates that resident assessment data must be submitted with respect to a resident’s
admission into and discharge from a SNF setting.
Per current requirements, the OBRA Discharge assessment is used when the resident is
physically discharged from the facility. The Part A PPS Discharge assessment is
completed when a resident’s Medicare Part A stay ends, but the resident remains in
the facility (unless it is an instance of an interrupted stay). Item A0310H, “Is this a
Part A PPS Discharge Assessment?” identifies whether or not the discharge is a Part A
PPS Discharge assessment for the purposes of the SNF QRP (see Chapter 3, Section A
for further details and coding instructions). The Part A PPS Discharge assessment must
also be combined with the OBRA Discharge assessment when a resident receiving
services under SNF Part A PPS has a Discharge Date (A2000) that occurs on the day of
or one day after the End Date of Most Recent Medicare Stay (A2400C), because in this
instance, both the OBRA and Part A PPS Discharge assessments would be required. In

October 2024

Page 2-45

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

situations in which the OBRA and Part A PPS Discharge assessments are combined, the
ARD (A2300) equals the day of discharge as listed in A2000.
Part A PPS Discharge Assessment (A0310H = 1):
•

•

For the Part A PPS Discharge assessment, the ARD (item A2300) is not set prospectively
as with other assessments. The ARD (A2300) for a standalone Part A PPS Discharge
assessment is always equal to the End Date of the Most Recent Medicare Stay (A2400C).
The ARD may be coded on the assessment any time during the assessment completion
period (i.e., End Date of Most Recent Medicare Stay (A2400C) + 14 calendar days).
If the End Date of the Most Recent Medicare Stay (A2400C) occurs on the day of or
one day before the Discharge Date (A2000), the OBRA Discharge assessment and Part
A PPS Discharge assessment are both required and must be combined. When the OBRA
and Part A PPS Discharge assessments are combined, the ARD (A2300) must be equal to
the Discharge Date (A2000). The Part A PPS Discharge assessment may be combined
with most OBRA-required assessments when requirements for all assessments are met
(please see Section 2.10 Combining PPS Assessments and OBRA Assessments).

•
•

•

If the resident’s Medicare Part A stay ends and the resident is physically discharged from
the facility, an OBRA Discharge assessment is required.
The Part A PPS Discharge assessment must be completed (item Z0500B) within 14 days
after the End Date of Most Recent Medicare Stay (A2400C + 14 calendar days).
The Part A PPS Discharge assessment must be submitted within 14 days after the MDS
completion date (Z0500B + 14 calendar days).
Consists of demographic, administrative, and clinical items.
If the resident’s Medicare Part A stay ends and the resident subsequently returns to a
skilled level of care and Medicare Part A benefits do not resume within 3 days, the PPS
schedule starts again with a 5-Day assessment. If the Medicare Part A stay does resume
within the 3-day interruption window, then this is an interrupted stay (see below).
If the resident leaves the facility for an interrupted stay, no Part A PPS Discharge
Assessment is required when the resident leaves the building at the outset of the
interrupted stay; however, an OBRA Discharge record is required if the discharge criteria
are met (see Section 2.5). If the resident returns to the facility within the interruption
window, as defined above, an Entry tracking form is required; however, no new 5-Day
assessment is required.

The following chart summarizes the PPS assessments, tracking records, and discharge
assessments:

October 2024

Page 2-46

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

PPS Assessments, Tracking Records, and Discharge
Assessment Reporting Schedule for SNFs and Swing Bed Facilities
Assessment Type/
Item Set for PPS
5-Day
A0310B = 01

Interim Payment Assessment
(IPA)
A0310B = 08

Billing Cycle
Used by the
Business
Office

Days 1-8

Sets payment
rate for the
entire stay
(unless an IPA
is completed.
See below.)

• See Section 2.12 for instructions
involving beneficiaries who transfer
or expire day 8 or earlier.
• CAAs must be completed only if the
5-Day assessment is dually coded as
an OBRA Admission, Annual, SCSA
or SCPA.

Optional

Sets payment
for remainder
of the stay
beginning on
the ARD.

• Optional assessment.
• Does not reset variable per diem
adjustment schedule.
• May not be combined with another
assessment.

N/A

• Completed when the resident’s
Medicare Part A stay ends, but the
resident remains in the facility, or is
combined with an OBRA Discharge
assessment if the Part A stay ends on
the same day or the day before the
resident’s Discharge Date (A2000).

Assessment Reference
Date (ARD) Can be
Set on Any of
Following Days

Part A PPS Discharge Assessment
A0310H = 1

End date of most
recent Medicare Stay
(A2400C)

Special Comment

2.9 MDS PPS Assessments for SNFs

The MDS has been constructed to identify the OBRA Reasons for Assessment and the SNF PPS
Reasons for Assessment in items A0310A and A0310B respectively. If the assessment is being
used for reimbursement under the SNF PPS, the PPS Reason for Assessment must be coded in
item A0310B. The OBRA Reason for Assessment is described earlier in this section while the
PPS assessments are described below. A SNF provider may combine assessments to meet both
OBRA and PPS requirements. When combining assessments, all completion deadlines and other
requirements for both types of assessments must be met. If all requirements cannot be met, the
assessments must be completed separately. The relationship between OBRA and PPS
assessments is discussed below and in more detail in Sections 2.10 and 2.11.

PPS Assessments for a Medicare Part A Stay
01. 5-Day Assessment
•
•
•
•
•

ARD (item A2300) must be set for Days 1 through 8 of the Part A SNF covered stay.
Must be completed (item Z0500B) within 14 days after the ARD (ARD + 14 days).
Authorizes payment for entire PPS stay (except in cases when an IPA is completed).
Must be submitted electronically and accepted into iQIES within 14 days after
completion (item Z0500B) (completion + 14 days).
If combined with the OBRA Admission assessment, the assessment must be completed
by the end of day 14 of admission (admission date plus 13 calendar days).

October 2024

Page 2-47

CMS’s RAI Version 3.0 Manual

•
•
•
•

CH 2: Assessments for the RAI

Is the first PPS-required assessment to be completed when the resident is first admitted
for a SNF Part A stay.
Is the first PPS-required assessment to be completed when the resident is re-admitted to
the facility for a Part A stay following a discharge assessment – return not anticipated or
if the resident returns more than 30 days after a discharge assessment-return anticipated.
A 5-Day assessment is not required at the time when a resident returns to a Part Acovered stay following an interrupted stay, regardless of the reason for the interruption
(facility discharge, resident no longer skilled, payer change, etc.).
If a resident changes payers from Medicare Advantage to Medicare Part A, the SNF must
complete a 5-Day assessment with the ARD set for one of days 1 through 8 of the
Medicare Part A stay, with the resident’s first day covered by Medicare Part A serving as
Day 1, unless it is a case of an interrupted stay.

02. Interim Payment Assessment
•
•

•
•

•
•
•

Optional assessment.
ARD (item A2300) may be set for any day of the SNF PPS stay, beyond the ARD of the
5-Day assessment.
Must be completed (item Z0500B) within 14 days after the ARD (ARD + 14 days).
Authorizes payment for remainder of the PPS stay, beginning on the ARD.
Must be submitted electronically and accepted into iQIES within 14 days after
completion (item Z0500B) (completion + 14 days).
The ARD for an IPA may not precede that of the 5-Day assessment.
May not be combined with any other assessments (PPS or OBRA).

03. Part A PPS Discharge Assessment
•

See definition provided in Section 2.8, Part A PPS Discharge Assessment (A0310H = 1).

2.10 Combining PPS Assessments and OBRA Assessments 7
SNF providers are required to meet two assessment standards in a Medicare certified nursing
facility:
•
•
•

The OBRA standards are designated by the reason selected in item A0310A, Federal
OBRA Reason for Assessment, and item A0130F, Entry/Discharge Reporting and are
required for all residents.
The PPS standards are designated by the reason selected in item A0310B, PPS
Assessment and item A0310H, Is this a SNF Part A PPS Discharge Assessment?
When the OBRA and PPS assessment time frames coincide (except the IPA), one
assessment may be used to satisfy both requirements. PPS and OBRA assessments (except

OBRA assessments do not apply to Swing Bed providers; however, Swing Bed providers are required to
complete the Entry Tracking record, Swing Bed PPS (SP), Swing Bed Discharge (SD) assessment, and Death in
Facility Tracking record.

October 2024

Page 2-48

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

the IPA) may be combined when the ARD windows overlap allowing for a common
assessment reference date. When combining the OBRA and PPS assessments, the most
stringent requirements for ARD, item set, and CAA completion requirements must be met.
For example, the skilled nursing facility staff must be very careful in selecting the ARD for
an OBRA Admission assessment combined with a 5-Day assessment. For the OBRA
Admission, the ARD must be set between days 1 and 14 counting the date of admission as
day 1. For the 5-Day, the ARD must be set for days 1 through 8. However, when
combining a 5-Day assessment with the OBRA Admission assessment, the use of the latter
end of the OBRA Admission ARD window would cause the 5-Day assessment to be
considered late. To assure the assessment meets both standards, an ARD of a day between
Day 1 and 8 would have to be chosen in this situation. In addition, the completion
standards must be met. While a PPS assessment can be completed within 14 days after the
ARD when it is not combined with an OBRA assessment, the CAA completion date for the
OBRA Admission assessment (item V0200B2) must be day 14 or earlier. With the
combined OBRA Admission/ 5-Day assessment, completion by day 14 would be required.
Finally, when combining a PPS assessment with an OBRA assessment, the SNF staff must
ensure that all required items are completed.

Some states require providers to complete additional state-specific items (Section S) for selected
assessments. States may also add comprehensive items to the Quarterly and/or PPS item sets.
Providers must ensure that they follow their state requirements in addition to any OBRA and/or
PPS requirements.

The following tables provide the item set for each type of assessment or tracking record. When
two or more assessments are combined, then the appropriate item set contains all items that
would be necessary if each of the combined assessments were being completed individually.
Item Sets by Assessment Type for Skilled Nursing Facilities
Comprehensive
Item Sets

•
•
•
•

Combined
Assessment
Types

•
•
•
•
•

OBRA Admission
Annual
Significant Change in
Status (SCSA)
Significant Correction to
Prior Comprehensive
(SCPA)

•
•

OBRA Admission and
5-Day
Annual and 5-Day
SCSA and 5-Day
SCPA and 5-Day
Any OBRA
comprehensive and any
Discharge

•
•

•

Quarterly
Significant Correction to Prior
Quarterly
5-Day

Other Assessments and Tracking
Records/Item Sets
•
•
•
•
•

•
•

Entry Tracking Record
OBRA Discharge assessments
Death in Facility Tracking
Record
Part A PPS Discharge
Interim Payment Assessment
(IPA)

Standalone
Assessment
Types

Quarterly and PPS*
Item Sets

Quarterly and 5-Day
Significant Correction to Prior
Quarterly and 5-Day
5-Day and any Discharge
Significant Correction to Prior
Quarterly and any Discharge

•

OBRA Discharge assessment
and Part A PPS Discharge
Assessment

*Nursing home-based SNFs must check with their State Agency to determine if the state requires additional items to be
completed for the required OBRA Quarterly and PPS assessments.

October 2024

Page 2-49

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

Item Sets by Assessment Type for Swing Bed Providers
Other Assessments/Tracking Item Sets for
Swing Bed Providers

Swing Bed PPS/Item Set
Assessment Type

•

(SP) Swing Bed PPS assessment

•
•
•
•

Entry Tracking record
Death in Facility Tracking record
(SD) Swing Bed Discharge
Interim Payment Assessment (IPA)

Assessment Type
Combinations

•

(SP) Swing Bed PPS assessment and (SD)
Swing Bed Discharge

•

N/A

Tracking records (Entry and Death in Facility) and the Interim Payment Assessment can never be
combined with other assessments.

2.11 PPS and OBRA Assessment Combinations
Below are some of the allowed possible assessment combinations. A provider may choose to
combine more than two assessment types when all requirements are met. The coding of items in
A0310 will provide the item set that the facility is required to complete. For SNFs that use a
paper format to collect MDS data, the provider must ensure that the item set selected meets the
requirements of all assessments coded in item A0310 (see Section 2.14).

5-Day Assessment and OBRA Admission Assessment
•

Comprehensive item set.

•

ARD (item A2300) must be set for days 1 through 8 of the Part A SNF stay.

•

Must be completed (item Z0500B) by the end of day 14 of the stay (admission date plus
13 calendar days).

•

See Section 2.7 and Chapter 4 for requirements for CAA process and care plan
completion.

5-Day Assessment and OBRA Quarterly Assessment
•

Quarterly item set.

•

ARD (item A2300) must be set for days 1 through 8 of the Part A SNF stay.

•

See Section 2.6 for OBRA Quarterly assessment completion requirements.

5-Day Assessment and Annual Assessment
•

Comprehensive item set.

•

ARD (item A2300) must be set for days 1 through 8 of the Part A SNF stay.

•

See Section 2.6 for OBRA Annual assessment completion requirements.

•

See Section 2.7 and Chapter 4 for requirements for CAA process and care plan
completion.

October 2024

Page 2-50

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

5-Day Assessment and Significant Change in Status Assessment
•

Comprehensive item set.

•

ARD (item A2300) must be set for days 1 through 8 of the Part A SNF stay.

•

Must be completed (item Z0500B) within 14 days after the determination that the criteria
are met for a Significant Change in Status assessment.

•

See Section 2.7 and Chapter 4 for requirements for CAA process and care plan
completion.

5-Day Assessment and Significant Correction to Prior Comprehensive
Assessment
•

Comprehensive item set.

•

ARD (item A2300) must be set for days 1 through 8 of the Part A SNF stay.

D
•

Must be completed (item Z0500B) within 14 days after the determination that an
uncorrected significant error in the prior comprehensive assessment has occurred.

•

See Section 2.7 and Chapter 4 for requirements for CAA process and care plan
completion.

5-Day Assessment and Significant Correction to Prior Quarterly Assessment

•

See 5-Day assessment and OBRA Quarterly Assessment.

5-Day Assessment and OBRA Discharge Assessment
•

PPS item set.

•

ARD (item A2300) must be set for the day of discharge (item A2000) and the date of
discharge must fall within the allowed window of the 5-Day as described earlier in
Section 2.9.

•

Must be completed (item Z0500B) within 14 days after the ARD.

5-Day Assessment and Part A PPS Discharge Assessment
•

PPS item set.

•

ARD (item A2300) must be set for the last day of the Medicare Part A Stay (A2400C)
and the last day of the Medicare Part A stay must fall within the allowed window of the
5-Day assessment as described earlier in Section 2.9.

•

Must be completed (item Z0500B) within 14 days after the ARD.

October 2024

Page 2-51

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

2.12 Factors Impacting SNF PPS Assessment Scheduling

Resident Expires Before or On the Eighth Day of SNF Stay
If the beneficiary dies in the SNF or while on a leave of absence before or on the eighth day of
the covered SNF stay, the provider should prepare a 5-Day assessment as completely as possible
and submit the assessment as required. If there is not a PPS assessment in iQIES, the provider
must bill the default rate for any Medicare days. The provider must also complete a Death in
Facility Tracking Record (see Section 2.6 for greater detail).
Resident Transfers or Is Discharged Before or On the Eighth Day of SNF Stay

If the beneficiary is discharged from the SNF or the Medicare Part A stay ends (e.g., transferred
to another payer source) before or on the eighth day of the covered SNF stay, the provider should
prepare a 5-Day assessment as completely as possible and submit the assessment as required. If
there is not a PPS assessment in iQIES, the provider must bill the default rate for any Medicare
days.
When the Medicare Part A stay ends on or before the eighth day of the covered SNF stay, and
the beneficiary remains in the facility, a Part A PPS Discharge assessment is required.

When the beneficiary is discharged from the SNF, the provider must also complete an OBRA
Discharge assessment, but if the Medicare Part A stay ends on or before the eighth day of the
covered SNF stay and the beneficiary is physically discharged from the facility the day of or the
day after the Part A stay ends, the Part A PPS and OBRA Discharge assessments must be
combined. (See Sections 2.10 and 2.11 for details on combining a PPS assessment with a
Discharge assessment.)

Resident Is Admitted to an Acute Care Facility and Returns

If a Medicare Part A resident is admitted to an acute care facility and later returns to the SNF to
resume Part A coverage, the resident requires a new 5-Day assessment, unless it is an instance of
an interrupted stay. If it is a case of an interrupted stay (i.e., the resident returns to the SNF and
resumes Part A services in the same SNF within the 3-day interruption window), then no PPS
assessment is required upon reentry, only an Entry tracking form. An IPA may be completed, if
deemed appropriate.
Resident Is Sent to Acute Care Facility, Not in SNF over Midnight, and Is Not
Admitted to Acute Care Facility

If a resident is out of the facility over a midnight, but for less than 24 hours, and is not admitted
to an acute care facility, a new 5-Day PPS assessment is not required, though an IPA may be
completed, if deemed appropriate. However, there are payment implications: the day preceding
the midnight on which the resident was absent from the nursing home is not a covered Part A
day. This is known as the “midnight rule.” For example, if the resident goes to the emergency
room at 10 p.m. Wednesday, day 22 of their Part A stay, and returns at 3 a.m. the next day,
Wednesday is not billable to Part A. As a result, the day of their return to the SNF, Thursday,
8 These requirements/policies also apply to swing bed providers.

October 2024

Page 2-52

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

becomes day 22 of their Part A stay. This means that this day is skipped for purposes of the
variable per diem adjustment, described in Chapter 6.
Resident Takes a Leave of Absence from the SNF
If a resident is out of the facility for a Leave of Absence (LOA) as defined on page 2-13 in this
chapter, there may be payment implications. For example, if a resident leaves a SNF at 6:00 p.m.
on Wednesday, which is Day 27 of the resident’s stay and returns to the SNF on Thursday at
9:00 a.m., then Wednesday becomes a non-billable day and Thursday becomes Day 27 of the
resident’s stay.
If the beneficiary experiences a leave of absence during part of the assessment observation
period, the facility may include services furnished during the beneficiary’s temporary absence
(when permitted under MDS coding guidelines; see Chapter 3).

Resident Discharged from Part A Skilled Services and from the Facility and
Returns to SNF Part A Skilled Level Services
In the situation when a beneficiary is discharged from Medicare Part A and is physically
discharged from the facility, but returns to resume SNF Part A skilled services after the
interruption window has closed, the OBRA Discharge and Part A PPS Discharge must be
completed and can be combined (see Part A PPS Discharge in Section 2.5).

On return to the facility, this is considered a new Part A stay (as long as resumption of Part A
occurs within the 30-day window allowed by Medicare), and a new 5-Day and Entry Tracking
record must be completed. If the resident was discharged return anticipated, no OBRA
assessment is required. However, if the resident was discharged return not anticipated, the
facility must complete a new OBRA Admission assessment. See Chapter 6, Section 6.7 for
greater detail to determine whether or not the resident is eligible for Part A SNF coverage.

However, in the case of an interrupted stay, that is, if a resident leaves the facility and resumes
Part A within the 3-day interruption window, only an OBRA Discharge is required. An Entry
Tracking record is required on reentry, but no 5-Day is required. If the resident was discharged
return anticipated, no OBRA assessment is required. However, if the resident was discharged
return not anticipated, the facility must complete a new OBRA Admission assessment.
The beneficiary should be assessed to determine if there was a significant change in status.

Resident Discharged from Part A Skilled Services Is Not Physically Discharged
from the Skilled Nursing Facility

In the situation when a resident’s Medicare Part A stay ends, but the resident is not physically
discharged from the facility, remaining in a Medicare and/or Medicaid certified bed with another
payer source, the facility must continue with the OBRA schedule from the beneficiary’s original
date of admission (item A1900) and must also complete a Part A PPS Discharge assessment.
If Part A benefits resume, there is no reason to change the OBRA schedule; the PPS schedule
would start again with a 5-Day assessment, MDS item A0310B = 01, unless it is a case of an

October 2024

Page 2-53

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

interrupted stay—that is, if the resident is discharged from Part A, remains in the facility, and
resumes Part A within the 3-day interruption window, no Part A PPS Discharge is completed,
nor is a 5-Day required when Part A resumes.
Delay in Requiring and Receiving Skilled Services
There are instances when the beneficiary does not require SNF level of care services when
initially admitted to the SNF. See Chapter 6, Section 6.7.
Non-Compliance with the PPS Assessment Schedule

According to Part 42 Code of Federal Regulation (CFR) Section 413.343, an assessment that
does not have its ARD within the prescribed ARD window will be paid at the default rate for the
number of days the ARD is out of compliance. Frequent late assessment scheduling practices or
missed assessments may result in additional review. The default rate takes the place of the
otherwise applicable Federal rate. It is equal to the rate paid for the Health Insurance Prospective
Payment System (HIPPS) code reflecting the lowest acuity level for each PDPM component and
would generally be lower than the Medicare rate payable if the SNF had submitted an assessment
in accordance with the prescribed assessment schedule.
Late PPS Assessment

If the SNF fails to set the ARD within the defined ARD window for a 5-Day assessment, and the
resident is still on Part A, the SNF must complete a late assessment. The ARD can be no earlier
than the day the error was identified.

The SNF will bill the default rate for the number of days that the assessment is out of
compliance. This is equal to the number of days between the day following the last day of the
available ARD window and the late ARD (including the late ARD). The SNF would then bill
the HIPPS code established by the late assessment for the remainder of the SNF stay,
unless the SNF chooses to complete an IPA. For example, a 5-Day assessment with an ARD of
Day 11 is out of compliance for 3 days and therefore would be paid at the default rate for Days 1
through 3 of the Part A stay and the HIPPS code from the late 5-Day assessment for the
remainder of the Part A stay, unless an IPA is completed.

Missed PPS Assessment

If the SNF fails to set the ARD of a 5-Day assessment prior to the end of the last day of the ARD
window, and the resident was already discharged from Medicare Part A when this error is
discovered, the provider cannot complete an assessment for SNF PPS purposes and the days
cannot be billed to Part A.
Errors on a PPS Assessment

To correct an error on an MDS that has been submitted to iQIES, the SNF must follow the
normal MDS correction procedures (see Chapter 5).

2.13 Expected Order of MDS Records
The MDS records for a nursing home resident are expected to occur in a specific order. For
example, the first record for a resident is expected to be an Entry record with entry type (item
A1700) indicating admission, and the next record is expected to be an Admission assessment, a

October 2024

Page 2-54

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

5-Day assessment, a Discharge assessment, or Death in Facility tracking record. iQIES will issue
a warning when an unexpected record is submitted. Examples include an assessment record after
a discharge (an entry is expected) or any record after a Death in Facility tracking record.
The target date, rather than the submission date, is used to determine the order of records. The
target date is the Assessment Reference Date (item A2300) for assessment records, the Entry
Date (item A1600) for entry records, and the Discharge Date (item A2000) for discharge or
Death in facility records. In the following table, the prior record is represented in the columns
and the next (subsequent) record is represented in the rows. A “no” has been placed in a cell
when the next record is not expected to follow the prior record; iQIES will issue a record order
warning for record combinations that contain a “no.” A “yes” indicates that the next record is
expected to follow the prior record; a record order warning will not be issued for these
combinations. Note that there are not any iQIES record order warnings produced for Swing Bed
MDS records.

D
October 2024

Page 2-55

Prior Record

IPA

OBRA
Discharge

Part A
PPS
Discharge

Death in
facility

No prior
record

yes

Entry

OBRA
Admission

OBRA
Annual

OBRA
Quarterly

5-Day

OBRA Admission

yes

OBRA Annual

yes

OBRA Quarterly, sign. change, sign
correction

yes

5-Day

yes

Next Record

IPA
OBRA Discharge
Part A PPS Discharge
Death in facility

Entry

yes

CMS՚s RAI Version 3.0 Manual

October 2024

Expected Order of MDS Records

Note: “No” indicates that the record sequence is not expected; record order warnings will be issued for these combinations.
“Yes” indicates expected record sequences; no record order warning will be issued for these combinations.
CH 2: Assessments for the RAI

Page 2-56

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

2.14 Determining the Item Set for an MDS Record
The item set for a particular MDS record is completely determined by the reason for assessment
items (A0310A, A0310B, A0310F, and A0310H). Item set determination is complicated and
standard MDS software from CMS and private vendors will automatically make this
determination. This section provides manual lookup tables for determining the item set when
automated software is unavailable.

The first lookup table is for nursing home records. The first 4 columns are entries for the reason
for assessment (RFA) items A0310A, A0310B, A0310F, and A0310H. To determine the item set
for a record, locate the row that includes the values of items A0310A, A0310B, A0310F, and
A0310H for that record. When the row is located, then the item set is identified in the item set
code (ISC) and Description columns for that row. If the combination of items A0310A, A0310B,
A0310F, and A0310H values for the record cannot be located in any row, then that combination
of RFAs is not allowed and any record with that combination will be rejected by iQIES.
Nursing Home Item Set Code (ISC) Reference Table

02, 06
99
99
99
99
99

PPS RFA
(A0310B)
01, 99

Entry/
Discharge
(A0310F)
10, 11, 99

Part A PPS
Discharge
(A0310H)
0, 1

ISC
NC

Description
Comprehensive

01, 99

10, 11, 99

0, 1

Quarterly

10, 11, 99

0, 1

PPS

OBRA RFA
(A0310A)
01, 03, 04, 05

IPA

PPS (Optional)

10, 11

0, 1

OBRA Discharge

01, 12

Tracking

NPE

Part A PPS Discharge

Consider examples of the use of this table. If items A0310A = 01, A0310B = 99, item A0310F =
99, and A0310H = 0 (a standalone OBRA Admission assessment), then these values are matched
in row 1 and the item set is an OBRA comprehensive assessment (NC). The same row would be
selected if item A0310F is changed to 10 (Admission assessment combined with a return not
anticipated Discharge assessment). The item set is again an OBRA comprehensive assessment
(NC). If items A0310A = 99, A0310B = 99, item A0310F = 12, and A0310H = 0 (a Death in
Facility tracking record), then these values are matched in the second to last row and the item set
is a tracking record (NT). Finally, if items A0310A = 99, A0310B = 99, A0310F = 99, and
A0310H = 0, then no row matches these entries, and the record is invalid and would be rejected.

There is one additional item set not listed in the above table used for inactivation request records.
This is the set of items active on a request to inactivate a record in iQIES. An inactivation request
is indicated by A0050 = 3. The item set for this type of record is “Inactivation” with an ISC code
of XX.
The next lookup table is for swing bed records. The first 4 columns are entries for the reason for
assessment (RFA) items A0310A, A0310B, A0310F, and A0310H. To determine the item set for
a record, locate the row that includes the values of items A0310A, A0310B, A0310F, and
October 2024

Page 2-57

CMS’s RAI Version 3.0 Manual

CH 2: Assessments for the RAI

A0310H for that record. When the row is located, then the item set is identified in the ISC and
Description columns for that row. If the combination of A0310A, A0310B, A0310F, and
A0310H values for the record cannot be located in any row, then that combination of RFAs is
not allowed and any record with that combination will be rejected by iQIES.
Swing Bed Item Set Code (ISC) Reference Table
Entry/
Discharge
(A0310F)
10, 11, 99

Part A
Discharge
(A0310H)
0, 1

ISC
SP

Description
PPS

IPA

PPS (Optional)

10, 11

0, 1

Discharge

Tracking

OBRA RFA
(A0310A)
99

PPS RFA
(A0310B)
01

01, 12

The “Inactivation” (XX) item set is also used for swing beds when item A0050 = 3.

October 2024

Page 2-58

CMS’s RAI Version 3.0 Manual

CH 3: Overview of Guide to MDS Items

CHAPTER 3: OVERVIEW TO THE ITEM-BY-ITEM
GUIDE TO THE MDS 3.0
This chapter provides item-by-item coding instructions for all required sections and items in the
MDS Version 3.0 item sets. The goal of this chapter is to facilitate the accurate coding of the
MDS resident assessment and to provide assessors with the rationale and resources to optimize
resident care and outcomes.

3.1 Using this Chapter

Throughout this chapter, MDS assessment sections are presented using a standard format for
ease of review and instruction. In addition, screenshots of each section are available for
illustration purposes. Note: There are images imbedded in this manual and if you are using a
screen reader to access the content contained in the manual you should refer to the MDS 3.0 item
set to review the referenced information. The order of the sections is as follows:
•

Intent. The reason(s) for including this set of assessment items in the MDS.

•

Item Display. To facilitate accurate resident assessment using the MDS, each

•

Item Rationale. The purpose of assessing this aspect of a resident’s clinical or

•

Health-related Quality of Life. How the condition, impairment, improvement, or
decline being assessed can affect a resident’s quality of life, along with the importance of
staff understanding the relationship of the clinical or functional issue related to quality of
life.

•

Planning for Care. How assessment of the condition, impairment, improvement, or

assessment section is accompanied by screenshots, which display the item from the MDS
3.0 item set.
functional status.

decline being assessed can contribute to appropriate care planning.

•

Steps for Assessment. Sources of information and methods for determining the

•

Coding Instructions. The proper method of recording each response, with

•

Coding Tips and Special Populations. Clarifications, issues of note, and
conditions to be considered when coding individual MDS items.

•

Examples. Case examples of appropriate coding for most, if not all, MDS

correct response for coding each MDS item.

explanations of individual response categories.

sections/items.

Additional layout issues to note include: (1) the
symbol is displayed in all MDS 3.0
sections/items that require a resident interview, and (2) important definitions are highlighted in
text boxes, and may be found, along with other definitions of interest, in Appendix A: Glossary
and Common Acronyms.
October 2024

Page 3-1

CMS’s RAI Version 3.0 Manual

CH 3: Overview of Guide to MDS Items

3.2 Becoming Familiar with the MDS-recommended
Approach

1. First, reading the Manual is essential.
• The CMS Long-Term Care Facility Resident Assessment Instrument User’s
Manual is the primary source of information for completing an MDS assessment.
• Notice how the manual is organized.
• Using it correctly will increase the accuracy of your assessments.
• While it is important to understand and apply the information in Chapter 3,
facilities should also become familiar with Chapters 1, 2, 4, 5 and 6. These
Chapters provide the framework and supporting information for data collected on
the item set as well as the process for further assessment and care planning,
submitting and modifying assessments, and information on the SNF PPS payment
system.
• It is important to understand the entire process of the RAI in conjunction with the
intent and rationale for coding items on the MDS 3.0 item set.
• Check the MDS 3.0 Web site regularly for updates at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html.
• If you require further assistance, submit your question to your State RAI
Coordinator listed in Appendix B: State Agency and CMS Locations RAI/MDS
Contacts available in the Downloads section on CMS’ website:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html.
2. Second, review the MDS item sets.
• Notice how sections are organized and where information should be recorded.
• Work through one section at a time.
• Examine item definitions and response categories as provided on the item sets,
realizing that more detailed definitions and coding information is found in each
Section of Chapter 3.
• There are several item sets, and depending on which item set you are completing,
the skip patterns and items active for each item set may be different.
3. Complete a thorough review of Chapter 3.
• Review procedural instructions, time frames, and general coding conventions.
• Become familiar with the intent of each item, rationale and steps for assessment.
• Become familiar with the item itself with its coding choices and response options,
keeping in mind the clarifications, issues of note, and other pertinent information
needed to understand how to code the item.
• Do the definitions and instructions differ from current practice at your facility?
• Do your facility processes require updating to comply with MDS requirements?

October 2024

Page 3-2

CMS’s RAI Version 3.0 Manual

CH 3: Overview of Guide to MDS Items

•

Complete a test MDS assessment for a resident at your facility. Enter the
appropriate codes on the MDS.
• Make a note where your review could benefit from additional information,
training, and using the varying skill sets of the interdisciplinary team. Be certain
to explore resources available to you.
• As you are completing this test case, read through the instructions that apply to
each section as you are completing the MDS. Work through the Manual and item
set one section at a time until you are comfortable coding items. Make sure you
understand this information before going on to another section.
• Review the test case you completed. Would you still code it the same way? Are
you surprised by any definitions, instructions, or case examples? For example, do
you understand how to code Functional Abilities?
• As you review the coding choices in your test case against the manual, make
notations corresponding to the section(s) of this Manual where you need further
clarification, or where questions arose. Note sections of the manual that help to
clarify these coding and procedural questions.
• Would you now complete your initial case differently?
• It will take time to go through all this material. Do it slowly and carefully without
rushing. Discuss any clarifications, questions or issues with your State RAI
Coordinator (see Appendix B: State Agency and CMS Locations RAI/MDS
Contacts available in the Downloads section on CMS’ website:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html).
4. Use of information in this chapter:
• Keep this chapter with you during the assessment process.
• Where clarification is needed, review the intent, rationale and specific coding
instructions for each item in question.

3.3 Coding Conventions

There are several standard conventions to be used when completing the MDS assessment, as
follows.
• The standard look-back period for the MDS 3.0 is 7 days, unless otherwise stated.
• With the exception of certain items (e.g., some items in Sections J, K and O), the
look-back period does not extend into the preadmission period unless the item
instructions state otherwise. In the case of reentry, the look-back period does not extend
into time prior to the reentry, unless instructions state otherwise.
• When determining the response to items that have a look-back period relating back to the
Admission/Entry, Reentry, or Prior OBRA or scheduled PPS assessment, whichever is
most recent, staff must only consider those assessments that are required to be submitted
to iQIES. PPS assessments that are completed for private insurance and Medicare
Advantage Plans must not be submitted to iQIES and therefore should not be considered
when determining the “prior assessment.”

October 2024

Page 3-3

CMS’s RAI Version 3.0 Manual

•

CH 3: Overview of Guide to MDS Items

There are a few instances in which scoring on one item will govern how scoring is
completed for one or more additional items. This is called a skip pattern. The instructions
direct the assessor to “skip” over the next item (or several items) and go on to another.
When you encounter a skip pattern, leave the item blank and move on to the next item as
directed (e.g., item B0100, Comatose, if B0100 is answered code 1, yes, the assessor is
instructed to skip to item GG0110, Activities of Daily Living (ADL) Assistance. The
intervening items from B0200–F0800 would not be coded (i.e., left blank). If B0100 was
answered code 0, no, then the assessor would continue to code the MDS at the next item,
B0200, Hearing).
Use a check mark for boxes where the instructions state to “check all that apply,” if the
specified condition is met; otherwise, these boxes should remain blank (e.g., F0800, Staff
Assessment of Daily and Activity Preferences, boxes A-Z).

•
•

•

Use a numeric response (a number or pre-assigned value) for blank boxes (e.g., M1030,
Number of Venous and Arterial Ulcers).
When completing hard copy forms to be used for data entry, capital letters may be easiest
to read. Print legibly to ensure accurate encoding of data.
When recording month, day, and year for dates, enter two digits for the month and the
day and four digits for the year. For example, the third day of January in the year 2020 is
recorded as:

Almost all MDS 3.0 items allow a dash (-) value to be entered and submitted to iQIES.
— A dash value indicates that an item was not assessed. This most often occurs when a
resident is discharged before the item could be assessed.
— Dash values allow a partial assessment to be submitted when an assessment is
required for payment purposes.
— There are four date items (A2400C, O0400A6, O0400B6, and O0400C6) that use a
dash-filled value to indicate that the event has not yet occurred. For example, if there
is an ongoing Medicare stay, then the end date for that Medicare stay (A2400C) has
not occurred, therefore, this item would be dash-filled.
— The few items that do not allow dash values include identification items in Section A
[e.g., Legal Name of Resident (Item A0500), Assessment Reference Date (Item
A2300), Type of Assessment (Item A0310), and Gender (Item A0800)] and ICD
diagnosis codes (Item I8000). All items for which a dash is not an acceptable value
can be found on the CMS MDS 3.0 Technical Information web page at the following
link: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html.
When the term “physician” is used in this manual, it should be interpreted as including
nurse practitioners, physician assistants, or clinical nurse specialists, if allowable under
state licensure laws and Medicare.

•

October 2024

Page 3-4

CMS’s RAI Version 3.0 Manual

•
•

•

CH 3: Overview of Guide to MDS Items

Residents should be the primary source of information for resident assessment items.
Should the resident not be able to participate in the assessment, the resident’s family,
significant other, and guardian or legally authorized representative should be consulted.
Several times throughout the manual the word “significant” is used. The term may have
different connotations depending on the circumstance in which it is used. For the MDS
3.0, the term “significant” when discussing clinical, medical, or laboratory findings refers
to measures of supporting evidence that are considered when developing or assigning a
diagnosis, and therefore reflects clinical judgment. When the term “significant” is used in
discussing relationships between people, as in “significant other,” it means a person, who
may be a family member or a close friend that is important or influential in the life of the
resident.
When completing the MDS 3.0, there are some items that require a count or
measurement, however, there are instances where the actual results of the count or
measurement are greater than the number of available boxes. For example, number of
pressure ulcers, or weight. When the result of a count or measurement is greater than the
number of available boxes, facilities are instructed to maximize the count/measurement
by placing a "9" in each box (e.g., for item K0200B, if the weight was 1010 lbs., you
would enter 999 in the available boxes). Even though the number is not exact, the facility
should document the correct number in the resident's medical record and ensure that an
appropriate plan of care is completed that addresses the additional counts/measurements.

October 2024

Page 3-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

SECTION A: IDENTIFICATION INFORMATION
Intent: The intent of this section is to obtain the reasons for assessment, administrative
information, and key demographic information to uniquely identify each resident, potential care
needs including access to transportation, and the home in which they reside.

A0050: Type of Record

Coding Instructions for A0050, Type of Record

D
•

Code 1, Add new record: if this is a new record that has not been previously

submitted and accepted in iQIES. If this item is coded as 1, continue to A0100 Facility
Provider Numbers.

•

If there is an existing database record for the same resident, the same facility, the same
reasons for assessment/tracking, and the same date (assessment reference date, entry date,
or discharge date), then the current record is a duplicate and not a new record. In this
case, the submitted record will be rejected and not accepted in iQIES and a “fatal” error
will be reported to the facility on the Final Validation Report.
Code 2, Modify existing record: if this is a request to modify the MDS items for a

record that already has been submitted and accepted in the Internet Quality Improvement
and Evaluation System (iQIES).
If this item is coded as 2, continue to A0100, Facility Provider Numbers.
When a modification request is submitted, iQIES will take the following steps:

1. The system will attempt to locate the existing record in iQIES for this facility with the
resident, reasons for assessment/tracking, and date (Assessment Reference Date
(ARD), entry date, or discharge date) indicated in subsequent Section X items.
2. If the existing record is not found, the submitted modification record will be rejected
and not accepted in iQIES. A “fatal” error will be reported to the facility on the Final
Validation Report.
3. If the existing record is found, then the items in all sections of the submitted
modification record will be edited. If there are any fatal errors, the modification
record will be rejected and not accepted in iQIES. The “fatal” error(s) will be
reported to the facility on the Final Validation Report.

4. If the modification record passes all the edits, it will replace the prior record being
modified in iQIES. The prior record will be moved to a history file in iQIES.

October 2024

Page A-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0050: Type of Record (cont.)
•

Code 3, Inactivate existing record: if this is a request to inactivate a record that

already has been submitted and accepted in iQIES.

If this item is coded as 3, skip to X0150, Type of Provider.
When an inactivation request is submitted, iQIES will take the following steps:
1. The system will attempt to locate the existing record in iQIES for this facility with the
resident, reasons for assessment/tracking, and date (ARD, entry date, or discharge
date) indicated in subsequent Section X items.

2. If the existing record is not found in iQIES, the submitted inactivation request will be
rejected and a “fatal” error will be reported to the facility on the Final Validation
Report.
3. All items in Section X of the submitted record will be edited. If there are any fatal
errors, the current inactivation request will be rejected and no record will be
inactivated in iQIES.
4. If the existing record is found, it will be removed from the active records in iQIES
and moved to a history file.

Identification of Record to be Modified/Inactivated

The Section X items from X0200 through X0700 identify the existing iQIES assessment or
tracking 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 database.

Example: A MDS assessment for Joan L. Smith is submitted and accepted by iQIES.

A data entry error is then identified on the previously submitted and accepted record: The
encoder mistakenly entered “John” instead of “Joan” when entering a prior assessment
for Joan L. Smith. To correct this data entry error, the facility will modify the erroneous
record and complete the items in Section X including items under Identification of
Record to be Modified/Inactivated. When completing X0200A, the Resident First Name,
“John” will be entered in this item. This will permit the MDS system to locate the
previously submitted assessment that is being corrected. If the correct name “Joan” were
entered, iQIES would not locate the prior assessment.
The correction to the name from “John” to “Joan” will be made by recording “Joan” in the
“normal” A0500A, Resident First Name in the modification record. The modification record
must include all items appropriate for that assessment, not just the corrected name. This
modification record will then be submitted and accepted into iQIES, which causes the desired
correction to be made.

October 2024

Page A-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0100: Facility Provider Numbers

Item Rationale
•

DEFINITIONS

Allows the identification of the facility submitting the
assessment.

Coding Instructions
•

Enter the facility provider numbers:

CMS CERTIFICATION
NUMBER (CCN)
Replaces the term
“Medicare/Medicaid Provider
Number” in survey,
certification, and
assessment-related
activities.

A. National Provider Identifier (NPI).
B. CMS Certification Number (CCN) – If A0410 = 3
(federal required submission), then A0100B
(facility CCN) must not be blank.
C. State Provider Number (optional). This number is
assigned by the State survey agency and provided to
the intermediary. When known, enter the State
Provider Number in A0100C. Completion of this is
not required; however, your State may require the
completion of this item.

NATIONAL PROVIDER
IDENTIFIER (NPI)
A unique Federal number
that identifies providers of
health care services. The
NPI applies to the nursing
home for all of its residents.

A0200: Type of Provider

•

Item Rationale

Allows designation of type of provider.

Coding Instructions
•

Code 1, nursing home (SNF/NF): if a Medicare
skilled nursing facility (SNF) or Medicaid nursing
facility (NF).

•

Code 2, swing bed: if a non-critical access hospital

with swing bed approval.

October 2024

STATE PROVIDER
NUMBER
Medicaid Provider Number
established by a state.

DEFINITION

SWING BED
A rural non-critical access
hospital with less 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.

Page A-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0310: Type of Assessment
For all Federally required assessments and records as well as all PPS assessments.

•

D
Item Rationale

Allows identification of needed assessment content.

October 2024

Page A-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0310: Type of Assessment (cont.)
Coding Instructions for A0310, Type of Assessment
Enter the code corresponding to the reason or reasons for completing this assessment.
If the assessment is being completed for both Omnibus Budget Reconciliation Act (OBRA)–
required clinical reasons (A0310A) and Prospective Payment System (PPS) reasons (A0310B),
all requirements for both types of assessments must be met. See Chapter 2, Section 2.10,
Combining PPS Assessments and OBRA Assessments, for details of these requirements.
Assessments completed for other reasons (e.g., to facilitate billing for Medicare Advantage
Plans) are not coded in A0310 and are not submitted to iQIES.

Coding Instructions for A0310A, Federal OBRA Reason for
Assessment
Document the reason for completing the assessment, using the categories of assessment
types. For detailed information on the requirements for scheduling and timing of the
assessments, see Chapter 2 on assessment schedules.

•

Enter the number corresponding to the OBRA reason for assessment. This item contains
2 digits. For codes 01-06, enter “0” in the first box and place the correct number in the
second box. If the assessment is not coded 01-06, enter code “99”.
01.
02.
03.
04.
05.
06.
99.

•

Admission assessment (required by day 14)
Quarterly review assessment
Annual assessment
Significant change in status assessment
Significant correction to prior comprehensive assessment
Significant correction to prior quarterly assessment
None of the above

Coding Tips and Special Populations
•

If a nursing home resident elects the hospice benefit, the nursing home is required to
complete an MDS Significant Change in Status Assessment (SCSA). The nursing home
is required to complete an SCSA when the resident comes off the hospice benefit
(revoke). See Chapter 2 for details on this requirement.

•

It is a CMS requirement to have an SCSA completed EVERY time the hospice benefit
has been elected, even if a recent MDS was done and the only change is the election of
the hospice benefit.

October 2024

Page A-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0310: Type of Assessment (cont.)
Coding Instructions for A0310B, PPS
Assessment
•

Enter the number corresponding to the PPS reason for
completing this assessment. This item contains 2 digits.
For codes 01 and 08, enter “0” in the first box and place
the correct number in the second box. If the assessment
is not coded as 01 or 08, enter code “99.”

•

See Chapter 2 on assessment schedules for detailed
information on the timing of the assessments.

DEFINITION
PROSPECTIVE
PAYMENT SYSTEM
(PPS)
Method of reimbursement in
which Medicare payment is
made based on the
classification system of that
service.

PPS Scheduled Assessment for Medicare Part A Stay
01. 5-day scheduled assessment
PPS Unscheduled Assessment for Medicare Part A Stay
08. IPA-Interim Payment Assessment

Not PPS Assessment
99. None of the above

Coding Instructions for A0310E, Is This Assessment the First
Assessment (OBRA, Scheduled PPS, or OBRA Discharge) since
the Most Recent Admission/Entry or Reentry?
•

Code 0, no: if this assessment is not the first of these assessments since the most recent

•

Code 1, yes: if this assessment is the first of these assessments since the most recent

admission/entry or reentry.

Coding Tips and Special Populations
A0310E = 0 for:

•

o Entry or Death in Facility tracking records (A0310F = 01 or 12);

o A standalone Part A PPS Discharge assessment (A0310A = 99, A0310B = 99,
A0310F = 99, and A0310H = 1); or

o An Interim Payment Assessment (A0310A = 99, A0310B = 08, A0310F = 99, and
A0310H=0).
•

A0310E = 1 on the first OBRA, Scheduled PPS or OBRA Discharge assessment that is
completed and submitted once a facility obtains CMS certification. Note: the first
submitted assessment may not be an OBRA Admission assessment.

October 2024

Page A-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0310: Type of Assessment (cont.)
Coding Instructions for A0310F, Federal OBRA & PPS
Entry/Discharge Reporting
•

Enter the number corresponding to the reason for
completing this assessment or tracking record. This
item contains 2 digits. For code 01, enter “0” in the first
box and place “1” in the second box. If the assessment
is not coded as “01” or “10 or “11” or “12,” enter “99”:
Entry tracking record
Discharge assessment-return not anticipated
Discharge assessment-return anticipated
Death in facility tracking record
None of the above

01.
10.
11.
12.
99.

Coding Instructions for A0310G, Type of
Discharge (complete only if A0310F = 10
or 11)
Enter the number corresponding to the type of
discharge.

•

Code 1: if type of discharge is a planned discharge.

•

Code 2: if type of discharge is an unplanned

Part A PPS Discharge
Assessment
A discharge assessment
developed to inform current
and future Skilled Nursing
Facility Quality Reporting
Program (SNF QRP)
measures and the calculation
of these measures. The
Part A PPS Discharge
assessment is completed
when a resident’s Medicare
Part A stay ends, but the
resident remains in the
facility; and must be
combined with an OBRA
Discharge if the Part A stay
ends on the same day or the
day before the resident’s
Discharge Date (A2000).

•

DEFINITION

discharge.

ft
October 2024

Page A-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0310: Type of Assessment (cont.)

Coding Instructions for A0310G1, Is this a
SNF Part A Interrupted Stay?
•

Code 0, no: if the resident was discharged from SNF

•

Code 1, yes: if the resident was discharged from

care (i.e., from a Medicare Part A-covered stay) but did
not resume SNF care in the same SNF within the
interruption window.

SNF care (i.e., from a Medicare Part A-covered stay)
but did resume SNF care in the same SNF within the
interruption window.

Coding Tips

Item A0310G1 indicates whether or not an interrupted
stay occurred.

•

The interrupted stay policy applies to residents who
either leave the SNF, then return to the same SNF
within the interruption window, or to residents who are
discharged from Part A-covered services and remain in
the SNF, but then resume a Part A-covered stay within
the interruption window.

Interrupted Stay
Is a Medicare Part A SNF
stay in which a resident is
discharged from SNF care
(i.e., the resident is
discharged from a Medicare
Part A-covered stay) and
subsequently resumes SNF
care in the same SNF for a
Medicare Part A-covered
stay during the interruption
window.
Interruption Window
Is a 3-day period, starting
with the calendar day of Part
A discharge and including
the 2 immediately following
calendar days. In other
words, if a resident in a
Medicare Part A SNF stay is
discharged from Part A, the
resident must resume Part A
services, or return to the
same SNF (if physically
discharged) to resume Part A
services, by 11:59 p.m. at the
end of the third calendar day
after their Part A-covered
stay ended. The interruption
window begins with the first
non-covered day following a
Part A-covered stay and
ends at 11:59 p.m. on the
third consecutive noncovered day following a Part
A-covered SNF stay. If these
conditions are met, the
subsequent stay is
considered a continuation of
the previous Medicare Part
A-covered stay for the
purposes of both the variable
per diem schedule and PPS
assessment completion.

•

DEFINITIONS

October 2024

Page A-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0310: Type of Assessment (cont.)
•

The following is a list of examples of an interrupted stay when the resident leaves the
SNF and then returns to the same SNF to resume Part A-covered services within the
interruption window. Examples include, but are not limited to, the following:
o Resident transfers to an acute care setting for evaluation or treatment due to a
change in condition and returns to the same SNF within the interruption window.
o Resident transfers to a psychiatric facility for evaluation or treatment and returns
to the same SNF within the interruption window.
o Resident transfers to an outpatient facility for a procedure or treatment and returns
to the same SNF within the interruption window.

o Resident transfers to an assisted living facility or a private residence with home
health services and returns to the same SNF within the interruption window.
o Resident leaves against medical advice and returns to the same SNF within the
interruption window.

•

The following is a list of examples of an interrupted stay when the resident under a Part
A-covered stay remains in the facility but the stay stops being covered under the Part A
PPS benefit, and then resumes Part A-covered services in the SNF within the interruption
window. Examples include, but are not limited to, the following:
o Resident elects the hospice benefit, thereby declining the SNF benefit, and then
revokes the hospice benefit and resumes SNF-level care within the interruption
window.
o Resident refuses to participate in rehabilitation and has no other daily skilled
need; this ends the Part A coverage. Within the interruption window, the resident
decides to engage in the planned rehabilitation regime and Part A coverage
resumes.

o Resident changes payer sources from Medicare Part A to an alternate payer source
(i.e., hospice, private pay or private insurance) and then wishes to resume their
Medicare Part A stay, at the same SNF, within the interruption window.
•

If a resident is discharged from SNF care, remains in the facility, and resumes a Part Acovered stay in the SNF within the interruption window, this is an interrupted stay. No
discharge assessment (OBRA or Part A PPS) is required, nor is an Entry Tracking Record
or 5-Day required on resumption.

•

If a resident leaves the SNF and returns to resume Part A-covered services in the same
SNF within the interruption window, this is an interrupted stay. Although this situation
does not end the resident’s Part A PPS stay, the resident left the SNF, and therefore an
OBRA Discharge assessment is required. On return to the SNF, no 5-Day would be
required. An OBRA Admission would be required if the resident was discharged return
not anticipated. If the resident was discharged return anticipated, no new OBRA
Admission would be required.

October 2024

Page A-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0310: Type of Assessment (cont.)
When an interrupted stay occurs, a 5-Day PPS assessment is not required upon reentry or
resumption of SNF care in the same SNF, because an interrupted stay does not end the
resident’s Part A PPS stay.

•

If a resident is discharged from SNF care, remains in the SNF and does not resume Part
A-covered services within the interruption window, an interrupted stay did not occur. In
this situation, a Part A PPS Discharge is required. If the resident qualifies and there is a
resumption of Part A services within the 30-day window allowed by Medicare, a 5-Day
would be required as this would be considered a new Part A stay. The OBRA schedule
would continue from the resident’s original date of admission (item A1900).

•

If a resident leaves the SNF and does not return to resume Part A-covered services in the
same SNF within the interruption window, an interrupted stay did not occur. In this
situation, both the Part A PPS and OBRA Discharge assessments are required (and must
be combined if the Medicare Part A stay ends on the day of, or one day before, the
resident’s Discharge Date (A2000)). If the resident returns to the same SNF, this would
be considered a new Part A stay. An Entry Tracking record and 5-Day would be required
on return. An OBRA Admission would be required if the resident was discharged return
not anticipated. If the resident was discharged return anticipated, no new OBRA
Admission would be required.

•

The OBRA assessment schedule is unaffected by the interrupted stay policy. Please refer
to Chapter 2 for guidance on OBRA assessment scheduling requirements.

Coding Instructions for A0310H, Is this a Part A PPS Discharge
Assessment?
Code 0, no: if this is not a Part A PPS Discharge assessment.

•

Code 1, yes: if this is a Part A PPS Discharge assessment.

•

A Part A PPS Discharge assessment (NPE Item Set) is required under the Skilled Nursing
Facility Quality Reporting Program (SNF QRP) when the resident’s Medicare Part A stay
ends (as documented in A2400C, End Date of Most Recent Medicare Stay) but the
resident remains in the facility.

•

If the End Date of the Most Recent Medicare Stay (A2400C) occurs on the day of or one
day before the Discharge Date (A2000), the OBRA Discharge assessment and Part A PPS
Discharge assessment are both required and must be combined. When the OBRA and
Part A PPS Discharge assessments are combined, the ARD (A2300) must be equal to the
Discharge Date (A2000).

October 2024

•

Page A-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0410: Unit Certification or Licensure Designation

Item Rationale
In coding this item, the facility must consider its Medicare and/or Medicaid status as well
as the state’s authority to collect MDS records. State regulations may require submission
of MDS data to iQIES or directly to the state for residents residing in licensed-only beds.

•

Nursing homes must be certain they are submitting MDS assessments to iQIES for those
residents who are on a Medicare and/or Medicaid certified unit. Swing bed facilities must
be certain that they are submitting MDS assessments only for those residents whose stay
is covered by Medicare Part A benefits. For those residents who are in licensed-only
beds, nursing homes must be certain they are submitting MDS assessments either to
iQIES or directly to the state in accordance with state requirements.

•

Payer source is not the determinant by which this item is coded. This item is coded solely
according to the authority CMS has to collect MDS data for residents who are on a
Medicare and/or Medicaid certified unit and the authority that the state may have to
collect MDS data under licensure. Consult Chapter 5, page 5-1 of this Manual for a
discussion of what types of records should be submitted to iQIES.

Steps for Assessment

1. Ask the nursing home administrator or representative which units in the nursing home are
Medicare certified, Medicaid certified or dually certified (Medicare/Medicaid).
2. If some or all of the units in the nursing home are neither Medicare nor Medicaid certified,
ask the nursing home administrator or representative if there are units that are state licensed
and if the state requires MDS submission for residents on that unit.

3. Identify all units in the nursing home that are not certified or licensed by the state, if any.

October 2024

Page A-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0410: Unit Certification or Licensure Designation (cont.)
Coding Instructions
•

Code 1, Unit is neither Medicare nor Medicaid certified and MDS data is
not required by the State: if the MDS record is for a resident on a unit that is

neither Medicare nor Medicaid certified, and neither CMS nor the state has authority to
collect MDS information for residents on this unit, the facility may not submit MDS
records to iQIES. If any records are submitted under this certification designation, they
will be rejected by iQIES.
•

Code 2, Unit is neither Medicare nor Medicaid certified but MDS data is
required by the State: if the nursing home resident is on a unit that is neither

Medicare nor Medicaid certified, but the state has authority under state licensure to
collect MDS information for residents on such units, the facility should submit the
resident’s MDS records per the state’s requirement to iQIES or directly to the state.

Note that this certification designation does not apply to swing-bed facilities.
Assessments for swing-bed residents on which A0410 is coded “2” will be rejected by
iQIES.

•

Code 3, Unit is Medicare and/or Medicaid certified: if the resident is on a

Medicare and/or Medicaid certified unit, regardless of payer source (i.e., even if the
resident is private pay or has their stay covered under Medicare Advantage, Medicare
HMO, private insurance, etc.), the facility is required to submit MDS records (OBRA and
SNF PPS only) to iQIES for these residents. Consult Chapter 5, page 5-1 of this Manual
for a discussion of what types of records should be submitted to iQIES.

A0500: Legal Name of Resident

Item Rationale
•

Allows identification of resident.

•

Also used for matching each of the resident’s records.

Steps for Assessment
1. Ask resident, family, significant other, and/or
guardian/legally authorized representative.

October 2024

DEFINITION

LEGAL NAME
Resident’s name as it
appears on the Medicare
card. If the resident is not
enrolled in the Medicare
program, use the resident’s
name as it appears on a
Medicaid card or other
government-issued
document.

Page A-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0500: Legal Name of Resident (cont.)
2. Check the resident’s name on their Medicare card, or if not in the program, check a Medicaid
card or other government-issued document.

Coding Instructions
Use printed letters. Enter in the following order:
A. First Name
B. Middle Initial (if the resident has no middle initial, leave Item A0500B blank; if the
resident has two or more middle names, use the initial of the first middle name)
C. Last Name
D. Suffix (e.g., Jr./Sr.)

A0600: Social Security and Medicare Numbers

Item Rationale
•
•

Allows identification of the resident.
Allows records for resident to be matched in system.

Coding Instructions
•

•
•

Enter the Social Security Number (SSN) in A0600A,
one number per space starting with the leftmost space.
If no SSN is available for the resident (e.g., if the
resident is a recent immigrant or a child) the item may
be left blank. Note: A valid SSN should be submitted in
A0600A whenever it is available so that resident
matching can be performed as accurately as possible.
Enter Medicare number in A0600B exactly as it appears
on the resident’s documents.
For PPS assessments (A0310B = 01 or 08), the
Medicare number (A0600B) must be present (i.e., may
not be left blank).
A0600B must be a Medicare number.

October 2024

SOCIAL SECURITY
NUMBER
A tracking number assigned
to an individual by the U.S.
Federal government for
taxation, benefits, and
identification purposes.

•

DEFINITIONS

MEDICARE NUMBER
An identifier assigned to an
individual for participation in
national health insurance
program. The Medicare
Health Insurance identifier is
different from the resident’s
Social Security Number
(SSN) and may contain both
letters and numbers.

Page A-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0700: Medicaid Number

Item Rationale
•

Assists in correct resident identification.

Coding Instructions
Record this number if the resident is a Medicaid recipient.
Enter one number or letter per box beginning in the leftmost box.
Recheck the number to make sure you have entered the digits correctly.
Enter a “+” in the leftmost box if the number is pending. If you are notified later that the
resident does have a Medicaid number, just include it on the next assessment.
If not applicable because the resident is not a Medicaid recipient, enter “N” in the
leftmost box.

•
•
•
•
•

Coding Tips and Special Populations
•
•

To obtain the Medicaid number, check the resident’s Medicaid card, admission or
transfer records, or medical record.
Confirm that the resident’s name on the MDS matches the resident’s name on the
Medicaid card.
It is not necessary to process an MDS correction to add the Medicaid number on a prior
assessment. However, a correction may be a State-specific requirement.

•

A0800: Gender

•
•

Item Rationale

Assists in correct identification.
Provides demographic gender specific health trend information.

Coding Instructions
•

Code 1: if resident is male.

•

Code 2: if resident is female.

Coding Tips and Special Populations
•

Resident gender on the MDS must match what is in the Social Security system.

October 2024

Page A-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A0900: Birth Date

Item Rationale
•

Assists in correct identification.

•

Allows determination of age.

Coding Instructions
•

Fill in the boxes with the appropriate birth date. If the complete birth date is known, do
not leave any boxes blank. If the month or day contains only a single digit, fill the first
box in with a “0.” For example: January 2, 1918, should be entered as 01-02-1918.

•

Sometimes, only the birth year or the birth year and birth month will be known. These
situations are handled as follows:

— If only the birth year is known (e.g., 1918), then enter the year in the “year” portion
of A0900, and leave the “month” and “day” portions blank. If the birth year and birth
month are known, but the day of the month is not known, then enter the year in the
“year” portion of A0900, enter the month in the “month” portion of A0900, and leave
the “day” portion blank.

A1005: Ethnicity

ft
October 2024

Page A-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1005: Ethnicity (cont.)
Item Rationale
•

•

The ability to improve understanding of and address
ethnic disparities in health care outcomes requires
the availability of better data related to social
determinants of health, including ethnicity.

The ethnicity data element uses a one-question
multi-response format based on whether or not the
resident is of Hispanic, Latino/a, or Spanish origin.
Collection of ethnic data provides data granularity
important for documenting and tracking health
disparities and conforms to the 2011 Health and
Human Services Data Standards.

DEFINITION
ETHNICITY
HISPANIC OR LATINO/A
A person of Cuban, Mexican,
Puerto Rican, South or Central
American or other Spanish
culture or origin regardless of
race. The term “Spanish Origin”
can be used in addition to
Hispanic or Latino/a.

This item uses the common uniform language approved by the Office of Management
and Budget (OMB) to report ethnic categories. Response choices A1005B through
A1005E roll up to the Hispanic or Latino/a category of the OMB standard (see Definition
Ethnicity). The categories in this classification are social-political constructs and should
not be interpreted as being scientific or anthropological in nature.

•

Collection of ethnicity data is an important step in improving quality of care and health
outcomes.

•

Standardizing self-reported data collection for ethnicity allows for the comparison of data
within and across multiple post-acute-care settings.

•

These categories are NOT used to determine eligibility for participation in any Federal
program.

•

For the source of these categories and definitions, see “Racial and Ethnic Categories and
Definitions for NIH Diversity Programs and for Other Reporting Purposes, Notice
Number: NOT-OD-15-089” available at https://grants.nih.gov/grants/guide/noticefiles/NOT-OD-15-089.html. Additional information on Data Collection Standards for
Race, Ethnicity, Sex, Primary Language, and Disability Status is available at
https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=53.

•

October 2024

Page A-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1005: Ethnicity (cont.)
Steps for Assessment: Interview Instructions
1. Ask the resident to select the category or categories that most closely correspond to their
ethnicity from the list in A1005.
•

Individuals may be more comfortable if this question is introduced by saying, “We want
to make sure that all our residents get the best care possible, regardless of their ethnic
background. We would like you to tell us your ethnic background so that we can review
the treatment that all residents receive and make sure that everyone gets the highest
quality of care” (Baker et al., 2005).

2. If the resident is unable to respond, the assessor may ask a family member, significant other,
and/or guardian/legally authorized representative.
3. Ethnic category definitions are provided only if requested in order to answer the item.
4. Respondents should be offered the option of selecting one or more ethnic designations.

5. Only use medical record documentation to code A1005, Ethnicity if the resident is unable to
respond and no family member, significant other, and/or guardian/legally authorized
representative provides a response for this item.

6. If the resident declines to respond, do not code based on other resources (family, significant
other, or guardian/legally authorized representative or medical records).

Coding Instructions
Check all that apply.

If the resident provides a response, check the box(es) indicating the ethnic category or
categories identified by the resident.

•

Code X, Resident unable to respond: if the resident is unable to respond.

•

— If the resident is unable to respond and no other resources (family, significant other,
or legally authorized representative or medical records) provided the necessary
information, code A1005 as X. Resident unable to respond.

October 2024

Page A-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1005: Ethnicity (cont.)
•

Code Y, Resident declines to respond: if the resident declines to respond.

— When the resident declines to respond, code only Y. Resident declines to respond.
— When the resident declines to respond do not code based on other resources (family,
significant other, or legally authorized representative or medical records).

Examples
1. Resident R is admitted following an acute cerebral vascular accident (CVA) with mental
status changes and is unable to respond to questions regarding their ethnicity. Their spouse
informs the nurse that Resident R is Cuban.

Coding: A1005 would be coded as D. Yes, Cuban and X. Resident unable to respond.
Rationale: If Resident R is unable to respond but their family, significant other, or

legally authorized representative provided the response, code both that response and
X. Resident unable to respond.

2. Resident K is admitted following a total hip arthroplasty and declines to respond when asked
their ethnicity.

Coding: A1005, Ethnicity would be coded as Y. Resident declines to respond.
Rationale: If a resident declines to respond to this item, code only Y. Resident declines

to respond. Do not use other resources (family, significant other, or legally authorized
representative or medical record documentation) to complete A1005, Ethnicity when a
resident declines to respond.

ft
October 2024

Page A-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1010. Race

D
October 2024

Page A-19

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1010. Race (cont.)
Item Rationale
•

The ability to improve understanding of and address
racial disparities in health care outcomes requires the
availability of better data related to social determinants
of health, including race.
Collection of A1010. Race provides data granularity
important for documenting and tracking health
disparities and conforms to the 2011 Health and Human
Services Data Standards.

•

This item uses the common uniform language approved
by the Office of Management and Budget (OMB) to
report racial categories (see Definitions: Race).
Response choices A1010D through A1010J roll up to
the Asian category of the OMB standard. Response
choices A1010K through A1010N roll up to the Native
Hawaiian or Other Pacific Islander category of the
OMB standard. The categories in this classification are
social-political constructs and should not be interpreted
as being scientific or anthropological in nature.

AMERICAN INDIAN OR
ALASKAN NATIVE
A person having origins in any
of the original peoples of North
and South America (including
Central America), and who
maintains tribal affiliation or
community attachment.
ASIAN
A person having origins in any
of the original peoples of the Far
East, Southeast Asia, or the
Indian subcontinent including,
for example, Cambodia, China,
India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands,
Thailand, Vietnam.

Collection of race data is an important step in
improving quality of care and health outcomes.

•

Standardizing self-reported data collection for race
allows for the equal comparison of data across multiple
post-acute-care settings.

•

These categories are NOT used to determine eligibility
for participation in any Federal program.

Steps for Assessment: Interview Instructions
1. Ask the resident to select the category or categories that
most closely correspond to the resident’s race from the list
in A1010, Race.

Individuals may be more comfortable if this question is
introduced by saying, “We want to make sure that all
our residents get the best care possible, regardless of
their racial background. We would like you to tell us
your racial background so that we can review the
treatment that all residents receive and make sure that
everyone gets the highest quality of care” (Baker et al.,
2005).

October 2024

BLACK OR AFRICAN
AMERICAN
A person having origins in any
of the black racial groups of
Africa. Terms such as “Haitian”
or “Negro” can be used in
addition to “Black” or “African
American.”

•

RACE

•

DEFINITION

NATIVE HAWAIIAN OR
OTHER PACIFIC
ISLANDER

A person having origins in any
of the original peoples of
Hawaii, Guam, Samoa, or other
Pacific Islands.
WHITE
A person having origins in any
of the original peoples of
Europe, the Middle East, or
North Africa.

Page A-20

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1010. Race (cont.)
2. If the resident is unable to respond, the assessor may ask a family member, significant other,
and/or guardian/legally authorized representative.
3. Racial category definitions are provided only if requested in order to answer the item.
4. Respondents should be offered the option of selecting one or more racial designations.
5. Only use medical record documentation to code A1010, Race if the resident is unable to
respond and no family member, significant other, and/or guardian/legally authorized
representative provides a response for this item.
6. If the resident declines to respond, do not code based on other resources (family,
significant other, or legally authorized representative or medical records).

Coding Instructions
Check all that apply.
•

If the resident provides a response, check the box(es) indicating the race category or
categories identified by the resident.

•

Code X, Resident unable to respond: if the resident is unable to respond.

— In the cases where the resident is unable to respond and the response is determined
via family, significant other, or legally authorized representative input or medical
records, check all boxes that apply, including X. Resident unable to respond.
— If the resident is unable to respond and no other resources (family, significant other,
or legally authorized representative or medical records) provided the necessary
information, code as X. Resident unable to respond.
•

Code Y, Resident declines to respond: if the resident declines to respond.

— When the resident declines to respond, code only Y. Resident declines to respond.

— When the resident declines to respond do not code based on other resources (family,
significant other, or legally authorized representative or medical records).
•

Code Z, None of the above: if the resident reports or it is determined from other

resources (family, significant other, or legally authorized representative or medical
records) that none of the listed races apply.

October 2024

Page A-21

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1010. Race (cont.)
Examples
1. Resident W has severe dementia with agitation. During the Admission assessment, they are
unable to provide their race. Their child informs the nurse that Resident W is Korean and
African American.
Coding: A1010, Race would be coded as B. Black or African American, H. Korean, and

X. Resident unable to respond.

Rationale: If Resident W is unable to respond but their family, significant other, or

legally authorized representative provided the response, code those responses and X.
Resident unable to respond.

2. Resident Q declines to provide their race during the admission assessment stating “I’d rather
not answer.”
Coding: A1010, Race would be coded as Y. Resident declines to respond.
Rationale: If a resident declines to respond to this item, then code only Y. Resident

declines to respond. Do not make attempts to code A1010, Race when a resident declines
to respond based on other resources (family, significant other, or legally authorized
representative or medical records).

3. Resident V, who is admitted to the SNF following a recent CVA resulting in confusion, is
unable to answer when asked their race. Their family member reports that none of the listed
races apply.
Coding: A1010, Race would be coded as X. Resident unable to respond and Z. None of

the above.

Rationale: If a resident is unable to respond, family, significant other, or legally

authorized representative input may be used to code A1010, Race and the assessor should
code both the information determined via family, significant other, or legally authorized
representative input or medical records (in this case, Z. None of the above) and X.
Resident unable to respond.

October 2024

Page A-22

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1110: Language

Item Rationale
Health-related Quality of Life
•

Inability to make needs known and to engage in social interaction because of a language
barrier can be very frustrating and can lead to social isolation, depression, resident safety
issues, and unmet needs.
Language barriers can interfere with accurate assessment.

•

Planning for Care

•
•

•

When a resident needs or wants interpreter services, the nursing home must ensure that
an interpreter is available.
An alternate method of communication also should be made available to help ensure that
basic needs can be expressed at all times (e.g., communication board with pictures on it
for the resident to point to, if able).
Identifies residents who need interpreter services in order to answer interview items or
participate in consent process.

Steps for Assessment

1. Ask for the resident’s preferred language.
2. Ask the resident if they need or want an interpreter to communicate with a doctor or health
care staff.
3. If the resident—even with the assistance of an interpreter—is unable to respond, a family
member, significant other, and/or guardian/legally authorized representative should be asked.
4. If neither the resident nor a family member, significant other, nor guardian/legally authorized
representative source is able to provide a response for this item, medical documentation may
be used.
5. It is acceptable for a family member, significant other, and/or legally authorized
representative to be the interpreter if the resident is comfortable with it and if the family
member, significant other, and/or guardian/legally authorized representative will translate
exactly what the resident says without providing their interpretation.

October 2024

Page A-23

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1110: Language (cont.)
Coding Instructions for A1110A
•

Enter the preferred language the resident primarily speaks or understands after
interviewing the resident and family, significant other and/or guardian/legally authorized
representative and/or reviewing the medical record.

•

If the resident, family member, significant other, guardian/legally authorized
representative and/or medical record documentation cannot or does not identify preferred
language, enter a dash (—) in the first box. A dash indicates “no information.” CMS
expects dash use to be a rare occurrence.

Coding Instructions for A1110B
•

Code 0, No: if the resident (family, significant other, guardian/legally authorized

•

Code 1, Yes: if the resident (family, significant other, guardian/legally authorized

•

Code 9, Unable to determine: if the resident is unable or declines to respond or

representative or medical record) indicates there is no need or want of an interpreter to
communicate with a doctor or health care staff.
representative or medical record) indicates the need or want of an interpreter to
communicate with a doctor or health care staff. Ensure that preferred language is
indicated.

any available source (family, significant other, guardian/legally authorized representative
or medical records) cannot or does not identify the need or want of an interpreter.

Coding Tips and Special Populations
•

An organized system of signing such as American Sign Language (ASL) can be reported
as the preferred language if the resident needs or wants to communicate in this manner.

ft
October 2024

Page A-24

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1200: Marital Status

Item Rationale
•

Allows understanding of the formal relationship the resident has and can be important for
care and discharge planning.

•

Demographic information.

Steps for Assessment

1. Ask the resident about their marital status.
2. If the resident is unable to respond, ask a family member or other significant other.
3. If neither the family member nor significant other can report, review the medical record for
information.

Coding Instructions
•

Choose the answer that best describes the current marital status of the resident and enter
the corresponding number in the code box:
Never Married
Married
Widowed
Separated
Divorced

October 2024

1.
2.
3.
4.
5.

Page A-25

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1250. Transportation

D
Item Rationale

Health-related Quality of Life
Access to transportation for ongoing health care and medication access needs is essential
for effective care management.

•

Understanding resident transportation needs can help organizations assess barriers to care
and facilitate connections with available community resources.

•

Planning for Care
•

Assessing for transportation barriers will facilitate better care coordination and discharge
planning for follow-up care.

Steps for Assessment: Interview Instructions
1. Ask the resident:

“In the past six months to a year, has lack of transportation kept you from medical
appointments or from getting your medications?”

•

“In the past six months to a year, has lack of transportation kept you from non-medical
meetings, appointments, work, or from getting things that you need?”

•

2. Respondents should be offered the option of selecting more than one “yes” designation, if
applicable.

3. If the resident is unable to respond, the assessor may ask a family member, significant other,
and/or guardian/legally authorized representative.
4. Only if the resident is unable to respond and no family member, significant other, and/or
guardian/legally authorized representative may provide a response for this item, use
medical record documentation.
5. If the resident declines to respond, do not code based on other resources (family,
significant other, or legally authorized representative or medical records).

October 2024

Page A-26

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1250. Transportation (cont.)
Coding Instructions
•

Code A, Yes, it has kept me from medical appointments or from getting
my medications: if the resident indicates that lack of transportation has kept the

resident from medical appointments or from getting medications.
•

Code B, Yes, it has kept me from non-medical meetings, appointments,
work, or from getting things that I need: if the resident indicates that lack of

transportation has kept the resident from non-medical meetings, appointments, work, or
from getting things that the resident needs.
•

Code C, No: if the resident indicates that a lack of transportation has not kept the

resident from medical appointments, getting medications, non-medical meetings,
appointments, work, or getting things that the resident needs.

•

Code X, Resident unable to respond: if the resident is unable to respond.

•

Code Y, Resident declines to respond: if the resident declines to respond.

ft
October 2024

Page A-27

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1250. Transportation (cont.)
Example
1. Resident E is admitted with Multiple Sclerosis. They are confused and unable to understand
when asked if they have had a lack of transportation that has kept them from medical
appointments, meetings, work, or from getting things needed for daily living. No family,
significant other, or legally authorized representative with related information is available,
but their medical record indicates that their spouse uses their car to transport Resident E
wherever they need to go.
Coding: A1250 would be coded as C. No and X. Resident unable to respond.
Rationale: If neither Resident E nor their family, significant other, or legally authorized

representative was able to provide a response but the medical record documentation can
provide the necessary information, code both the information in the medical record and
X. Resident unable to respond.

A1300: Optional Resident Items

Item Rationale
•
•
•

•

Some facilities prefer to include the nursing home medical record number on the MDS to
facilitate tracking.
Some facilities conduct unit reviews of MDS items in addition to resident and nursing
home level reviews. The unit may be indicated by the room number.
Preferred name and lifetime occupation help nursing home staff members personalize
their interactions with the resident.
Many people are called by a nickname or middle name throughout their life. It is
important to call residents by the name they prefer in order to establish comfort and
respect between staff and resident. Also, some cognitively impaired or hearing impaired
residents might have difficulty responding when called by their legal name, if it is not the
name most familiar to them.
Others may prefer a more formal and less familiar address. For example, a physician
might appreciate being referred to as “Doctor.”

October 2024

•

Page A-28

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1300: Optional Resident Items (cont.)
•
•

Knowing a person’s lifetime occupation is also helpful for care planning and
conversation purposes. For example, a carpenter might enjoy pursuing hobby shop
activities.
These are optional items because they are not needed for CMS program function.

Coding Instructions for A1300A, Medical Record Number
•

Enter the resident’s medical record number (from the nursing home medical record,
admission office or Health Information Management Department) if the nursing home
chooses to exercise this option.

Coding Instructions for A1300B, Room Number
•

Enter the resident’s room number if the nursing home chooses to exercise this option.

Coding Instructions for A1300C, Name by Which Resident Prefers to
Be Addressed
•
•

Enter the resident’s preferred name. This field captures a preferred nickname, middle
name, or title that the resident prefers staff use.
Obtained from resident self-report or family or significant other if resident is unable to
respond.

Coding Instructions for A1300D, Lifetime Occupation(s)
•

Enter the job title or profession that describes the resident’s main occupation(s) before
retiring or entering the nursing home. When two occupations are identified, place a slash
(/) between each occupation.

•

The lifetime occupation of a person whose primary work was in the home should be
recorded as “homemaker.” For a resident who is a child or an intellectually
disabled/developmentally disabled adult resident who has never had an occupation,
record as “none.”

ft
October 2024

Page A-29

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1500: Preadmission Screening and Resident Review (PASRR)

Item Rationale
Health-related Quality of Life
•

All individuals who are admitted to a Medicaid certified nursing facility, regardless of the
individual’s payment source, must have a Level I PASRR completed to screen for
possible mental illness (MI), intellectual disability (ID), developmental disability (DD),
or related conditions (please contact your local State Medicaid Agency for details
regarding PASRR requirements and exemptions).

Individuals who have or are suspected to have MI or ID/DD or related conditions may
not be admitted to a Medicaid-certified nursing facility unless approved through Level II
PASRR determination. Those residents covered by Level II PASRR process may require
certain care and services provided by the nursing home, and/or specialized services
provided by the State.

•

A resident with MI or ID/DD must have a Resident Review (RR) conducted when there
is a significant change in the resident’s physical or mental condition. Therefore, when an
SCSA is completed for a resident with MI or ID/DD, the nursing home is required to
notify the State mental health authority, intellectual disability or developmental disability
authority (depending on which operates in their State) in order to notify them of the
resident’s change in status. Section 1919(e)(7)(B)(iii) of the Social Security Act requires
the notification or referral for a significant change. 1

•

Each State Medicaid Agency might have specific processes and guidelines for referral,
and which types of significant changes should be referred. Therefore, facilities should
become acquainted with their own State requirements.

•

Please see https://www.medicaid.gov/medicaid/long-term-services-supports/institutionallong-term-care/preadmission-screening-and-resident-review/index.html for CMS
information on PASRR.

•

1 The statute may also be referenced as 42 USC 1396r(e)(7)(B)(iii). Note that as of this revision date the statute supersedes
Federal regulations at 42 CFR 483.114(c), which still reads as requiring annual resident review. The regulation has not yet
been updated to reflect the statutory change to resident review upon significant change in condition.

October 2024

Page A-30

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1500: Preadmission Screening and Resident Review (PASRR)
(cont.)
Planning for Care
The Level II PASRR determination and the evaluation report specify services to be
provided by the nursing home and/or specialized services defined by the State.

•

The State is responsible for providing specialized services to individuals with MI or
ID/DD. In some States specialized services are provided to residents in Medicaidcertified facilities (in other States specialized services are only provided in other facility
types such as a psychiatric hospital). The nursing home is required to provide all other
care and services appropriate to the resident’s condition.

•

The services to be provided by the nursing home and/or specialized services provided by
the State that are specified in the Level II PASRR determination and the evaluation report
should be addressed in the plan of care.

•

Identifies individuals who are subject to Resident Review upon change in condition.

Steps for Assessment

1. Complete if A0310A = 01, 03, 04 or 05 (Admission assessment, Annual assessment, SCSA,
Significant Correction to Prior Comprehensive Assessment).
2. Review the Level I PASRR form to determine whether a Level II PASRR was required.
3. Review the PASRR report provided by the State if Level II screening was required.

Coding Instructions
•

Code 0, no: and skip to A1550, Conditions Related to ID/DD Status, if any of the

following apply:

— PASRR Level I screening did not result in a referral for Level II screening, or

— Level II screening determined that the resident does not have a serious MI and/or
ID/DD or related conditions, or

— PASRR screening is not required because the resident was admitted from a hospital
after requiring acute inpatient care, is receiving services for the condition for which
they received care in the hospital, and the attending physician has certified before
admission that the resident is likely to require less than 30 days of nursing home care.

October 2024

Page A-31

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1500: Preadmission Screening and Resident Review (PASRR)
(cont.)
•

Code 1, yes: if PASRR Level II screening determined that the resident has a serious
mental illness and/or ID/DD or related condition, and continue to A1510, Level II
Preadmission Screening and Resident Review (PASRR) Conditions.

•

Code 9, not a Medicaid-certified unit: if bed is not in a Medicaid-certified

nursing home. Skip to A1550, Conditions Related to ID/DD Status. The PASRR process
does not apply to nursing home units that are not certified by Medicaid (unless a State
requires otherwise) and therefore the question is not applicable.

— Note that the requirement is based on the certification of the part of the nursing home
the resident will occupy. In a nursing home in which some parts are Medicaid
certified and some are not, this question applies when a resident is admitted, or
transferred to, a Medicaid certified part of the building.

A1510: Level II Preadmission Screening and Resident Review
(PASRR) Conditions

Steps for Assessment

2. Check all that apply.

Coding Instructions
•
•
•

1. Complete if A0310A = 01, 03, 04 or 05 (Admission assessment, Annual assessment, SCSA,
Significant Correction to Prior Comprehensive Assessment).

Code A, Serious mental illness: if resident has been diagnosed with a serious

mental illness.

Code B, Intellectual Disability: if resident has been diagnosed with intellectual

disability/developmental disability.

Code C, Other related conditions: if resident has been diagnosed with other

related conditions.

October 2024

Page A-32

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1550: Conditions Related to Intellectual
Disability/Developmental Disability (ID/DD) Status

D
Item Rationale
•

To document conditions associated with intellectual or
developmental disabilities.

DOWN SYNDROME
A common genetic disorder
in which a child is born with
47 rather than 46
chromosomes, resulting in
developmental delays,
intellectual disability, low
muscle tone, and other
possible effects.

Steps for Assessment

DEFINITIONS

1. If resident is 22 years of age or older on the ARD, complete
only if A0310A = 01 (Admission assessment).
2. If resident is 21 years of age or younger on the ARD,
complete if A0310A = 01, 03, 04, or 05 (Admission
assessment, Annual assessment, SCSA, Significant
Correction to Prior Comprehensive Assessment).

Coding Instructions

AUTISM
A developmental disorder
that is characterized by
impaired social interaction,
problems with verbal and
nonverbal communication,
and unusual, repetitive, or
severely limited activities and
interests.

•

Check all conditions related to ID/DD status that were
present before age 22.

•

When age of onset is not specified, assume that the
condition meets this criterion AND is likely to continue
indefinitely.

•

Code A: if Down syndrome is present.

•

Code B: if autism is present.

•

Code C: if epilepsy is present.

•

Code D: if other organic condition related to ID/DD is present.

October 2024

EPILEPSY
A common chronic
neurological disorder that is
characterized by recurrent
unprovoked seizures.

Page A-33

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1550: Conditions Related to Intellectual
Disability/Developmental Disability (ID/DD)
Status (cont.)
•

Code E: if an ID/DD condition is present but the

•

Code Z: if ID/DD condition is not present.

resident does not have any of the specific conditions
listed.

DEFINITION

OTHER ORGANIC
CONDITION RELATED
TO ID/DD
Examples of diagnostic
conditions include congenital
syphilis, maternal
intoxication, mechanical
injury at birth, prenatal
hypoxia, neuronal lipid
storage diseases,
phenylketonuria (PKU),
neurofibromatosis,
microcephalus,
macroencephaly,
meningomyelocele,
congenital hydrocephalus,
etc.

A1600–A1805: Most Recent Admission/Entry or Reentry into this
Facility

October 2024

Page A-34

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1600: Entry Date

Item Rationale
•

DEFINITION

To document the date of admission/entry or reentry into
the facility.

Coding Instructions
•

Enter the most recent date of admission/entry or reentry
to this facility. Use the format: Month-Day-Year: XXXX-XXXX. For example, October 12, 2010, would be
entered as 10-12-2010.

ENTRY DATE
The initial date of admission
to the facility, or the date the
resident most recently
returned to your facility after
being discharged.

•

In the case of an interrupted stay, the return date (i.e., date of continuation of Medicare
Part A stay in the same SNF) is entered in A1600 using the format above.

A1700: Type of Entry

Item Rationale
•

Captures whether date in A1600 is an admission/entry or reentry date.

Coding Instructions
•

1. resident has never been admitted to this facility before; OR
2. resident has been in this facility previously and was discharged return not anticipated;
OR
3. resident has been in this facility previously and was discharged return anticipated and
did not return within 30 days of discharge.
Code 2, reentry: when all three of the following occurred prior to this entry; the
resident was:

•

Code 1, admission: when one of the following occurs:

1. admitted to this facility, AND
2. discharged return anticipated, AND
3. returned to facility within 30 days of discharge.

October 2024

Page A-35

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1805: Entered From

Item Rationale
Knowing the setting the individual was in immediately prior to facility admission/entry or
reentry informs the delivery of services and care planning that the resident receives
during their stay and may also inform discharge planning. See the Glossary and Common
Acronyms in Appendix A for additional descriptions of these settings.

•

Demographic information.

•

Steps for Assessment

1. Review transfer and admission records.

2. Ask the resident and/or family member, significant other, and/or guardian/legally authorized
representative.
DEFINITIONS

Coding Instructions

Enter the two-digit code that best describes the setting the
resident was in immediately preceding this admission/entry or
reentry.

•

Code 01, Home/Community: if the resident was

•

PRIVATE HOME OR
APARTMENT
Any house, condominium, or
apartment in the community
whether owned by the
resident or another person.
Also included in this category
are retirement communities
and independent housing for
the elderly.

admitted from a private home, apartment, board and
care, assisted living facility, group home, transitional
living, or adult foster care. A community residential
setting is defined as any house, condominium, or
apartment in the community, whether owned by the
resident or another person; retirement communities; or
independent housing for the elderly.

Code 02, Nursing Home (long-term care
facility): if the resident was admitted from an

institution that is primarily engaged in providing
medical and non-medical care to people who have a
chronic illness or disability.

October 2024

BOARD AND CARE/
ASSISTED LIVING/
GROUP HOME
A non-institutional community
residential setting that
includes services of the
following types: home health
services, homemaker/
personal care services, or
meal services.

Page A-36

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1805: Entered From (cont.)
•

•
•

Code 03, Skilled Nursing Facility (SNF, swing bed): if the resident was

admitted from a nursing facility with staff and equipment for the provision of skilled
nursing services, skilled rehabilitative services, and/or other related health services. This
category also includes residents admitted from a SNF swing bed in a swing bed hospital.
A swing bed hospital is a hospital or critical access hospital (CAH) participating in
Medicare that has CMS approval to provide posthospital SNF care and meets certain
requirements.
Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident
was admitted from a hospital that is contracted with Medicare to provide acute inpatient
care and accepts a predetermined rate as payment in full.
Code 05, Long-Term Care Hospital (LTCH): if the resident was admitted from a
Medicare certified acute care hospital that focuses on patients who stay, on average, more
than 25 days. Most patients in LTCHs are chronically and critically ill and have been
transferred there from an intensive or critical-care unit.

•

rehabilitation unit of a hospital that provides an intensive rehabilitation program to
inpatients. This category also includes residents admitted from a rehabilitation unit of a
critical access hospital.
Code 07, Inpatient Psychiatric Facility (psychiatric hospital or unit): if
the resident was admitted from an institution that provides, by or under the supervision of
a physician, psychiatric services for the diagnosis and treatment of mentally ill patients.
This category also includes residents admitted from a psychiatric unit of a critical access
hospital.
Code 08, Intermediate Care Facility (ID/DD): if the resident was admitted from
an institution that is engaged in providing, under the supervision of a physician, any
health and rehabilitative services for individuals with intellectual disabilities (ID) or
developmental disabilities (DD).
Code 09, Hospice (home/non-institutional): if the resident was admitted from a
community-based program for terminally ill persons.
Code 10, Hospice (institutional facility): if the resident was admitted from an
inpatient program for terminally ill persons where an array of services is necessary for the
palliation and management of terminal illness and related conditions. The hospice must
be licensed by the State as a hospice provider and/or certified under the Medicare
program as a hospice provider.
Code 11, Critical Access Hospital (CAH): if the resident was admitted from a
Medicare-participating hospital located in a rural area or an area that is treated as rural
and that meets all of the criteria to be designated by CMS as a CAH and was receiving
acute care services from the CAH at the time of discharge.

•

Code 06, Inpatient Rehabilitation Facility (IRF, free standing facility or
unit): if the resident was admitted from a rehabilitation hospital or a distinct

Code 12, Home under care of organized home health service
organization: if the resident was admitted from home under care of an organized home

health service organization. This includes only skilled services provided by a home health
agency.

October 2024

Page A-37

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1805: Entered From (cont.)
•

Code 99, Not listed: if the resident was admitted from none of the above.

Coding Tips and Special Populations
•

If an individual was enrolled in a home-based hospice program enter 09, Hospice,
instead of 01, Home/Community.

A1900: Admission Date (Date this episode of care in this facility
began)

D
Item Rationale
•

To document the date this episode of care in this facility began.

Coding Instructions

Enter the date this episode of care in this facility began. Use the format: Month-DayYear: XX-XX-XXXX. For example, October 12, 2010, would be entered as 10-12-2010.

•

The Admission Date may be the same as the Entry Date (A1600) for the entire stay (i.e.,
if the resident is never discharged).

Examples

•

1. Resident H was admitted to the facility from an acute care hospital on 09/14/2020 for
rehabilitation after a hip replacement. In completing their Admission assessment, the
facility entered 09/14/2020 in A1600, Entry Date; coded A1700 = 1, Admission; chose
Code 04, Short-Term General Hospital (acute hospital, IPPS) in item A1805, Entered
From; and entered 09/14/2020 in item A1900, Admission Date.

2. The facility received communication from an acute care hospital discharge planner
stating that Resident H, a former resident of the facility who was discharged home return
not anticipated on 11/02/2020 after a successful recovery and rehabilitation, was admitted
to their hospital on 2/8/2021 and wished to return to the facility for rehabilitation after
hospital discharge. Resident H returned to the facility on 2/15/2021. Although Resident H
was a resident of the facility in September of 2020, they were discharged home return not
anticipated; therefore, the facility rightly considered Resident H as a new admission. In
completing their Admission assessment, the facility entered 02/15/2021 in A1600, Entry
Date; coded A1700 = 1, Admission; chose Code 04, Short-Term General Hospital (acute
hospital, IPPS) in item A1805, Entered From; and entered 02/15/2021 in item A1900,
Admission Date.

October 2024

Page A-38

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1900: Admission Date (Date this episode of care in this facility
began) (cont.)
3. Resident K was admitted to the facility on 10/05/2020 and was discharged to the hospital,
return anticipated, on 10/20/2020. They returned to the facility on 10/26/2020. Since
Resident K was a resident of the facility, was discharged return anticipated, and returned
within 30 days of discharge, Resident K was considered as continuing in their current
stay. Therefore, when the facility completed Resident K’s Entry Tracking Record on
return from the hospital, they entered 10/26/2020 in A1600, Entry Date; coded A1700 =
2, Reentry; chose Code 04, Short-Term General Hospital (acute hospital, IPPS) in item
A1805; and entered 10/05/2020 in item A1900, Admission Date.

Approximately a month after their return, Resident K was again sent to the hospital,
return anticipated on 11/05/2020. They returned to the facility on 11/22/2020. Again,
since Resident K was a resident of the facility, was discharged return anticipated, and
returned within 30 days of discharge, Resident K was considered as continuing in their
current stay. Therefore, when the facility completed Resident K’s Entry Tracking Record,
they entered 11/22/2020 in A1600, Entry Date; coded A1700 = 2, Reentry; chose Code
04, Short-Term General Hospital (acute hospital, IPPS) in item A1805; and entered
10/05/2020 in item A1900, Admission Date.

4. Resident S was admitted to the facility on 8/26/2021 for rehabilitation after a total knee
replacement. Three days after admission, Resident S spiked a fever and their surgical site
was observed to have increased drainage, was reddened, swollen and extremely painful.
The facility sent Resident S to the emergency room and completed their OBRA
Discharge assessment as return anticipated. The hospital called the facility to inform
them Resident S was admitted. A week into their hospitalization, Resident S developed a
blood clot in their affected leg, further complicating their recovery. The facility was
contacted to readmit Resident S for rehabilitative services following discharge from the
hospital on 10/10/2021. Even though Resident S was a former patient in the facility’s
rehabilitation unit and was discharged return anticipated, they did not return within 30
days of discharge to the hospital. Therefore, Resident S is considered a new admission to
the facility. On their return, when the facility completed Resident S’s Admission
assessment, they entered 10/10/2021 in A1600, Entry Date; coded A1700 = 1,
Admission; chose Code 04, Short-Term General Hospital (acute hospital, IPPS) in item
A1805, Entered From; and entered 10/10/2021 in item A1900, Admission Date.

Coding Tips and Special Populations
•

Both swing bed facilities and nursing homes must apply the above instructions for coding
items A1600 through A1900 to determine whether a patient or resident is an
admission/entry or reentry.

•

In determining if a patient or resident returns to the facility within 30 days, the day of
discharge from the facility is not counted in the 30 days. For example, a resident
discharged return anticipated on December 1 would need to return to the facility by
December 31 to meet the “within 30 days” requirement.

October 2024

Page A-39

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A1900: Admission Date (Date this episode of care in this facility
began) (cont.)
If the Type of Entry for this assessment is an Admission (A1700 = 1), the Admission
Date (A1900) and the Entry Date (A1600) must be the same.

•

If the Type of Entry for this assessment is a Reentry (A1700 = 2), the Admission Date
(A1900) will remain the same, and the Entry Date (A1600) must be later than the date in
A1900.

•

Item A1900 (Admission Date) is tied to items A1600 (Entry Date), A1700 (Type of
Entry), and A1805 (Entered From). It is also tied to the concepts of a “stay” and an
“episode.” A stay is a set of contiguous days in the facility and an episode is a series of
one or more stays that may be separated by brief interruptions in the resident’s time in the
facility. An episode continues across stays until one of three events occurs: the resident is
discharged with return not anticipated, the resident is discharged with return anticipated
but is out of the facility for more than 30 days, or the resident dies in the facility.

•

A1900 (Admission Date) should remain the same on all assessments for a given episode
even if it is interrupted by temporary discharges from the facility. If the resident is
discharged and reenters within the course of an episode, that will start a new stay. The
date in item A1600 (Entry Date) will change, but the date in item A1900 (Admission
Date) will remain the same. If the resident returns after a discharge return not anticipated
or after a gap of more than 30 days outside of the facility, a new episode would begin and
a new admission would be required.

•

When a resident is first admitted to a facility, item A1600 (Entry Date) should be coded
with the date the person first entered the facility, and A1700 (Type of Entry) should be
coded as 1, Admission. The place where the resident was admitted from should be
documented in A1805 (Entered From), and the date in item A1900 (Admission Date)
should match the date in A1600 (Entry Date). These items would be coded the same way
for all subsequent assessments within the first stay of an episode. If the resident is briefly
discharged (e.g., brief hospitalization) and then reenters the facility, a new (second) stay
would start, but the current episode would continue. On the Entry Tracking Record and
on subsequent assessments for the second stay, the date in A1600 (Entry Date) would
change depending on the date of reentry, and item A1700 (Type of Entry) would be
coded as 2, Reentry. Item A1805 (Entered From) would reflect where the resident was
prior to this reentry, and item A1900 (Admission Date) would continue to show the
original admission date (the date that began their first stay in the episode).

•

October 2024

Page A-40

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2000: Discharge Date

Item Rationale
•

Closes the episode in iQIES.

Coding Instructions
Enter the date the resident was discharged (whether or not return is anticipated). This is
the date the resident leaves the facility.

•

For OBRA Discharge assessments, the Discharge Date (A2000) and ARD (A2300) must
be the same date.

•

Do not include leave of absence or hospital observational stays less than 24 hours unless
admitted to the hospital.

•

Obtain data from the medical, admissions or transfer records.

•

Coding Tips and Special Populations

A Part A PPS Discharge assessment (NPE Item Set) is required under the SNF QRP
when the resident’s Medicare Part A stay ends, but the resident does not leave the
facility.

•

The PPS Discharge assessment is completed whenever a Medicare Part A stay ends. The
PPS Discharge assessment must be combined with the OBRA Discharge assessment
when the Medicare Part A stay ends on or one day prior to the day of discharge from the
facility. When the OBRA and Part A discharge assessments are combined, the ARD
(A2300) must be equal to the day of discharge from the facility (A2000).

•

The PPS Discharge assessment is also completed when the resident’s Medicare Part A
stay ends, but the resident remains in the facility. When this occurs, the ARD (A2300) of
the PPS Discharge assessment must be the last Medicare Part A covered day. The PPS
Discharge assessment may be combined with most OBRA-required assessments when
requirements for all assessments are met (please see Section 2.10 Combining PPS
Assessments and OBRA Assessments).

October 2024

•

Page A-41

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2105: Discharge Status

Item Rationale
•

This item documents the location to which the resident is being discharged at the time of
discharge. Knowing the setting to which the individual was discharged helps to inform
discharge planning. See the Glossary and Common Acronyms in Appendix A for
additional descriptions of these settings.

•

Demographic and outcome information.

Steps for Assessment

1. Review the medical record including the discharge plan and discharge orders for
documentation of discharge location.

Coding Instructions

Select the two-digit code that corresponds to the resident’s discharge status.
•

apartment, board and care, assisted living facility, group home, transitional living, or
adult foster care. A community residential setting is defined as any house, condominium,
or apartment in the community, whether owned by the resident or another person;
retirement communities; or independent housing for the elderly.
Code 02, Nursing Home (long-term care facility): if the resident was
discharged to an institution that is primarily engaged in providing medical and nonmedical care to people who have a chronic illness or disability.

October 2024

•

Code 01, Home/Community: if the resident was discharged to a private home,

Page A-42

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2105: Discharge Status (cont.)
•

•
•

Code 03, Skilled Nursing Facility (SNF, swing beds): if the resident was

discharged to a nursing facility with staff and equipment for the provision of skilled
nursing services, skilled rehabilitative services, and/or other related health services. This
category also includes patients admitted from a SNF swing bed in a swing bed hospital. A
swing bed hospital is a hospital or critical access hospital (CAH) participating in
Medicare that has CMS approval to provide posthospital SNF care and meets certain
requirements.
Code 04, Short-Term General Hospital (acute hospital/IPPS): if the resident
was discharged to a hospital that is contracted with Medicare to provide acute, inpatient
care and accepts a predetermined rate as payment in full.
Code 05, Long-Term Care Hospital (LTCH): if the resident was discharged to a
Medicare certified acute care hospital that focuses on patients who stay, on average, more
than 25 days. Most patients in LTCHs are chronically and critically ill and have been
transferred there from an intensive or critical-care unit.

•

October 2024

•

rehabilitation unit of a hospital that provides an intensive rehabilitation program to
inpatients. This category also includes residents discharged to a rehabilitation unit of a
critical access hospital.
Code 07, Inpatient Psychiatric Facility (psychiatric hospital or unit): if
the resident was discharged to an institution that provides, by or under the supervision of
a physician, psychiatric services for the diagnosis and treatment of mentally ill residents.
This category also includes residents discharged to a psychiatric unit of a critical access
hospital.
Code 08, Intermediate Care Facility (ID/DD): if the resident was discharged to
an institution that is engaged in providing, under the supervision of a physician, any
health and rehabilitative services for individuals who have intellectual disabilities (ID) or
developmental disabilities (DD).
Code 09, Hospice (home/non-institutional): if the resident was discharged to a
community-based program for terminally ill persons.
Code 10, Hospice (institutional facility): if the resident was discharged to an
inpatient program for terminally ill persons where an array of services is necessary for the
palliation and management of terminal illness and related conditions. The hospice must
be licensed by the State as a hospice provider and/or certified under the Medicare
program as a hospice provider.
Code 11, Critical Access Hospital (CAH): if the resident was discharged to a
Medicare-participating hospital located in a rural area or an area that is treated as rural
and that meets all of the criteria to be designated by CMS as a CAH and was receiving
acute care services from the CAH at the time of discharge.

•

Code 06, Inpatient Rehabilitation Facility (IRF, free standing facility or
unit): if the resident was discharged to a rehabilitation hospital or a distinct

Page A-43

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2105: Discharge Status (cont.)
•

Code 12, Home under care of organized home health service
organization: if the resident was discharged home under care of an organized home

•

health service organization. This includes only skilled services provided by a home health
agency.
Code 13, deceased: if resident is deceased.

•

Code 99, Not listed: if the resident was discharged to none of the above.

A2121. Provision of Current Reconciled Medication List to
Subsequent Provider at Discharge
Complete only if A0310H = 1 and A2105 = 02-12.

D
•

Item Rationale

The transfer of a current reconciled medication list at the time of discharge can improve
care coordination and quality of care and help subsequent providers reconcile
medications, and it may mitigate adverse outcomes related to medications.
Communication of medication information at discharge is critical to ensure safe and
effective transitions from one health care setting to another.

Steps for Assessment

1. Determine whether the resident was discharged to one of the subsequent providers defined
below under Coding Tips, based on discharge location item A2105.
2. If yes, determine whether, at the time of discharge, your facility provided a current
reconciled medication list to the resident’s subsequent provider.

Coding Instructions
•

Code 0, No: if at discharge to a subsequent provider, your facility did not provide the

•

Code 1, Yes: if at discharge to a subsequent provider, your facility did provide the

resident’s current reconciled medication list to the subsequent provider, or the resident
was not discharged to a subsequent provider.
resident’s current reconciled medication list to the subsequent provider.

October 2024

Page A-44

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2121. Provision of Current Reconciled Medication List to
Subsequent Provider at Discharge (cont.)
Coding Tips
•

Subsequent provider—For the purposes of coding this item, a subsequent provider is
based on the discharge locations in A2105 and defined as any of the following:
Nursing home (long-term care facility)
Skilled nursing facility (SNF, swing beds)
Short-term general hospital (acute hospital, IPPS)
Long-term care hospital (LTCH)
Inpatient rehabilitation facility (IRF, free standing facility or unit)
Inpatient psychiatric facility (psychiatric hospital or unit)
Intermediate care facility (ID/DD facility)
Hospice (home/non-institutional)
DEFINITION
Hospice (institutional facility)
Critical access hospital (CAH)
MEANS OF PROVIDING A
CURRENT RECONCILED
Home under care of organized home
MEDICATION LIST
health service organization

•

02.
03.
04.
05.
06.
07.
08.
09.
10.
11.
12.

While the resident may receive care from other
providers after discharge from your facility, such as
primary care providers, other outpatient providers, and
residential treatment centers, these locations are not
considered to be a subsequent provider for the purpose
of coding this item.

Current Reconciled Medication list—This refers to a
list of the resident’s current medications at the time of
discharge that was reconciled by the facility prior to the
resident’s discharge.

Providing the current reconciled
medication list at the time of
transfer or discharge can be
accomplished by any means,
including active means (e.g., by
mail, electronically, or verbally)
and more passive means (e.g., a
common electronic health record
[EHR]), giving providers access
2
to a portal).

•

Your facility should be guided by current standards of care and any applicable
regulations and guidelines (e.g., Requirements of Participation) in determining what
information should be included in a current reconciled medication list.

•

In the case of a standalone Medicare Part A PPS Discharge assessment (A0310A = 99,
A0310B = 99, A0310F = 99, and A0310H = 1) with the resident staying on the same unit
and with the same team of interdisciplinary professionals, code A2121. Provision of
Current Reconciled Medication List to Subsequent Provider at Discharge as 1, Yes.

2 A portal is a secure online website that gives providers, patients, and others convenient, 24-hour access to personal

health information from anywhere with an Internet connection. Using a secure username and password, providers
and patients can view health information such as current medications, recent doctor visits and discharge
summaries. Retrieved from https://www.healthit.gov/faq/what-patient-portal April 2, 2019.

October 2024

Page A-45

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2121. Provision of Current Reconciled Medication List to
Subsequent Provider at Discharge (cont.)
•

In the case of a standalone Medicare Part A PPS Discharge assessment (A0310A = 99,
A0310B = 99, A0310F = 99, and A0310H = 1) and the resident is moving to a different
unit and/or interdisciplinary team (IDT), code A2121. Provision of Current Reconciled
Medication List to Subsequent Provider at Discharge based on whether a member of the
resident’s IDT transferred the resident’s current reconciled medication list to the
subsequent unit and/or IDT.

Additional Considerations for Important Medication List Content
•

The following information on the important content that may be included in a reconciled
medication list is provided as guidance. This guidance does not dictate what information
should be included in your facility’s current reconciled medication list in order to code 1,
Yes, that a current reconciled medication list was provided to the subsequent provider.
The completeness of this reconciled medication list is left to the discretion of the
providers who are coordinating this care with the resident. Examples of information that
could be part of a reconciled medication list can be, but are not limited to:

— Types of medications—Current prescribed and over-the-counter (OTC) medications,
nutritional supplements, vitamins, and homeopathic and herbal products administered
by any route at the time of discharge. Medications may also include total parenteral
nutrition (TPN) and oxygen.
— The list of reconciled medications could include those that are:

o active, including those that are scheduled to be discontinued after discharge;

o held during the stay and planned to be continued/resumed after discharge; and

o discontinued during the stay, if potentially relevant to the resident’s subsequent
care.

— Information included—A reconciled medication list often includes important
information about (1) the resident—including their name, date of birth, active
diagnoses, known medication and other allergies, and known drug sensitivities and
reactions; and (2) each medication, including the name, strength, dose, route of
medication administration, frequency or timing, purpose/indication, and any special
instructions (e.g., crush medications). For any held medications, it may include the
reason for holding the medication and when medication should resume. This
information can improve medication safety. Additional information may be
applicable and important to include in the medication list, such as the resident’s
weight and date taken, preferred language, and ability to self-administer medication;
when the last dose of the medication was administered by the discharging provider;
and when the final dose should be administered (e.g., end of treatment).

October 2024

Page A-46

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2121. Provision of Current Reconciled Medication List to
Subsequent Provider at Discharge (cont.)
Examples
1. Resident B is being discharged from the SNF to an acute care hospital in the same health care
system that uses the same electronic health record (EHR), also sometimes referred to as an
electronic medical record (EMR) (see Definitions: EHR/EMR and definition in the glossary).
Resident B’s current reconciled medication list at the time of discharge from the SNF is
accessible to the subsequent acute care hospital staff admitting Resident B, and this is how
the medication list is shared.
Coding: A2121 would be coded 1, Yes.

Rationale: Having access to Resident B’s medication list through the same EHR

system is one way to transfer a medication list. This code of 1, Yes, is used for this
passive means of transferring the medication list when the sending and receiving provider
can access the same EHR system.

2. Resident D is not taking any prescribed or over-the-counter medications at the time of
discharge.

Coding: If the lack of any medications for a resident is clearly documented and

communicated to the subsequent provider when the resident is discharged, code 1, Yes,
that the medication list was transferred. If this information is not communicated to the
subsequent provider, code 0, No.

Rationale: Information confirming that the resident is not taking any medications at

discharge is important for the subsequent provider.

3. Resident F was transferred to an acute care hospital with a reconciled medication list that
included a list of their current medications, but with less additional information than is
usually provided by the SNF at discharge because of the urgency of the situation. Some of
the contraindications for the medications, as well as resident weight and height and dates
taken, were omitted from the medication list.
Coding: A2121 would be coded 1, Yes.

Rationale: As long as a current reconciled list of medications is provided to the

admitting provider, this item should be coded 1, Yes.

4. Resident J’s Medicare Part A stay ended, and they were transferred to a long-term care unit
in the same nursing home. The IDT from the subacute unit staff provided and reviewed with
the long-term care unit staff a reconciled medication list at the time of transfer.
Coding: A2121 would be coded 1, Yes.
Rationale: If a current reconciled list of medications is provided to the subsequent

provider (in this case, a different unit staff in the same nursing home), this item should be
coded 1, Yes.

October 2024

Page A-47

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2121. Provision of Current Reconciled Medication List to
Subsequent Provider at Discharge (cont.)
5. Resident P’s Medicare Part A stay ended, and they remained in the same dually certified bed
in the nursing home with care provided by the same IDT.
Coding: A2121 would be coded 1, Yes
Rationale: As the same IDT continued to care for Resident P and have access to the

current list of reconciled medications, this item should be coded 1, Yes.

6. Resident G’s reconciled medication list was electronically faxed to the subsequent provider,
and this action is documented in their clinical record. However, the subsequent provider’s
records do not show documentation that the fax was successfully received.

Coding: A2121, would be coded 1, Yes.
Rationale: Documentation of the subsequent provider’s successful receipt of the

reconciled medication list is not a required component for this item.

A2122. Route of Current Reconciled Medication List
Transmission to Subsequent Provider

ra
The guidance below addresses coding A2122. Route of Current Reconciled Medication List
Transmission to Subsequent Provider. Assessors should apply this same guidance to A2124.
Route of Current Reconciled Medication List Transmission to Resident.

Item Rationale

This item collects important data to monitor how medication lists are transmitted at discharge.

Steps for Assessment
1. Identify all routes of transmission that were used to provide the resident’s current reconciled
medication list to the subsequent provider.

October 2024

Page A-48

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2122. Route of Current Reconciled Medication List
Transmission to Subsequent Provider (cont.)
Coding Instructions

Select the codes that correspond to the routes of transmission used to provide the medication
list to the subsequent provider.
DEFINITIONS
• Check A2122A, Electronic Health Record: if
your facility has an EHR, sometimes referred to as an
EHR/EMR
electronic medical record (EMR), and used it to
transmit or provide access to the reconciled medication
An electronic health record
(EHR), sometimes referred to as
list to the subsequent provider. This would include
an electronic medical record
situations in which both the discharging and receiving
(EMR), is an electronic version of
provider have direct access to a common EHR system.
a resident’s medical history that is
Checking this route does not require confirmation that
by the provider over
the subsequent provider has accessed the common EHR maintained
time. 3
system for the medication list.
•

PORTAL
A portal is a secure online
website that gives providers,
residents, and others convenient,
24-hour access to personal
health information from anywhere
4
with an Internet connection.

•

Check A2122B, Health Information
Exchange: if your facility participates in a Health
Information Exchange (HIE) and used the HIE to
electronically exchange the current reconciled medication
list with the subsequent provider.
Check A2122C, Verbal: if the current reconciled

medication list information was verbally communicated
(e.g., in-person, telephone, video conferencing) to the subsequent provider.

Check A2122D, Paper-Based: if the current reconciled medication list was
transmitted to the subsequent provider using a paper-based method such as a printout, fax,
or eFax.

•

Check A2122E, Other Methods: if the current reconciled medication list was

•

transmitted to the subsequent provider using another method not listed above (e.g.,
texting, email, CDs).

3 https://www.healthit.gov/faq/what-electronic-health-record-ehr.
4 Office of the National Coordinator, What is a patient portal? Available from https://www.healthit.gov/faq/what-

patient-portal, Accessed June 10, 2019.

October 2024

Page A-49

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2123. Provision of Current Reconciled Medication List to
Resident at Discharge
Complete only if A0310H = 1 and A2105 = 01, 99.

Item Rationale
•

Communication of medication information to the resident at discharge is critical to
ensuring safe and effective discharges. The item, collected at the time of discharge, can
improve care coordination and quality of care, aids in medication reconciliation, and may
mitigate adverse outcomes related to medications.

•

It is recommended that a reconciled medication list that is provided to the resident, family
member, guardian/legally authorized representative, or caregiver use consumer-friendly
terminology and plain language to ensure that the information provided is clear and
understandable. 5

Steps for Assessment

1. Determine whether the resident was discharged to a home setting, 01, defined below under
Coding Tips, or 99, Not Listed based on discharge location item A2105.
2. If yes, determine whether, at discharge, your facility provided the resident’s medication list
to the resident, family member, guardian/legally authorized representative, and/or caregiver.

Coding Instructions

Code 0, No: if at discharge to a home setting (A2105 = 01) or a not listed location
(A2105 = 99), your facility did not provide the resident’s current reconciled medication
list to the resident, family, guardian/legally authorized representative, and/or caregiver.

•

Code 1, Yes: if at discharge to a home setting (A2105 = 01) or a not listed location

•

(A2105 = 99), your facility did provide the resident’s current reconciled medication list to
the resident, family, guardian/legally authorized representative, and/or caregiver.

5 For examples of plain language resources for healthcare information see:

https://www.plainlanguage.gov/resources/content-types/healthcare/

October 2024

Page A-50

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2123. Provision of Current Reconciled Medication List to
Resident at Discharge (cont.)
Coding Tips
•

Resident, family, significant other, guardian/legally authorized representative
and/or caregiver—The recipient of the current reconciled medication list can be the
resident, family member, significant other, guardian/legally authorized representative,
and/or caregiver in order to code 1, Yes, a current reconciled medication list was
transferred. It is not necessary to provide the current reconciled medication list to all of
these recipients in order to code 1, Yes.

Examples

1. Resident D does not take any prescribed or over-the-counter medications at the time of
discharge.
Coding: If it is clearly documented that the resident is taking no medications and this is

then clearly communicated to the resident, family member, significant other, and/or
caregiver when the resident is discharged, A2123 would be coded 1, Yes, that the
medication list was transferred. If this information is not communicated to the resident,
family member, significant other, guardian/legally authorized representative, and/or
caregiver, code 0, No.

Rationale: Information confirming that the resident is not taking any medications at

discharge is important for the resident, family member, significant other, guardian/legally
authorized representative, and/or caregiver.

2. Resident F is cognitively impaired and unable to manage their medications after discharge.
Their medication list is provided to their sibling, who will be their primary caregiver.
Coding: A2123 would be coded 1, Yes.

Rationale: The medication list must be provided to the resident, family member,

significant other, guardian/legally authorized representative, and/or a caregiver in order to
code 1, Yes. In this example, Resident F’s sibling is a family member and a caregiver, so
code 1, Yes.

3. Resident P chooses to leave the facility before their treatment is completed. They tell the
charge nurse on their way out the door that their ride is waiting for them and they are going
home. The charge nurse explains that they have not completed their course of treatment and
are not ready to be discharged, but they insist that they are leaving now and proceed out of
the facility.
Coding: A2123 would be coded 0, No.
Rationale: No medication list review was completed, and no medication list was

provided to Resident P as they left against medical advice and did not want to keep their
ride waiting.

October 2024

Page A-51

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2124. Route of Current Reconciled Medication List Transmission
to Resident

Item Rationale

This item collects important data to monitor how medication lists are transmitted at discharge.

Steps for Assessment

1. Identify all routes of transmission that were used to provide the resident’s current reconciled
medication list to the resident, family member, significant other, guardian/legally authorized
representative, and/or caregiver.

Coding Instructions

Please refer to the coding instructions for A2122. Route of Current Reconciled Medication List
Transmission to Subsequent Provider.

Coding Tips for A2122 and A2124

The route of transmission usually is established with each subsequent provider,
depending on how it is able to receive information from your facility. The route(s) may
not always be documented in the resident’s record. It will be helpful to understand and
document how your facility typically transmits information to each subsequent provider
at discharge to prepare for coding this item.

•

More than one route of transmission may apply. Check all that apply.

October 2024

•

Page A-52

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2124. Route of Current Reconciled Medication List Transmission
to Resident (cont.)
Examples
1. A SNF is discharging and sending a resident to a hospital by ambulance. The driver obtains a
printout and brings the resident’s medication list to the hospital. The facility follows up with
a call to the subsequent provider and discusses the resident’s medications.
Coding: Check paper-based (D) and verbal (C) for A2122.
Rationale: Two routes for transmitting the medication list information were used—a

paper copy of the list (D) and follow up verbal discussion (C). Both of these occurred at
the time of discharge.

2. One of a SNF’s referral HHAs is preparing to admit a resident who will discharge soon. The
HHA intake nurse has secure access to the SNF’s EHR to obtain important care planning
information from the resident’s records, including the medication list.
Coding: Check Electronic Health Record (A) for A2122.
Rationale: The SNF provided access to the resident’s medication list through its EHR.

Even if there is no confirmation that the intake nurse accessed the medication list from
the SNF’s EHR system, code EHR (A) because it was made available by the SNF.

3. Resident P receives a paper copy of their medication list, receives education about their
medications from the SNF nurse at discharge, and is notified that the SNF’s patient portal is
another means by which they can obtain their discharge medication list.
Coding: Check Electronic Health Record (A), verbal (C), and paper-based (D) for

A2124.

Rationale: The copy of the medication list is paper-based (D). The information about

Resident P’s medication list was also communicated verbally by the nurse at the time of
discharge (C). The resident portal uses the SNF’s EHR to provide access to the
medication list (A). It is not necessary to confirm that Resident P is a registered user of
and accessed the patient portal in order to code EHR (A) as a route.

October 2024

Page A-53

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2124. Route of Current Reconciled Medication List Transmission
to Resident (cont.)
4. A SNF participates in a regional HIE as does a local acute care hospital. When residents are
discharged to this acute care hospital, the SNF’s discharge medication list is included in the
medications section of a transfer summary document from its EHR, which is electronically
exchanged through the HIE. The acute care hospital is then able to obtain and integrate the
medication information into its EHR.
Coding: Check Electronic Health Record (A) and Health Information Exchange (B) for

A2122.

Rationale: The medication information is exchanged by the regional HIE through

health IT standards. Sending the medication information in transfer summary allows the
acute care hospital to integrate the medication information into its EHR. Code as EHR
(A), since it was used to generate and exchange the information, and as HIE (B), since it
is the means through which information exchange is possible with external providers.

5. A SNF has developed an interface that allows documents from its EHR to be electronically
faxed to the subsequent provider. The SNF’s EHR connects via a phone line to a designated
receiver’s secure email at the subsequent provider.

Coding: Check paper-based (D) for A2122.

Rationale: Faxing information is considered paper-based as faxed documents are

comparable to hard-copy documents and not computable.

6. A SNF generates the current reconciled medication list electronically from the medication
administration record (MAR) and treatment administration record (TAR) and electronically
sends via secure email to the subsequent provider.
Coding: Check Other Method (E) for A2122.

Rationale: Providing the medication list through secure email is considered “Other

Method” for coding this item. The source of the medication list is not the EHR, and the
list is not transmitted directly to the subsequent provider’s EHR, so do NOT check EHR
(A).

October 2024

Page A-54

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2200: Previous Assessment Reference Date for Significant
Correction

Item Rationale
•

To identify the ARD of a previous comprehensive (A0310 = 01, 03, or 04) or Quarterly
assessment (A0310A = 02) in which a significant error is discovered.

Coding Instructions
Complete only if A0310A = 05 (Significant Correction to Prior Comprehensive
Assessment) or A0310A = 06 (Significant Correction to Prior Quarterly Assessment).

•

Enter the ARD of the prior comprehensive or Quarterly assessment in which a significant
error has been identified and a correction is required.

•

A2300: Assessment Reference Date

Item Rationale
•

Designates the end of the observation period so that all assessment items refer to the
resident’s status during the same period of time.

As the last day of the observation period, the ARD serves as the reference point for
determining the care and services captured on the MDS assessment. Anything that
happens after the ARD will not be captured on that MDS. For example, for an MDS item
with a 7-day observation period, assessment information is collected for a 7-day period
ending on and including the ARD which is the 7th day of this observation period. For an
item with a 14-day observation period, the information is collected for a 14-day period
ending on and including the ARD. The observation period includes observations and
events through the end of the day (midnight) of the ARD.

October 2024

Page A-55

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2300: Assessment Reference Date (cont.)
Steps for Assessment
1. Interdisciplinary team members should select the ARD
based on the reason for the assessment and compliance with
all timing and scheduling requirements outlined in
Chapter 2.

Coding Instructions
•

Enter the appropriate date on the lines provided. Do not
leave any spaces blank. If the month or day contains
only a single digit, enter a “0” in the first space. Use
four digits for the year. For example, October 2, 2010,
should be entered as: 10-02-2010.

D
•

For detailed information on the timing of the
assessments, see Chapter 2 on assessment schedules.

•

For discharge assessments, the discharge date item
(A2000) and the ARD item (A2300) must contain the
same date.

ASSESSMENT
REFERENCE DATE
(ARD)
The specific end-point for the
observation periods in the
MDS assessment process.
Almost all MDS items refer to
the resident’s status over a
designated time period
referring back in time from
the Assessment Reference
Date (ARD). Most frequently,
this observation period, also
called the look-back or
assessment period, is a 7day period ending on the
ARD. Observation periods
may cover the 7 days ending
on this date, 14 days ending
on this date, etc.

Coding Tips and Special Populations

DEFINITION

When the resident dies or is discharged prior to the end
of the observation period for a required assessment, the
ARD must be adjusted to equal the discharge date.

•

The observation period may not be extended simply because a resident was out of the
nursing home during part of the observation period (e.g., a home visit, therapeutic leave,
or hospital observation stay less than 24 hours when resident is not admitted). For
example, if the ARD is set at day 13 and there is a 2-day temporary leave during the
observation period, the 2 leave days are still considered part of the observation period.

•

When collecting assessment information, data from the time period of the leave of
absence is captured as long as the particular MDS item permits. For example, if the
family takes the resident to their home for a holiday and the resident falls, the assessor
will capture the fall in J1900: Number of Falls Since Admission/Entry or Reentry or
Prior Assessment (OBRA or Scheduled PPS), whichever is more recent. This
requirement applies to all assessments, regardless of whether they are being completed
for clinical or payment purposes.

October 2024

•

Page A-56

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2400: Medicare Stay

Item Rationale
Identifies when a resident is receiving services under the scheduled PPS.

•

Identifies when a resident’s Medicare Part A stay begins and ends.

•

Coding Instructions for A2400A, Has the
Resident Had a Medicare-covered Stay
since the Most Recent Entry?
Code 0, no: if the resident has not had a Medicare

•

Code 1, yes: if the resident has had a Medicare Part
A covered stay since the most recent admission/entry or
reentry. Continue to A2400B.

Part A covered stay since the most recent
admission/entry or reentry. Skip to B0100, Comatose.

Code the date of day 1 of this Medicare stay if
A2400A is coded 1, yes.

Coding Instructions for A2400C, End Date of
Most Recent Medicare Stay

Code the date of last day of this Medicare stay if
A2400A is coded 1, yes.

October 2024

MEDICARE-COVERED
STAY
Skilled Nursing Facility stays
billable to Medicare Part A.
Does not include stays
billable to Medicare
Advantage HMO plans.

Coding Instructions for A2400B, Start of Most
Recent Medicare Stay

•

MOST RECENT
MEDICARE STAY
This is a Medicare Part A
covered stay that has started
on or after the most recent
admission/entry or reentry to
the nursing facility.

•

DEFINITIONS

CURRENT MEDICARE
STAY
NEW ADMISSION: Day 1 of
Medicare Part A stay.
READMISSION: Day 1 of
Medicare Part A coverage
after readmission following a
discharge.

Page A-57

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2400: Medicare Stay (cont.)
•

If the Medicare Part A stay is ongoing, there will be no end date to report. Enter dashes to
indicate that the stay is ongoing.

•

The end of Medicare date is coded as follows, whichever occurs first:
— Date SNF benefit exhausts (i.e., the 100th day of the benefit); or
— Date of last day covered as recorded on the effective date from the Notice of
Medicare Non-Coverage (NOMNC); or
— The last paid day of Medicare A when payer source changes to another payer
(regardless if the resident was moved to another bed or not); or
— Date the resident was discharged from the facility (see Item A2000, Discharge Date).

Coding Tips and Special Populations
When a resident on Medicare Part A returns following a therapeutic leave of absence or a
hospital observation stay of less than 24 hours (without hospital admission), this is a
continuation of the Medicare Part A stay, not a new Medicare Part A stay.

•

When a resident on Medicare Part A has an interrupted stay (i.e., is discharged from SNF
care and subsequently readmitted to the same SNF within the interruption window after
the discharge), this is a continuation of the Medicare Part A stay, not a new Medicare Part
A stay.

•

The End Date of the Most Recent Medicare Stay (A2400C) may be earlier than the
actual Discharge Date (A2000) from the facility. If this occurs, the Part A PPS Discharge
assessment is required. If the resident subsequently physically leaves the facility, the
OBRA Discharge assessment would be required.

•

If the End Date of Most Recent Medicare Stay (A2400C) occurs on the day of or one
day before the Discharge Date (A2000), the OBRA Discharge assessment and Part A
PPS Discharge assessment are both required and must be combined. When the OBRA
and Part A PPS Discharge assessments are combined, the ARD (A2300) must be equal to
the Discharge Date (A2000).

•

If the End Date of Most Recent Medicare Stay (A2400C) occurs on the same day that
the resident dies, a Death in Facility Tracking Record is completed, with the Discharge
Date (A2000) equal to the date the resident died. In this case, a Part A PPS Discharge
assessment is not required.

•

For a standalone Part A PPS Discharge assessment, the End Date of the Most Recent
Medicare Stay (A2400C) must be equal to the ARD (Item A2300).

October 2024

•

Page A-58

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2400: Medicare Stay (cont.)
Examples
1. Resident G. began receiving services under Medicare Part A on October 14, 2021. Due to
their stable condition and ability to manage their medications and dressing changes, the
facility determined that they no longer qualified for Part A SNF coverage and began
planning their discharge. An Advanced Beneficiary Notice (ABN) and an NOMNC with
the last day of coverage as November 23, 2021 were issued. Resident G. was discharged
home from the facility on November 24, 2021. Code the following on their combined
OBRA and Part A PPS Discharge assessment:
A0310F = 10

•

A0310G = 1

•

A0310H = 1

•

A2000 = 11-24-2021

•

A2105 = 01

•

A2300 = 11-24-2021

•

A2400A = 1

•

A2400B = 10-14-2021

•

A2400C = 11-23-2021

•

Rationale: Because Resident G’s last day covered under Medicare was one day before
their physical discharge from the facility, a combined OBRA and Part A PPS Discharge
was completed.

•

A2400A = 1

•

A2400B = 12-11-2021

•

A2400C = ----------

2. Resident N began receiving services under Medicare Part A on December 11, 2021. They
were unexpectedly sent to the emergency department on December 19, 2021 at 8:30 p.m.
and were not admitted to the hospital. They returned to the facility on December 20,
2021, at 11:00 a.m. Upon Resident N’s return, their physician’s orders included
significant changes in their treatment regime. The facility staff determined that an Interim
Payment Assessment (IPA) was indicated as the PDPM nursing component was
impacted. They completed the IPA with an ARD of December 24, 2021. Code the
following on the IPA:

Rationale: Resident N was out of the facility at midnight but returned in less than 24
hours and was not admitted to the hospital, so was considered LOA. Therefore, no
Discharge assessment was required. Their Medicare Part A Stay is considered ongoing;
therefore, the date in A2400C is dashed.

October 2024

Page A-59

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2400: Medicare Stay (cont.)
3. Resident R. began receiving services under Medicare Part A on October 15, 2021. Due to
complications from their recent surgery, they were unexpectedly discharged to the
hospital for emergency surgery on October 20, 2021, but are expected to return within 30
days. Code the following on their OBRA Discharge assessment:
A0310F = 11

•

A0310G = 2

•

A0310H = 1

•

A2000 = 10-20-2021

•

A2105 = 03

•

A2300 = 10-20-2021

•

A2400A = 1

•

A2400B = 10-15-2021

•

A2400C = 10-20-2021

•

Rationale: Resident R’s physical discharge to the hospital was unplanned, yet it is
anticipated that they will return to the facility within 30 days. Therefore, only an OBRA
Discharge was required. Even though only an OBRA Discharge was required, when the
Date of the End of the Medicare Stay is on the day of or one day before the Date of
Discharge, MDS specifications require that A0310H be coded as 1.

4. Resident K began receiving services under Medicare Part A on October 4, 2021. They
were discharged from Medicare Part A services on December 17, 2021. They and their
family had already decided that Resident K would remain in the facility for long-term
care services, and they were moved into a private room (which was dually certified) on
December 18, 2021. Code the following on their Part A PPS Discharge assessment:
A0310F = 99

•

A0310G = ^

•

A0310H = 1

•

A2000 = ^

•

A2105 = ^

•

A2300 = 12-17-2021

•

A2400A = 1

•

A2400B = 10-04-2021

•

A2400C = 12-17-2021

•

Rationale: Because Resident K’s Medicare Part A stay ended, and they remained in the
facility for long-term care services, a standalone Part A PPS Discharge was required.

October 2024

Page A-60

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

A2400: Medicare Stay (cont.)
5. Resident W began receiving services under Medicare Part A on November 15, 2021.
Their Medicare Part A stay ended on November 25, 2021, and they were unexpectedly
discharged to the hospital on November 26, 2021. However, they are expected to return
to the facility within 30 days. Code the following on their OBRA Discharge assessment:
A0310F = 11

•

A0310G = 2

•

A0310H = 1

•

A2000 = 11-26-2021

•

A2105 = 03

•

A2300 = 11-26-2021

•

A2400A = 1

•

A2400B = 11-15-2021

•

A2400C = 11-25-2021

•

Rationale: Resident W’s Medicare stay ended the day before discharge and they are
expected to return to the facility within 30 days. Because their discharge to the hospital
was unplanned, only an OBRA Discharge assessment was required. Even though only an
OBRA Discharge was required, when the Date of the End of the Medicare Stay is on the
day of or one day before the Date of Discharge, MDS specifications require that A0310H
be coded as 1.

October 2024

Page A-61

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [A]

Medicare Stay End Date Algorithm
A2400C
Is the resident's
Medicare stay
ongoing?

Yes

Enter dashes

Yes

Enter the date of the
last covered day,
i.e., the 100th day

Did the resident's
SNF benefit
exhaust?

Was a generic
notice issued to the
resident?

Yes

Enter the effective
date on the Generic
Notice for last
covered day*

Did the resident's
payer source
change from Part A
to another payer?

Yes

Enter the date of the
last paid day of
Medicare A

Enter the date
resident was
discharged from
facility
*if resident leaves facility prior to last covered day as recorded on the generic
notice, enter date resident left facility.

October 2024

Page A-62

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

SECTION B: HEARING, SPEECH, AND VISION
Intent: The intent of items in this section is to document whether the resident is comatose, the
resident’s ability to hear (with assistive hearing devices, if they are used), understand, and
communicate with others, and the resident’s ability to see objects nearby in their environment.

B0100: Comatose

DEFINITION

Item Rationale

Health-related Quality of Life

•

Residents who are in a coma or persistent vegetative
state are at risk for the complications of immobility,
including skin breakdown and joint contractures.

Planning for Care

Care planning should center on eliminating or
minimizing complications and providing care consistent
with the resident’s health care goals.

•

COMATOSE (coma)
A pathological state in which
neither arousal (wakefulness,
alertness) nor awareness
exists. The person is
unresponsive and cannot be
aroused; they do not open
their eyes, do not speak and
do not move their extremities
on command or in response
to noxious stimuli (e.g., pain).

Steps for Assessment

1. Review the medical record to determine if a neurological diagnosis of comatose or persistent
vegetative state has been documented by a physician, or nurse practitioner, physician
assistant, or clinical nurse specialist if allowable under state licensure laws.

Coding Instructions
•

Code 0, no: if a diagnosis of coma or persistent vegetative state is not present during

•

Code 1, yes: if the record indicates that a physician, nurse practitioner or clinical nurse
specialist has documented a diagnosis of coma or persistent vegetative state that is
applicable during the 7-day look-back period. Skip to Section GG, Functional Abilities.

the 7-day look-back period. Continue to B0200 Hearing.

October 2024

Page B-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B0100: Comatose (cont.)

DEFINITION

Coding Tips
•

Only code if a diagnosis of coma or persistent
vegetative state has been assigned. For example, some
residents in advanced stages of progressive neurologic
disorders such as Alzheimer’s disease may have severe
cognitive impairment, be non-communicative and sleep
a great deal of time; however, they are usually not
comatose or in a persistent vegetative state, as defined
here.

B0200: Hearing

PERSISTENT
VEGETATIVE STATE
Sometimes residents who
were comatose after an
anoxic-ischemic injury (i.e.,
not enough oxygen to the
brain) from a cardiac
arrest, head trauma, or
massive stroke, regain
wakefulness but do not
evidence any purposeful
behavior or cognition. Their
eyes are open, and they may
grunt, yawn, pick with their
fingers, and have random
body movements.
Neurological exam shows
extensive damage to both
cerebral hemispheres.

Item Rationale

Health-related Quality of Life

Problems with hearing can contribute to sensory deprivation, social isolation, and mood
and behavior disorders.

•

Unaddressed communication problems related to hearing impairment can be mistaken for
confusion or cognitive impairment.

Planning for Care

•

Address reversible causes of hearing difficulty (such as cerumen impaction).

•

Evaluate potential benefit from hearing assistance devices.

•

Offer assistance to residents with hearing difficulties to avoid social isolation.

October 2024

Page B-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B0200: Hearing (cont.)
•

Consider other communication strategies for persons with hearing loss that is not
reversible or is not completely corrected with hearing devices.

•

Adjust environment by reducing background noise by lowering the sound volume on
televisions or radios, because a noisy environment can inhibit opportunities for effective
communication.

Steps for Assessment
Ensure that the resident is using their normal hearing appliance if they have one. Hearing
devices may not be as conventional as a hearing aid. Some residents by choice may use
hearing amplifiers or a microphone and headphones as an alternative to hearing aids. Ensure
the hearing appliance is operational.

Interview the resident and ask about hearing function in different situations (e.g. hearing
staff members, talking to visitors, using the telephone, watching TV, attending activities).

Observe the resident during your verbal interactions and when they interact with others
throughout the day.

Think through how you can best communicate with the resident. For example, you may
need to speak more clearly, use a louder tone, speak more slowly or use gestures. The
resident may need to see your face to understand what you are saying, or you may need to
take the resident to a quieter area for them to hear you. All of these are cues that there is a
hearing problem.

Review the medical record.

Consult the resident’s family, caregivers, direct care staff, activities personnel, and speech or
hearing specialists.

Coding Instructions

Code 0, adequate: No difficulty in normal conversation, social interaction, or

•

Code 1, minimal difficulty: Difficulty in some environments (e.g., when a person

•

Code 2, moderate difficulty: Speaker has to increase volume and speak distinctly.

•

listening to TV. The resident hears all normal conversational speech and telephone or
group conversation.

speaks softly or the setting is noisy). The resident hears speech at conversational levels
but has difficulty hearing when not in quiet listening conditions or when not in one-onone situations. The resident’s hearing is adequate after environmental adjustments are
made, such as reducing background noise by moving to a quiet room or by lowering the
volume on television or radio.
Although hearing-deficient, the resident compensates when the speaker adjusts tonal
quality and speaks distinctly; or the resident can hear only when the speaker’s face is
clearly visible.

October 2024

Page B-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B0200: Hearing (cont.)
•

Code 3, highly impaired: Absence of useful hearing. The resident hears only some

sounds and frequently fails to respond even when the speaker adjusts tonal quality,
speaks distinctly, or is positioned face-to-face. There is no comprehension of
conversational speech, even when the speaker makes maximum adjustments.

Coding Tips for Special Populations
•

Residents who are unable to respond to a standard hearing assessment due to cognitive
impairment will require alternate assessment methods. The resident can be observed in
their normal environment. Do they respond (e.g., turn their head) when a noise is made at
a normal level? Does the resident seem to respond only to specific noise in a quiet
environment? Assess whether the resident responds only to loud noise or do they not
respond at all.

D
Examples

1. “When I’m at home, I usually keep the TV on a low volume and hear it just fine. When I
have visitors, I can hear people from across the room.”
Coding: B0200 would be coded 0, Adequate.

Rationale: The resident hears normal conversational speech.

2. “Sitting at the dinner table, I can hear people who are sitting close by me within five feet, but
not much if they are sitting down one end of the table speaking at a normal volume, and I’m
at the other end of the table about eight feet away.”
Coding: B0200 would be coded 1. Minimal Difficulty.

Rationale: The resident has difficulty in some situations (when someone is sitting

farther away) but can hear clearly when someone is sitting close.

3. The resident failed to respond during an interview with the assessor despite the interviewer
increasing the volume of their voice and speaking distinctly. The resident’s family shared
that the resident cannot hear the spoken word, even when they are directly facing the resident
and speak loudly and distinctly, and they noted that they often use a picture board to point to
things to communicate with the resident.
Coding: B0200 would be coded 3, Highly Impaired.

Rationale: The resident has no comprehension of conversational speech, even when the

speaker makes maximum adjustments.

October 2024

Page B-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B0200: Hearing (cont.)
4. “I have trouble following normal conversations, especially when a lot of different people are
talking at the same time. I can usually make out what someone is saying if they talk a little
louder and make sure they speak clearly and I can see their face when they are talking to
me.”
Coding: B0200 would be coded 2. Moderate Difficulty.
Rationale: The resident has difficulty hearing people in conversation, but

comprehension is improved when the speaker makes adjustments like speaking at high
volume, speaking clearly, and sitting close by so that the speaker’s face is visible.

B0300: Hearing Aid

D
Item Rationale

Health-related Quality of Life
Problems with hearing can contribute to social isolation and mood and behavior
disorders.

•

Many residents with impaired hearing could benefit from hearing aids or other hearing
appliances.

•

Many residents who own hearing aids do not have the hearing aids with them or have
nonfunctioning hearing aids upon arrival.

•

Planning for Care

Knowing if a hearing aid was used when determining hearing ability allows better
identification of evaluation and management needs.

•

For residents with hearing aids, use and maintenance should be included in care planning.

•

Residents who do not have adequate hearing without a hearing aid should be asked about
history of hearing aid use.

•

Residents who do not have adequate hearing despite wearing a hearing aid might benefit
from a re-evaluation of the device or assessment for new causes of hearing impairment.

Steps for Assessment

•

Prior to beginning the hearing assessment, ask the resident if they own a hearing aid or other
hearing appliance and, if so, whether it is at the nursing home.

If the resident cannot respond, write the question down and allow the resident to read it.

October 2024

Page B-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B0300: Hearing Aid (cont.)
3. If the resident is still unable, check with family and care staff about hearing aid or other
hearing appliances.
4. Check the medical record for evidence that the resident had a hearing appliance in place
when hearing ability was recorded.
5. Ask staff and significant others whether the resident was using a hearing appliance when they
observed hearing ability (above).

Coding Instructions
Code 0, no: if the resident did not use a hearing aid (or other hearing appliance) for the
7-day hearing assessment coded in B0200, Hearing.

•

Code 1, yes: if the resident did use a hearing aid (or other hearing appliance) for the
hearing assessment coded in B0200, Hearing.

•

B0600: Speech Clarity

Item Rationale

Health-related Quality of Life

DEFINITION
SPEECH
The verbal expression of
articulate words.

•

Unclear speech or absent speech can hinder
communication and be very frustrating to an individual.

•

Unclear speech or absent speech can result in physical and psychosocial needs not
being met and can contribute to depression and social isolation.

Planning for Care
•

If speech is absent or is not clear enough for the resident to make needs known, other
methods of communication should be explored.

•

Lack of speech clarity or ability to speak should not be mistaken for cognitive
impairment.

Steps for Assessment
1.

Listen to the resident.

Ask primary assigned caregivers about the resident’s speech pattern.

Review the medical record.

October 2024

Page B-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B0600: Speech Clarity (cont.)
4.

Determine the quality of the resident’s speech, not the content or appropriateness—just
words spoken.

Coding Instructions
•

Code 0, clear speech: if the resident usually utters distinct, intelligible words.

•

Code 1, unclear speech: if the resident usually utters slurred or mumbled words.

•

Code 2, no speech: if there is an absence of spoken words.

B0700: Makes Self Understood

D
Item Rationale

MAKES SELF
UNDERSTOOD
Able to express or
communicate requests,
needs, opinions, and to
conduct social conversation
in their primary language,
whether in speech, writing,
sign language, gestures, or a
combination of these. Deficits
in the ability to make one’s
self understood (expressive
communication deficits) can
include reduced voice
volume and difficulty in
producing sounds, or
difficulty in finding the right
word, making sentences,
writing, and/or gesturing.

Health-related Quality of Life

DEFINITION

•

Problems making self understood can be very
frustrating for the resident and can contribute to social
isolation and mood and behavior disorders.

•

Unaddressed communication problems can be
inappropriately mistaken for confusion or cognitive
impairment.

Planning for Care

Ability to make self understood can be optimized by not
rushing the resident, breaking longer questions into
parts and waiting for reply, and maintaining eye contact
(if appropriate).

•

If a resident has difficulty making self understood:

•

— Identify the underlying cause or causes.
— Identify the best methods to facilitate
communication for that resident.

October 2024

Page B-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B0700: Makes Self Understood (cont.)
Steps for Assessment
1.

Assess using the resident’s preferred language or method of communication.

Interact with the resident. Be sure they can hear you or have access to their preferred method
for communication. If the resident seems unable to communicate, offer alternatives such as
writing, pointing, sign language, or using cue cards.

Observe their interactions with others in different settings and circumstances.

Consult with the primary nurse assistants (over all shifts) and the resident’s family and
speech-language pathologist.

Coding Instructions
Code 0, understood: if the resident expresses requests and ideas clearly.

•

Code 1, usually understood: if the resident has difficulty communicating some

•

Code 2, sometimes understood: if the resident has limited ability but is able to

•

Code 3, rarely or never understood: if, at best, the resident’s understanding is

•

words or finishing thoughts but is able if prompted or given time. They may have
delayed responses or may require some prompting to make self understood.

express concrete requests regarding at least basic needs (e.g., food, drink, sleep, toilet).

limited to staff interpretation of highly individual, resident-specific sounds or body
language (e.g., indicated presence of pain or need to toilet).

Coding Tips and Special Populations

This item cannot be coded as Rarely/Never Understood if the resident completed any of
the resident interviews, as the interviews are conducted during the look-back period for
this item and should be factored in when determining the residents’ ability to make self
understood during the entire 7-day look-back period.

•

While B0700 and the resident interview items are not directly dependent upon one
another, inconsistencies in coding among these items should be evaluated.

•

B0800: Ability to Understand Others

October 2024

Page B-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B0800: Ability to Understand Others (cont.)
Item Rationale
Health-related Quality of Life
•

Inability to understand direct person-to-person communication
— Can severely limit association with others.
— Can inhibit the individual’s ability to follow instructions that can affect health and
safety.

Planning for Care
•

Thorough assessment to determine underlying cause or
causes is critical in order to develop a care plan to
address the individual’s specific deficits and needs.

•

Every effort should be made by the facility to provide
information to the resident in a consistent manner that
they understand based on an individualized assessment.

Steps for Assessment

DEFINITION
ABILITY TO
UNDERSTAND OTHERS
Comprehension of direct
person-to-person
communication whether
spoken, written, or in sign
language or Braille. Includes
the resident’s ability to
process and understand
language. Deficits in one’s
ability to understand
(receptive communication
deficits) can involve declines
in hearing, comprehension
(spoken or written) or
recognition of facial
expressions.

Assess in the resident’s preferred language or preferred
method of communication.

If the resident uses a hearing aid, hearing device or other
communications enhancement device, the resident should
use that device during the evaluation of the resident’s
understanding of person-to-person communication.

Interact with the resident and observe their understanding
of other’s communication.

Consult with direct care staff over all shifts, if possible, the resident’s family, and speechlanguage pathologist (if involved in care).

Review the medical record for indications of how well the resident understands others.

Coding Instructions

•

Code 0, understands: if the resident clearly comprehends the message(s) and

•

Code 1, usually understands: if the resident misses some part or intent of the

•

Code 2, sometimes understands: if the resident demonstrates frequent difficulties
integrating information, and responds adequately only to simple and direct questions or

demonstrates comprehension by words or actions/behaviors.

message but comprehends most of it. The resident may have periodic difficulties
integrating information but generally demonstrates comprehension by responding in
words or actions.

October 2024

Page B-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B0800: Ability to Understand Others (cont.)
instructions. When staff rephrase or simplify the message(s) and/or use gestures, the
resident’s comprehension is enhanced.
•

Code 3, rarely/never understands: if the resident demonstrates very limited

ability to understand communication. Or, if staff have difficulty determining whether or
not the resident comprehends messages, based on verbal and nonverbal responses. Or, the
resident can hear sounds but does not understand messages.

B1000: Vision

D
Item Rationale

Health-related Quality of Life

DEFINITION
ADEQUATE LIGHT
Lighting that is sufficient or
comfortable for a person with
normal vision to see fine
detail.

A person’s reading vision often diminishes over time.

•

If uncorrected, vision impairment can limit the
enjoyment of everyday activities such as reading
newspapers, books or correspondence, and maintaining
and enjoying hobbies and other activities. It also limits the ability to manage personal
business, such as reading and signing consent forms.

•

Moderate, high or severe impairment can contribute to sensory deprivation, social
isolation, and depressed mood.

•

Planning for Care

Reversible causes of vision impairment should be sought.

•

Consider whether simple environmental changes such as better lighting or magnifiers
would improve ability to see.

•

Consider large print reading materials for persons with impaired vision.

•

For residents with moderate, high, or severe impairment, consider alternative ways of
providing access to content of desired reading materials or hobbies.

October 2024

•

Page B-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B1000: Vision (cont.)
Steps for Assessment
1. Ask family, caregivers, and/or direct care staff over all shifts, if possible, about the resident’s
usual vision patterns during the 7-day look-back period (e.g., is the resident able to see
newsprint, menus, greeting cards?).
2. Then ask the resident about their visual abilities.
3. Test the accuracy of your findings:
Ensure that the resident’s customary visual appliance for close vision is in place (e.g.,
eyeglasses, magnifying glass).

•

Ensure adequate lighting.

•

Ask the resident to look at regular-size print in a book or newspaper. Then ask the
resident to read aloud, starting with larger headlines and ending with the finest, smallest
print. If the resident is unable to read a newspaper, provide material with larger print,
such as a flyer or large textbook.

•

When the resident is unable to read out loud (e.g. due to aphasia, illiteracy), you should
test this by another means such as, but not limited to:

•

— Substituting numbers or pictures for words that are displayed in the appropriate print
size (regular-size print in a book or newspaper).

Coding Instructions
•

Code 0, adequate: if the resident sees fine detail, including regular print in

•

Code 1, impaired: if the resident sees large print, but not regular print in

•

Code 2, moderately impaired: if the resident has limited vision and is not able to

•

Code 3, highly impaired: if the resident’s ability to identify objects nearby in their

•

Code 4, severely impaired: if the resident has no vision, sees only light, colors or

newspapers/books.
newspapers/books.

see newspaper headlines but can identify objects nearby in their environment.

environment is in question, but the resident’s eye movements appear to be following
objects (especially people walking by).

shapes, or does not appear to follow objects with eyes.

Coding Tips and Special Populations
•

Some residents have never learned to read or are unable to read English. In such cases,
ask the resident to read numbers, such as dates or page numbers, or to name items in
small pictures. Be sure to display this information in two sizes (equivalent to regular and
large print).

October 2024

Page B-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B1000: Vision (cont.)
•

If the resident is unable to communicate or follow your directions for testing vision,
observe the resident’s eye movements to see if their eyes seem to follow movement of
objects or people. Though these are gross measures of visual acuity, they may assist you
in assessing whether or not the resident has any visual ability. For residents who appear
to do this, code 3, highly impaired.

Examples
1. When asked about whether they can see fine detail, including regular print in
newspaper/books, the resident responds, “When I wear my glasses, I can read the paper
fine. If I forget to wear glasses, it is harder to see unless I hold the paper a little closer.”
Coding: B1000 would be coded 0, Adequate.

Rationale: The resident can read regular print when wearing glasses.

2. The assessor asks the resident to read aloud from a newspaper, starting with larger
headlines and then the smaller print. The resident is able to read the headlines but not the
regular newspaper print.
Coding: B1000 would be coded 1. Impaired.

Rationale: The resident is able to read large, but not regular, print.

3. “I cannot read the newspaper headlines, even with glasses.” When the assessor presents
the resident with newspaper text, while wearing glasses, the resident is not able to
correctly read the headlines. The resident is able to identify the objects on the table a few
feet away.
Coding: B1000 would be coded 2, Moderately Impaired.

Rationale: The resident is not able to read large print (i.e., newspaper headlines)

but is able to identify objects in their environment.

4. During the assessment, the resident states, “I cannot see much of anything at this point, I
can see blurry shapes and I can tell what large objects are, but I cannot read books
anymore—even the ones with giant print. I do okay recognizing my caregivers by their
voices, but I couldn’t tell you what they look like. Everyone’s just a blob of color, even
with my glasses on.” The resident’s eyes appear to follow the assessor when they move
about the room. When the assessor presents the resident with newspaper text, while
wearing glasses, the resident is able to appropriately reach for and successfully hold the
paper but is not able to correctly read the headlines.
Coding: B1000 would be coded 3, Highly Impaired.
Rationale: The resident is able to follow objects and track movement in the

environment (e.g., people moving throughout the room) but is unable to see people or
objects in detail.

October 2024

Page B-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B1200: Corrective Lenses

Item Rationale
Health-related Quality of Life
Decreased ability to see can limit the enjoyment of everyday activities and can contribute
to social isolation and mood and behavior disorders.

•

Many residents who do not have corrective lenses could benefit from them, and others
have corrective lenses that are not sufficient.

•

Many persons who benefit from and own visual aids do not have them on arrival at the
nursing home.

•

Planning for Care

Knowing if corrective lenses were used when determining ability to see allows better
identification of evaluation and management needs.

•

Residents with eyeglasses or other visual appliances should be assisted in accessing them.
Use and maintenance should be included in care planning.

•

Residents who do not have adequate vision without eyeglasses or other visual appliances
should be asked about history of corrective lens use.

•

Residents who do not have adequate vision, despite using a visual appliance, might
benefit from a re-evaluation of the appliance or assessment for new causes of vision
impairment.

•

Steps for Assessment

1. Prior to beginning the assessment, ask the resident whether they use eyeglasses or other
vision aids and whether the eyeglasses or vision aids are at the nursing home. Visual aids do
not include surgical lens implants.
2. If the resident cannot respond, check with family and care staff about the resident’s use of
vision aids during the 7-day look-back period.

3. Observe whether the resident used eyeglasses or other vision aids during reading vision test
(B1000).

4. Check the medical record for evidence that the resident used corrective lenses when ability to
see was recorded.
5. Ask staff and significant others whether the resident was using corrective lenses when they
observed the resident’s ability to see.

October 2024

Page B-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B1200: Corrective Lenses (cont.)
Coding Instructions
•

Code 0, no: if the resident did not use eyeglasses or other vision aid during the
B1000, Vision assessment.

•

Code 1, yes: if corrective lenses or other visual aids were used when visual ability was
assessed in completing B1000, Vision.

B1300. Health Literacy
Complete only if A0310B = 01 or A0310H = 1.

D
Item Rationale

Health-related Quality of Life
•

Poor health literacy is linked to lower levels of
knowledge of health, worse outcomes, the receipt of
fewer preventive services, and higher medical costs and
rates of emergency department use.

Planning for Care
•

DEFINITION
HEALTH LITERACY
Health literacy is the degree
to which individuals have the
capacity to obtain, process,
and understand basic health
information and services
needed to make appropriate
health decisions.

•

Similar to language barriers, low health literacy
interferes with communication between provider and
resident. Health literacy can also affect residents’
ability to understand and follow treatment plans,
including medication management.

Assessing for health literacy will facilitate better care coordination and discharge
planning.

October 2024

Page B-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [B]

B1300. Health Literacy (cont.)
Steps for Assessment
This item is intended to be a resident self-report item. No other source should be used to
identify the response.
1. Ask the resident, “How often do you need to have someone help you when you read
instructions, pamphlets, or other written material from your doctor or pharmacy?”

Coding Instructions
•

Code 0, Never: if the resident indicates never needing help reading instructions,

•

Code 1, Rarely: if the resident indicates rarely needing help reading instructions,

•

Code 2, Sometimes: if the resident indicates sometimes needing help reading

•

Code 3, Often: if the resident indicates often needing help reading instructions,

•

Code 4, Always: if the resident indicates always needing help reading instructions,

•

Code 7, Resident declines to respond: if the resident declines to respond.

•

Code 8, Resident unable to respond: if the resident is unable to respond.

pamphlets, or other written materials from doctors or pharmacies.

instructions, pamphlets, or other written materials from doctors or pharmacies.

pamphlets, or other written materials from doctors or pharmacies.

Example

1. When asked how often they need help when reading the instructions provided by their
doctor, the resident reports that they never need help. The resident’s adult child is present and
shares that a family member must always accompany the resident to doctors’ visits and that
the resident often needs someone to explain the written materials to them multiple times
before they understand, providing examples of needing to frequently explain to the resident
why they are on a special diet and why and how to take some of their medications.
Coding: B1300, Health Literacy is coded as Code 0, Never.

Rationale: The resident indicates they never need help reading instructions from their

doctor or pharmacist. B1300, Health Literacy is intended to be a resident self-report item
and no other sources, including family members/caregivers, should be used to identify the
response to this item.

October 2024

Page B-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

SECTION C: COGNITIVE PATTERNS
Intent: The items in this section are intended to determine the resident’s attention, orientation
and ability to register and recall new information and whether the resident has signs and
symptoms of delirium. These items are crucial factors in many care-planning decisions.

C0100: Should Brief Interview for Mental Status Be Conducted?

Item Rationale

Health-related Quality of Life

•
•

Most residents are able to attempt the Brief Interview for Mental Status (BIMS), a
structured cognitive interview.
A structured cognitive test is more accurate and reliable than observation alone for
observing cognitive performance.
— Without an attempted structured cognitive interview, a resident might be mislabeled
based on their appearance or assumed diagnosis.
— Structured interviews will efficiently provide insight into the resident’s current
condition that will enhance good care.

Planning for Care

Structured cognitive interviews assist in identifying needed supports.
The structured cognitive interview is helpful for identifying possible delirium behaviors
(C1310).

Steps for Assessment

1. Interact with the resident using their preferred language (See A1110). Be sure they can hear
you and/or have access to their preferred method for communication. If the resident needs or
requires an interpreter, complete the interview with an interpreter. If the resident appears
unable to communicate, offer alternatives such as writing, pointing, sign language, or cue
cards.
2. Determine if the resident is rarely/never understood verbally, in writing, or using another
method. If rarely/never understood, skip to C0600, Should the Staff Assessment for Mental
Status be Conducted?, unless the assessment being completed is a stand-alone Part A PPS
Discharge; if that is the case, then skip to C1310. Signs and Symptoms of Delirium.

October 2024

Page C-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0100: Should Brief Interview for Mental Status Be Conducted?
(cont.)
Coding Instructions
•
•

Code 0, no: if the interview should not be conducted because the resident is

rarely/never understood; cannot respond verbally, in writing, or using another method; or
an interpreter is needed but not available.
Code 1, yes: if the interview should be conducted because the resident is at least
sometimes understood verbally, in writing, or using another method, and if an interpreter
is needed, one is available.

Coding Tips
Attempt to conduct the interview with ALL residents. This interview is conducted during
the look-back period of the Assessment Reference Date (ARD) and is not contingent
upon item B0700, Makes Self Understood.

•

If the resident needs an interpreter, including a resident who uses American Sign
Language (ASL), every effort should be made to have an interpreter present for the
BIMS. If it is not possible for a needed interpreter to participate on the day of the
interview, code C0100 = 0 to indicate interview not attempted and complete C0600C1000, Staff Assessment for Mental Status.

•

If the resident interview was not conducted within the look-back period (preferably the
day before or the day of) the ARD, item C0100 must be coded 1, Yes, and the standard
“no information” code (a dash “-”) entered in the resident interview items.

•

Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the
resident interview should have been conducted but was not done.

•

Because a PDPM cognitive level is utilized in the speech language pathology (SLP)
payment component of PDPM, only in the case of PPS assessments, staff may complete
the Staff Assessment for Mental Status for an interviewable resident when the resident is
unexpectedly discharged from a Part A stay prior to the completion of the BIMS. In this
case, the assessor should enter 0, No in C0100: Should Brief Interview for Mental Status
Be Conducted? and proceed to the Staff Assessment for Mental Status.

•

October 2024

Page C-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0200-C0500: Brief Interview for Mental Status (BIMS)

D
October 2024

Page C-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0200-C0500: Brief Interview for Mental Status (BIMS) (cont.)
Item Rationale
Health-related Quality of Life
•
•
•
•

•

Direct or performance-based testing of cognitive function decreases the chance of
incorrect labeling of cognitive ability and improves detection of delirium.
Cognitively intact residents may appear to be cognitively impaired because of extreme
frailty, hearing impairment or lack of interaction.
Some residents may appear to be more cognitively intact than they actually are.
If cognitive impairment is incorrectly diagnosed or missed, appropriate communication,
worthwhile activities and therapies may not be offered.
The BIMS is an opportunity to observe residents for signs and symptoms of delirium.

Planning for Care

•

Assessment of a resident’s mental state provides a direct understanding of resident
function that may:
— enhance future communication and assistance and
— direct nursing interventions to facilitate greater independence such as posting or
providing reminders for self-care activities.
A resident’s performance on cognitive tests can be compared over time.
— An abrupt change in cognitive status may indicate delirium and may be the only
indication of a potentially life-threatening illness.
— If performance worsens, then an assessment for delirium and/or depression should be
considered, as a decline in mental status may also be associated with a mood disorder.
Awareness of possible impairment may be important for maintaining a safe environment
and providing safe discharge planning.

Steps for Assessment: Basic Interview Instructions for BIMS (C0200C0500)
1. Refer to Appendix D for a review of basic approaches to effective interviewing techniques.
2. Interview any resident not screened out by Should Brief Interview for Mental Status Be
Conducted? (Item C0100).
3. Conduct the interview in a private setting, if possible.
4. Be sure the resident can hear you.
•
•
•

Residents with hearing impairment should be tested using their usual communication
devices/techniques, as applicable.
Try an external assistive device (headphones or hearing amplifier) if you have any doubt
about hearing ability.
Minimize background noise.

October 2024

Page C-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0200-C0500: Brief Interview for Mental Status (BIMS) (cont.)
5. Sit so that the resident can see your face. Minimize glare by directing light sources away
from the resident’s face.
6. Give an introduction before starting the interview.
Suggested language: “I would like to ask you some questions. We ask everyone these same
questions. This will help us provide you with better care. Some of the questions may seem
very easy, while others may be more difficult.”

7. If the resident expresses concern that you are testing their memory, they may be more
comfortable if you reply: “We ask these questions of everyone so we can make sure that our
care will meet your needs.”
8. Directly ask the resident each item in C0200 through C0400 at one sitting and in the order
provided.
9. If the resident chooses not to answer a particular item, accept their refusal and move on to the
next questions. For C0200 through C0400, code refusals as incorrect/no answer or could not
recall.

Coding Instructions

See coding instructions for individual items.
•

•

DEFINITION

Coding Tips

If the interviewer is unable to articulate or pronounce
COMPLETE INTERVIEW
any cognitive interview items clearly, for any reason
The BIMS is considered
(e.g., accent or speech impairment), have a different
complete if the resident
staff member conduct the BIMS.
attempted and provided
relevant answers to at least
Rules for stopping the BIMS before it is complete:
— Stop the interview after completing (C0300C) “Day four of the questions
included in C0200of the Week” if:
C0400C. Relevant answers
1. all responses up to this point have been
do not have to be correct
nonsensical (i.e., any response that is unrelated,
but do need to be related to
incomprehensible, or incoherent; not
the question that was
informative with respect to the item being
asked.
rated), OR
2. there has been no verbal or written response to any of the questions up to this
point, OR
3. there has been no verbal or written response to some questions up to this point
and for all others, the resident has given a nonsensical response.

October 2024

Page C-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0200-C0500: Brief Interview for Mental Status (BIMS) (cont.)
•

•

If the interview is stopped, do the following:
1. Code (—), dash in C0400A, C0400B, and C0400C.
2. Code 99 in the BIMS Summary Score (C0500), and if the assessment being
completed is a stand-alone Part A PPS Discharge, continue to C1310. Signs and
Symptoms of Delirium. Otherwise, proceed to step 3.
3. Code 1, yes in C0600, Should the Staff Assessment for Mental Status be
Conducted?
4. Complete the Staff Assessment for Mental Status.
If all responses to C0200, C0300A, C0300B, and
DEFINITION
C0300C are coded 0 because answers are incorrect,
continue interview.
NONSENSICAL

•

When staff identify that the resident’s primary method
RESPONSE
of communication is in written format, the BIMS can be Any response that is
administered in writing. The administration of the
unrelated,
BIMS in writing should be limited to only this
incomprehensible, or
incoherent; it is not
circumstance.
See Appendix E for details regarding how to administer informative with respect to
the item being rated.
the BIMS in writing.
Code 0 is used to represent three types of responses: incorrect answers (unless the item
itself provides an alternative response code), nonsensical responses, and questions the
resident chooses not to answer (or “refusals”). Since 0s resulting from these three
situations are treated differently when coding the BIMS Summary Score in C0500, the
interviewer may find it valuable to track the reason for each 0 response to aid in
accurately calculating the summary score.

Examples of Incorrect and Nonsensical Responses

1. Interviewer asks resident to state the year. The resident replies that it is 1935. This answer is
incorrect but related to the question.
Coding: This answer is coded 0, incorrect but would NOT be considered a
nonsensical response.
Rationale: The answer is wrong, but it is logical and relates to the question.

2. Interviewer asks resident to state the year. The resident says, “Oh what difference does the
year make when you’re as old as I am?” The interviewer asks the resident to try to name the
year, and the resident shrugs.
Coding: This answer is coded 0, incorrect but would NOT be considered a
nonsensical response.
Rationale: The answer is wrong because refusal is considered a wrong answer, but the
resident’s comment is logical and clearly relates to the question.

October 2024

Page C-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0200-C0500: Brief Interview for Mental Status (BIMS) (cont.)
3. Interviewer asks the resident to name the day of the week. Resident answers, “Sylvia, she’s
my daughter.” The interviewer asks the resident the question again to confirm the resident is
not hearing the question incorrectly, and the resident answers with the same response.
Coding: The answer is coded 0, incorrect; the response is illogical and nonsensical.
Rationale: The answer is wrong, and the resident’s comment clearly does not relate to
the question; it is nonsensical.

C0200: Repetition of Three Words

D
Item Rationale
•

Health-related Quality of Life

Inability to repeat three words on first attempt may indicate:
— a memory impairment,
— a hearing impairment,
— a language barrier, or

— inattention that may be a sign of delirium or another health issue.

Planning for Care
•

A cue can assist learning.

•

Cues may help residents with memory impairment who can store new information in
their memory but who have trouble retrieving something that was stored (e.g., not able to
remember someone’s name but can recall if given part of the first name).

•

Staff can use cues when assisting residents with learning and recall in therapy, and in
daily and restorative activities.

October 2024

Page C-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0200: Repetition of Three Words (cont.)
Steps for Assessment
Basic BIMS interview instructions are shown on pages C-4 and
C-5. In addition, for repetition of three words:

1. Say to the 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.” Interviewers
need to use the words and related category cues as
indicated. If the interview is being conducted with an
interpreter present, the interpreter should use the equivalent
words and similar, relevant prompts for category cues.
2. Immediately after presenting the three words, say to the
resident: “Now please tell me the three words.”
3. After the resident’s first attempt to repeat the items:

DEFINITION
CATEGORY CUE
Phrase that puts a word in
context to help with learning
and to serve as a hint that
helps prompt the resident.
The category cue for sock is
“something to wear.” The
category cue for blue is “a
color.” For bed, the category
cue is “a piece of furniture.”

If the resident correctly stated all three words, say, “That’s right, the words are sock,
something to wear; blue, a color; and bed, a piece of furniture” [category cues].

•

Category cues serve as a hint that helps prompt residents’ recall ability. Putting words in
context stimulates learning and fosters memory of the words that residents will be asked
to recall in item C0400, even among residents able to repeat the words immediately.

•

If the resident recalled two or fewer words, say to the resident: “Let me say the three
words again. They are sock, something to wear; blue, a color; and bed, a piece of
furniture. Now tell me the three words.” If the resident still does not recall all three words
correctly, you may repeat the words and category cues one more time.

•

If the resident does not repeat all three words after three attempts, re-assess ability to
hear. If the resident can hear, move on to the next question. If they are unable to hear,
attempt to maximize hearing (alter environment, use hearing amplifier) before
proceeding.

Coding Instructions

•

Record the maximum number of words that the resident correctly repeated on the first attempt.
This will be any number between 0 and 3.
•

•

The words may be recalled in any order and in any context. For example, if the words are
repeated back in a sentence, they would be counted as repeating the words.
Do not score the number of repeated words on the second or third attempt. These
attempts help with learning the item, but only the number correct on the first attempt go
into the total score. Do not record the number of attempts that the resident needed to
complete.
Code 0, none: if the resident did not repeat any of the 3 words on the first attempt.

•

Code 1, one: if the resident repeated only 1 of the 3 words on the first attempt.

•

Code 2, two: if the resident repeated only 2 of the 3 words on the first attempt.

•

Code 3, three: if the resident repeated all 3 words on the first attempt.

•

October 2024

Page C-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0200: Repetition of Three Words (cont.)
Examples
1. The interviewer says, “The words are sock, blue, and bed. Now please tell me the three
words.” The resident replies, “Bed, sock, and blue.” The interviewer repeats the three words
with category cues, by saying, “That’s right, the words are sock, something to wear; blue, a
color; and bed, a piece of furniture.”
Coding: C0200 would be coded 3, three words correct.
Rationale: The resident repeated all three items on the first attempt. The order of

repetition does not affect the score.

2. The interviewer says, “The words are sock, blue, and bed. Now please tell me the three
words.” The resident replies, “Sock, bed, black.” The interviewer repeats the three words
plus the category cues, saying, “Let me say the three words again. They are sock, something
to wear; blue, a color; and bed, a piece of furniture. Now tell me the three words.” The
resident says, “Oh yes, that’s right, sock, blue, bed.”
Coding: C0200 would be coded 2, two of three words correct.
Rationale: The resident repeated two of the three items on the first attempt. Residents

are scored based on the first attempt.

3. The interviewer says, “The words are sock, blue, and bed. Now please tell me the three
words.” The resident says, “Blue socks belong in the dresser.” The interviewer codes
according to the resident’s response. Then the interviewer repeats the three words plus the
category cues, saying, “Let me say the three words again. They are sock, something to wear;
blue, a color; and bed, a piece of furniture. Now tell me the three words.” The resident says,
“Oh yes, that’s right, sock, blue, bed.”
Coding: C0200 would be coded 2, two of the three words correct.
Rationale: The resident repeated two of the three items—blue and sock on the first

attempt. The resident put the words into a sentence, resulting in the resident repeating two
of the three words.

4. The interviewer says, “The words are sock, blue, and bed. Now please tell me the three
words.” The resident replies, “What were those three words?” The resident’s response is
coded, and then the interviewer repeats the three words plus the category cues.

Coding: C0200 would be coded 0, none of the words correct.
Rationale: The resident did not repeat any of the three words after the first time the

interviewer said them.

October 2024

Page C-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0300: Temporal Orientation (Orientation to Year, Month,
and Day)

D
Item Rationale

Health-related Quality of Life
A lack of temporal orientation may lead to decreased
communication or participation in activities.

•

Not being oriented may be frustrating or frightening.

TEMPORAL
ORIENTATION
In general, the ability to place
oneself in correct time. For
the BIMS, it is the ability to
indicate the correct date in
current surroundings.

•

DEFINITION

Planning for Care

If staff know that a resident has a problem with orientation, they can provide
reorientation aids and verbal reminders that may reduce anxiety and encourage resident
participation in activities.

•

Reorienting those who are disoriented or at risk of disorientation may be useful in
treating symptoms of delirium and cognitive problems associated with other medical
conditions.

•

Residents who are not oriented may need further assessment for delirium, especially if
this fluctuates or is recent in onset.

Steps for Assessment

•

Basic BIMS interview instructions are shown on pages C-4 and C-5.

1. Ask the resident each of the three questions in Item C0300 separately.
2. Allow the resident up to 30 seconds for each answer and do not provide clues.
3. If the resident specifically asks for clues (e.g., “Is it bingo day?”) respond by saying, “I need
to know if you can answer this question without any help from me.”

October 2024

Page C-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0300: Temporal Orientation (Orientation to Year, Month,
and Day) (cont.)
Coding Instructions for C0300A, Able to Report Correct Year
•

Code 0, missed by >5 years or no answer: if the resident’s answer is incorrect

•

Code 1, missed by 2-5 years: if the resident’s answer is incorrect and is within 2 to

and is greater than 5 years from the current year or the resident chooses not to respond or
the answer is nonsensical.
5 years from the current year.

•

Code 2, missed by 1 year: if the resident’s answer is incorrect and is within one

•

Code 3, correct: if the resident states the correct year.

year from the current year.

D
Examples

1. The date of interview is May 5, 2023. The resident, responding to the statement, “Please tell
me what year it is right now,” states that it is 2023.

Coding: C0300A would be coded 3, correct.
Rationale: 2023 is the current year at the time of this interview.

2. The date of interview is June 16, 2023. The resident, responding to the statement, “Please tell
me what year it is right now,” states that it is 2020.
Coding: C0300A would be coded 1, missed by 2-5 years.
Rationale: 2020 is within 2 to 5 years of 2023.

3. The date of interview is January 10, 2023. The resident, responding to the statement, “Please
tell me what year it is right now,” states that it is 1923.

years from 2023.

Coding: C0300A would be coded 0, missed by more than 5 years.
Rationale: Even though the ’23 part of the year would be correct, 1923 is more than 5

4. The date of interview is April 1, 2023. The resident, responding to the statement, “Please tell
me what year it is right now,” states that it is “’23”. The interviewer asks, “Can you tell me
the full year?” The resident still responds “’23,” and the interviewer asks again, “Can you tell
me the full year, for example, nineteen-eighty-two.” The resident states, “2023.”
Coding: C0300A would be coded 3, correct.
Rationale: Even though ’23 is partially correct, the only correct answer is the exact

year. The resident must state “2023,” not “’23” or “1823” or “1923.”

October 2024

Page C-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0300: Temporal Orientation (Orientation to Year, Month,
and Day) (cont.)
Coding Instructions for C0300B, Able to Report Correct Month
Count the current day as day 1 when determining whether the response was accurate within 5
days or missed by 6 days to 1 month.
•

Code 0, missed by >1 month or no answer: if the resident’s answer is incorrect

•

Code 1, missed by 6 days to 1 month: if the resident’s answer is accurate within

•

Code 2, accurate within 5 days: if the resident’s answer is accurate within 5 days,

by more than 1 month or if the resident chooses not to answer the item or the answer is
nonsensical.
6 days to 1 month.

D
count current date as day 1.

Coding Tips
•

Examples

In most instances, it will be immediately obvious which code to select. In some cases,
you may need to write the resident’s response in the margin and go back later to count
days if you are unsure whether the date given is within 5 days.

1. The date of interview is June 25, 2023. The resident, responding to the question, “What
month are we in right now?” states that it is June.
Coding: C0300B would be coded 2, accurate within 5 days.
Rationale: The resident correctly stated the month.

2. The date of interview is June 28, 2023. The resident, responding to the question, “What
month are we in right now?” states that it is July.

Coding: C0300B would be coded 2, accurate within 5 days.
Rationale: The resident correctly stated the month within 5 days, even though the

correct month is June. June 28th (day 1) + 4 more days is July 2nd, so July is within 5
days of the interview.

3. The date of interview is June 25, 2023. The resident, responding to the question, “What
month are we in right now?” states that it is July.
Coding: C0300B would be coded 1, missed by 6 days to 1 month.

Rationale: The resident missed the correct month by six days. June 25th (day 1) + 5

more days = June 30th. Therefore, the resident’s answer is incorrect within 6 days to 1
month.

October 2024

Page C-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0300: Temporal Orientation (Orientation to Year, Month,
and Day) (cont.)
4. The date of interview is June 30, 2023. The resident, responding to the question, “What
month are we in right now?” states that it is August.
Coding: C0300B would be coded 0, missed by more than 1 month.
Rationale: The resident missed the month by more than 1 month.

Coding Instructions for C0300C. Able to Report Correct Day of the
Week
•

Code 0, incorrect, or no answer: if the answer is incorrect or the resident chooses

not to answer the item or the answer is nonsensical.

D
•

Code 1, correct: if the answer is correct.

Examples

1. The day of interview is Monday, June 27, 2023. The interviewer asks: “What day of the
week is it today?” The resident responds, “It’s Monday.”

Coding: C0300C would be coded 1, correct.
Rationale: The resident correctly stated the day of the week.

2. The day of interview is Monday, June 27, 2023. The resident, responding to the question,
“What day of the week is it today?” states, “Tuesday.”
Coding: C0300C would be coded 0, incorrect.
Rationale: The resident incorrectly stated the day of the week.

3. The day of interview is Monday, June 27, 2023. The resident, responding to the question,
“What day of the week is it today?” states, “Today is a good day.”

Coding: C0300C would be coded 0, incorrect.
Rationale: The resident did not answer the question correctly.

October 2024

Page C-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0400: Recall

Item Rationale
•
•

Many persons with cognitive impairment can be helped to recall if provided cues.
Providing memory cues can help maximize individual function and decrease frustration
for those residents who respond.

Planning for Care

Care plans should maximize use of cueing for resident who respond to recall cues. This
will enhance independence.

•

Health-related Quality of Life

Steps for Assessment

Basic BIMS interview instructions are shown on pages C-4 and C-5.

Coding Instructions

1. Ask the resident the following: “Let’s go back to an earlier question. What were those three
words that I asked you to repeat?”
2. Allow up to 5 seconds for spontaneous recall of each word.
3. For any word that is not correctly recalled after 5 seconds, provide a category cue (refer to
“Steps for Assessment,” page C-8 for the definition of category cue). Category cues should
be used only after the resident is unable to recall one or more of the three words.
4. Allow up to 5 seconds after category cueing for each missed word to be recalled.

For each of the three words the resident is asked to remember:
•
•
•

Code 0, no—could not recall: if the resident cannot recall the word even after

being given the category cue or if the resident responds with a nonsensical answer or
chooses not to answer the item.
Code 1, yes, after cueing: if the resident requires the category cue to remember the
word.
Code 2, yes, no cue required: if the resident correctly remembers the word
spontaneously without cueing.

October 2024

Page C-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0400: Recall (cont.)
Coding Tips
•
•

If on the first try (without cueing), the resident names multiple items in a category, one of
which is correct, they should be coded as correct for that item.
If, however, the interviewer gives the resident the cue and the resident then names
multiple items in that category, the item is coded as could not recall, even if the correct
item was in the list.

Examples
1. The resident is asked to recall the three words that were initially presented. The resident
chooses not to answer the question and states, “I’m tired, and I don’t want to do this anymore.”

Coding: C0400A-C0400C would be coded 0, no—could not recall, could not

recall for each of the three words.
Rationale: Choosing not to answer a question often indicates an inability to answer the
question, so refusals are coded 0, no—could not recall. This is the most accurate
way to score cognitive function, even though, on occasion, residents might choose not to
answer for other reasons.

2. The resident is asked to recall the three words. The resident replies, “Socks, shoes, and bed.”
The examiner then cues, “One word was a color.” The resident says, “Oh, the shoes were
blue.”
Coding: C0400A, sock, would be coded 2, yes, no cue required.
Rationale: The resident’s initial response to the question included “sock.” They are

given credit for this response, even though they also listed another item in that category
(shoes), because they were answering the initial question, without cueing.
Coding: C0400B, blue, would be coded 1, yes, after cueing.
Rationale: The resident did not recall spontaneously but did recall after the category
cue was given. Responses that include the word in a sentence are acceptable.
Coding: C0400C, bed, would be coded 2, yes, no cue required.
Rationale: The resident independently recalled the item on the first attempt.

3. The resident is asked to recall the three words. The resident answers, “I don’t remember.”
The assessor then says, “One word was something to wear.” The resident says, “Clothes.”
The assessor then says, “OK, one word was a color.” The resident says, “Blue.” The assessor
then says, “OK, the last word was a piece of furniture.” The resident says, “Couch.”
Coding: C0400A, sock, would be coded 0, no—could not recall.
Rationale: The resident did not recall the item, even with a cue.
Coding: C0400B, blue, would be coded 1, yes, after cueing.
Rationale: The resident did recall after being given the cue.
Coding: C0400C, bed, would be coded 0, no—could not recall.
Rationale: The resident did not recall the item, even with a cue.

October 2024

Page C-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0400: Recall (cont.)
4. The resident is asked to recall the three words. The resident says, “I don’t remember.” The
assessor then says, “One word was something to wear.” The resident says, “Hat, shirt, pants,
socks, shoe, belt.”
Coding: C0400A, sock, would be coded 0, no—could not recall.
Rationale: After getting the category cue, the resident named more than one item (i.e.,

a laundry list of items) in the category. The resident’s response is coded as incorrect,
even though one of the items was correct, because the resident did not demonstrate recall
and likely named the item by chance.

C0500: BIMS Summary Score

D
Item Rationale

Health-related Quality of Life
The total score:

•

— Allows comparison with future and past performance.

— Decreases the chance of incorrect labeling of cognitive ability and improves detection
of delirium.
— Provides staff with a more reliable estimate of resident function and allows staff
interactions with residents that are based on more accurate impressions about resident
ability.

Planning for Care

The BIMS is a brief screener that aids in detecting cognitive impairment. It does not
assess all possible aspects of cognitive impairment. A diagnosis of dementia should only
be made after a careful assessment for other reasons for impaired cognitive performance.
The final determination of the level of impairment should be made by the resident’s
physician or mental health care specialist; however, these practitioners can be provided
specific BIMS results and the following guidance:

•

The BIMS total score is highly correlated with Mini-Mental State Exam (MMSE;
Folstein, Folstein, & McHugh, 1975) scores. Scores from a carefully conducted BIMS
assessment where residents can hear all questions and the resident is not delirious suggest
the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7:

October 2024

severe impairment

Page C-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0500: BIMS Summary Score (cont.)
•

Abrupt changes in cognitive status (as indicative of a delirium) often signal an underlying
potentially life-threatening illness and a change in cognition may be the only indication
of an underlying problem.

•

Care plans can be more individualized based upon reliable knowledge of resident
function.

Steps for Assessment
After completing C0200-C0400:
1. Add up the values for all questions from C0200 through C0400.
2. Do not add up the score while you are interviewing the resident. Instead, focus your full
attention on the interview.

D
Coding Instructions

Enter the total score as a two-digit number. The total possible BIMS score ranges from 00 to 15.
If the resident chooses not to answer a specific question(s), that question is coded as
incorrect and the item(s) counts in the total score. If, however, the resident chooses not to
answer four or more items, then the interview is coded as incomplete and the Staff
Assessment for Mental Status is completed.

•

To be considered a completed interview, the resident had to attempt and provide relevant
answers to at least four of the questions included in C0200-C0400. To be relevant, a
response only has to be related to the question (logical); it does not have to be correct.
See general coding tips below for residents who choose not to participate at all.

•

Code 99, unable to complete interview: if (a) the resident chooses not to

•

participate in the BIMS, (b) if four or more items were coded 0 because the resident
chose not to answer or gave a nonsensical response, or (c) if any but not all of the BIMS
items are coded with a dash (—).
— Note: a 0 score does not mean the BIMS was incomplete. For the BIMS to be
incomplete, a resident must choose not to answer or must give completely unrelated,
nonsensical responses to four or more items. If one or more of the 0s in C0200–
C0300 are due to incorrect answers, the interview should continue.

Coding Tips
•

Occasionally, a resident can communicate but chooses not to participate in the BIMS and
therefore does not attempt any of the items in the section. This would be considered an
incomplete interview; enter 99 for C0500, BIMS Summary Score, and complete the
Staff Assessment for Mental Status.

•

If all of the BIMS items are coded with a dash, then C0500, BIMS Summary Score must
also be coded with a dash.

October 2024

Page C-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0500: BIMS Summary Score (cont.)
Examples
1. The resident’s scores on items C0200-C0400 were as follows:
C0200 (repetition)
3
C0300A (year)
2
C0300B (month)
2
C0300C (day)
1
C0400A (recall “sock”)
2
C0400B (recall “blue”)
2
C0400C (recall “bed”)
0
Coding: C0500 would be coded 12 (Sum of C0200–C0400C). C0600. Should the Staff
Assessment for Mental Status be Conducted? is coded as 0, No, and the skip pattern is
followed.
2. The resident’s scores on items C0200–C0400C were as follows:
C0200 (repetition)
2
C0300A (year)
2
C0300B (month)
2
C0300C (day)
1
C0400A (recall “sock”)
0
C0400B (recall “blue”)
0
C0400C (recall “bed”)
0
Coding: C0500 would be coded 07 (Sum of C0200–C0400C). C0600. Should the Staff
Assessment for Mental Status be Conducted? is coded as 0, No, and the skip pattern is
followed.

3. The resident’s score on items C0200–C0400C were as follows:
C0200 (repetition)
0 (no response provided)
C0300A (year)
0 (nonsensical response provided)
C0300B (month)
0 (nonsensical response provided)
C0300C (day)
0 (no response provided and the interview was stopped)
C0400A (recall “sock”)
(—)
C0400B (recall “blue”)
(—)
C0400C (recall “bed”)
(—)
Coding: C0500 would be coded 99, resident was unable to complete the
interview.
Rationale: The interview was stopped because the resident did not respond to two

questions and provided nonsensical responses to two questions. Since the resident did not
attempt to answer two questions and did not provide relevant answers to two questions, the
BIMS interview is considered incomplete.

October 2024

Page C-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0600: Should the Staff Assessment for Mental Status (C0700C1000) Be Conducted?

Item Rationale
Health-related Quality of Life
•

•

Direct or performance-based testing of cognitive function using the BIMS is preferred as
it decreases the chance of incorrect labeling of cognitive ability and improves detection
of delirium. However, a minority of residents are unable or unwilling to participate in the
BIMS.
Mental status can vary among persons unable to communicate or who do not complete
the interview.
— Therefore, report of observed behavior is needed for persons unable to complete the
BIMS interview.
— When cognitive impairment is incorrectly diagnosed or missed, appropriate
communication, activities, and therapies may not be offered.

•

Planning for Care

Abrupt changes in cognitive status (as indicative of delirium) often signal an underlying
potentially life-threatening illness and a change in cognition may be the only indication
of an underlying problem.
— This remains true for persons who are unable to communicate or to complete the
BIMS.
Specific aspects of cognitive impairment, when identified, can direct nursing
interventions to facilitate greater independence and function.

Steps for Assessment

1. Review whether BIMS Summary Score item (C0500), is coded 99, unable to complete
interview.

October 2024

Page C-19

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0600: Should the Staff Assessment for Mental Status (C0700C1000) Be Conducted? (cont.)
Coding Instructions
•

Code 0, no: if the BIMS was completed and scored between 00 and 15. Skip to C1310.

•

Code 1, yes: if the resident chooses not to participate in the BIMS or if four or more
items were coded 0 because the resident chose not to answer or gave a nonsensical

response. Continue to C0700, Short-term Memory OK, to perform the Staff Assessment
for Mental Status. Note: C0500 should be coded 99.

Coding Tips
If a resident is scored 00 on C0500, the Staff Assessment for Mental Status should not be
completed. 00 is a legitimate value for C0500 and indicates that the interview was
complete. To have an incomplete interview, a resident had to choose not to answer or had
to give completely unrelated, nonsensical responses to four or more BIMS items.

•

C0700-C1000: Staff Assessment of Mental Status Item

ra
October 2024

Page C-20

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0700-C1000: Staff Assessment of Mental Status Item (cont.)
Item Rationale
Health-related Quality of Life
Cognitive impairment is prevalent among some groups of residents, but not all residents
are cognitively impaired.

•

Many persons with memory problems can function successfully in a structured, routine
environment.

•

Residents may appear to be cognitively impaired because of communication challenges
or lack of interaction but may be cognitively intact.

•

When cognitive impairment is incorrectly diagnosed or missed, appropriate
communication, worthwhile activities, and therapies may not be offered.

•

Planning for Care

•

The level and specific areas of impairment affect daily function and care needs. By
identifying specific aspects of cognitive impairment, nursing interventions can be
directed toward facilitating greater function.

•

Probing beyond first, perhaps mistaken, impressions is critical to accurate assessment and
appropriate care planning.

•

C0700: Short-term Memory OK

Item Rationale

Health-related Quality of Life
•

To assess the mental state of residents who cannot be interviewed, an intact 5-minute
recall (“short-term memory OK”) indicates greater likelihood of normal cognition.

•

An observed “memory problem” should be taken into consideration in Planning for Care.

October 2024

Page C-21

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0700: Short-term Memory OK (cont.)
Planning for Care
•

Identified memory problems typically indicate the need for:
— Assessment and treatment of an underlying related medical problem (particularly if
this is a new observation) or adverse medication effect, or
— possible evaluation for other problems with thinking
— additional nursing support
— at times frequent prompting during daily activities
— additional support during recreational activities.

Steps for Assessment

1. Determine the resident’s short-term memory status by asking them:
•

to describe an event 5 minutes after it occurred if you can validate the resident’s
response, or

•

to follow through on a direction given 5 minutes earlier.

2. Observe how often the resident has to be re-oriented to an activity or instructions.
3. Staff members also should observe the resident’s cognitive function in varied daily activities.
4. Observations should be made by staff across all shifts and departments and others with close
contact with the resident.
5. Ask direct care staff across all shifts and family or significant others about the resident’s
short-term memory status.
6. Review the medical record for clues to the resident’s short-term memory during the lookback period.

Coding Instructions

Based on all information collected regarding the resident’s short-term memory during the 7-day
look-back period, identify and code according to the most representative level of function.
•

Code 0, memory OK: if the resident recalled information after 5 minutes.

•

Code 1, memory problem: if the most representative level of function shows the

absence of recall after 5 minutes.

Coding Tips
•

If the test cannot be conducted (resident will not cooperate, is non-responsive, etc.) and
staff members were unable to make a determination based on observing the resident, use
the standard “no information” code (a dash, “-”) to indicate that the information is not
available because it could not be assessed.

October 2024

Page C-22

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0700: Short-term Memory OK (cont.)
Example
1. A resident has just returned from the activities room where they and other residents were
playing bingo. You ask them if they enjoyed themself playing bingo, but they return a blank
stare. When you ask them if they were just playing bingo, they say, “no.” Code 1, memory
problem.
Coding: C0700, would be coded 1, memory problem.
Rationale: The resident could not recall an event that took place within the past 5 minutes.

C0800: Long-term Memory OK

D
Item Rationale

•

An observed “long-term memory problem” may indicate the need for emotional support,
reminders, and reassurance. It may also indicate delirium if this represents a change from
the resident’s baseline.
An observed “long-term memory problem” should be taken into consideration in
Planning for Care.

•

Health-related Quality of Life

Planning for Care

Steps for Assessment

Long-term memory problems indicate the need for:
— Exclusion of an underlying related medical problem (particularly if this is a new
observation) or adverse medication effect, or
— possible evaluation for other problems with thinking
— additional nursing support
— at times frequent prompting during daily activities
— additional support during recreational activities.

1. Determine resident’s long-term memory status by engaging in conversation, reviewing
memorabilia (photographs, memory books, keepsakes, videos, or other recordings that are
meaningful to the resident) with the resident or observing response to family who visit.
2. Ask questions for which you can validate the answers from review of the medical record,
general knowledge, the resident’s family, etc.
• Ask the resident, “Are you married?” “What is your spouse’s name?” “Do you have any
children?” “How many?” “When is your birthday?”

October 2024

Page C-23

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0800: Long-term Memory OK (cont.)
3. Observe if the resident responds to memorabilia or family members who visit.
4. Observations should be made by staff across all shifts and departments and others with close
contact with the resident.
5. Ask direct care staff across all shifts and family or significant others about the resident’s
memory status.
6. Review the medical record for clues to the resident’s long-term memory during the look-back
period.

Coding Instructions
•

Code 0, memory OK: if the resident accurately recalled long past information.

•

Code 1, memory problem: if the resident did not recall long past information or did

not recall it correctly.

Coding Tips
•

If the test cannot be conducted (resident will not cooperate, is non-responsive, etc.) and
staff were unable to make a determination based on observation of the resident, use the
standard “no information” code (a dash, “-”), to indicate that the information is not
available because it could not be assessed.

Item Rationale
•

•

C0900: Memory/Recall Ability

Health-related Quality of Life

An observed “memory/recall problem” with these items may indicate:
— cognitive impairment and the need for additional support with reminders to support
increased independence; or
— delirium, if this represents a change from the resident’s baseline.

Planning for Care

An observed “memory/recall problem” with these items may indicate the need for:
— Exclusion of an underlying related medical problem (particularly if this is a new
observation) or adverse medication effect; or
— possible evaluation for other problems with thinking;
— additional signs, directions, pictures, verbal reminders to support the resident’s
independence;

October 2024

Page C-24

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C0900: Memory/Recall Ability (cont.)
— an evaluation for acute delirium if this represents a change over the past few days to
weeks;
— an evaluation for chronic delirium if this represents a change over the past several
weeks to months; or
— additional nursing support;
— the need for emotional support, reminders and reassurance to reduce anxiety and
agitation.

Steps for Assessment

1. Ask the resident about each item. For example, “What is the current season? Is it fall, winter,
spring, or summer?” “What is the name of this place?” If the resident is not in their room,
ask, “Will you show me to your room?” Observe the resident’s ability to find the way.
2. For residents with limited communication skills, in order to determine the most
representative level of function, ask direct care staff across all shifts and family or significant
other about recall ability.
• Ask whether the resident gave indications of recalling these subjects or recognizing them
during the look-back period.
3. Observations should be made by staff across all shifts and departments and others with close
contact with the resident.
4. Review the medical record for indications of the resident’s recall of these subjects during the
look-back period.

Coding Instructions

For each item that the resident recalls, check the corresponding answer box. If the resident
recalls none, check none of above.
•

•

(e.g., correctly refers to weather for the time of year, legal holidays, religious
celebrations, etc.).
Check C0900B, location of own room: if resident is able to locate and recognize
own room. It is not necessary for the resident to know the room number, but they should
be able to find the way to the room.
Check C0900C, staff names and faces: if resident is able to distinguish staff
members from family members, strangers, visitors, and other residents. It is not necessary
for the resident to know the staff member’s name, but they should recognize that the
person is a staff member and not the resident’s child, etc.
Check C0900D, that they are in a nursing home/hospital swing bed: if
resident is able to determine that they are currently living in a nursing home. To check
this item, it is not necessary that the resident be able to state the name of the nursing
home, but they should be able to refer to the nursing home by a term such as a “home for
older people,” a “hospital for the elderly,” “a place where people who need extra help
live,” etc.

•

Check C0900A, current season: if resident is able to identify the current season

Check C0900Z, none of above was recalled.

October 2024

Page C-25

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C1000: Cognitive Skills for Daily Decision Making

Item Rationale
Health-related Quality of Life
•

An observed “difficulty with daily decision making”
may indicate:

— underlying cognitive impairment and the need for
additional coaching and support or
— possible anxiety or depression.

Planning for Care

•

An observed “difficulty with daily decision making”
may indicate the need for:

DAILY DECISION
MAKING
Includes: choosing clothing;
knowing when to go to
meals; using environmental
cues to organize and plan
(e.g., clocks, calendars,
posted event notices); in the
absence of environmental
cues, seeking information
appropriately (i.e. not
repetitively) from others in
order to plan the day; using
awareness of one’s own
strengths and limitations to
regulate the day’s events
(e.g., asks for help when
necessary); acknowledging
need to use appropriate
assistive equipment such as
a walker.

— a more structured plan for daily activities and
support in decisions about daily activities,

DEFINITION

— encouragement to participate in structured activities,
or
— an assessment for underlying delirium and medical
evaluation.

Steps for Assessment

1. Review the medical record. Consult family and direct care staff across all shifts. Observe the
resident.
2. Observations should be made by staff across all shifts and departments and others with close
contact with the resident.
3. The intent of this item is to record what the resident is doing (performance). Focus on
whether or not the resident is actively making these decisions and not whether staff believes
the resident might be capable of doing so.
4. Focus on the resident’s actual performance. Where a staff member takes decision-making
responsibility away from the resident regarding tasks of everyday living, or the resident does
not participate in decision making, whatever their level of capability may be, the resident
should be coded as impaired performance in decision making.

October 2024

Page C-26

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C1000: Cognitive Skills for Daily Decision Making (cont.)
Coding Instructions
Record the resident’s actual performance in making everyday decisions about tasks or activities
of daily living. Enter one number that corresponds to the most correct response.
•
•
•

Code 0, independent: if the resident’s decisions in organizing daily routine and

making decisions were consistent, reasonable and organized reflecting lifestyle, culture,
values.
Code 1, modified independence: if the resident organized daily routine and made
safe decisions in familiar situations, but experienced some difficulty in decision making
when faced with new tasks or situations.
Code 2, moderately impaired: if the resident’s decisions were poor; the resident
required reminders, cues, and supervision in planning, organizing, and correcting daily
routines.
Code 3, severely impaired: if the resident’s decision making was severely
impaired; the resident never (or rarely) made decisions.

•

Coding Tips

•

If the resident “rarely or never” made decisions, despite being provided with
opportunities and appropriate cues, Item C1000 would be coded 3, severely
impaired. If the resident makes decisions, although poorly, code 2, moderately
impaired.
A resident’s considered decision to exercise their right to decline treatment or
recommendations by interdisciplinary team members should not be captured as impaired
decision making in Item C1000, Cognitive Skills for Daily Decision Making.

Examples

•

1. Resident B seems to have severe cognitive impairment and is non-verbal. They usually clamp
their mouth shut when offered a bite of food.
2. Resident C does not generally make conversation or make their needs known, but replies
“yes” when asked if they would like to take a nap.
Coding: For the above examples, Item C1000 would be coded 3, severe
impairment.
Rationale: In both examples, the residents are primarily non-verbal and do not make

their needs known, but they do give basic verbal or non-verbal responses to simple
gestures or questions regarding care routines. More information about how the residents
function in the environment is needed to definitively answer the questions. From the
limited information provided it appears that their communication of choices is limited to
very particular circumstances, which would be regarded as “rarely/never” in the relative
number of decisions a person could make during the course of a week on the MDS. If
such decisions are more frequent or involved more activities, the resident may be only
moderately impaired or better.

October 2024

Page C-27

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C1000: Cognitive Skills for Daily Decision Making (cont.)
3. A resident makes their own decisions throughout the day and is consistent and reasonable in
their decision-making except that they constantly walk away from the walker they have been
using for nearly 2 years. Asked why they don’t use their walker, they reply, “I don’t like it. It
gets in my way, and I don’t want to use it even though I know all of you think I should.”
Coding: C1000 would be coded 0, independent.
Rationale: This resident is making and expressing understanding of their own

decisions, and their decision is to decline the recommended course of action – using the
walker. Other decisions they made throughout the look-back period were consistent and
reasonable.

4. A resident routinely participates in coffee hour on Wednesday mornings, and often does not
need a reminder. Due to renovations, however, the meeting place was moved to another
location in the facility. The resident was informed of this change and was accompanied to the
new location by the activities director. Staff noticed that the resident was uncharacteristically
agitated and unwilling to engage with other residents or the staff. They eventually left and
were found sitting in the original coffee hour room. Asked why they came back to this
location, they responded, “the aide brought me to the wrong room, I’ll wait here until they
serve the coffee.”

Coding: C1000 would be coded 1, modified independent.
Rationale: The resident is independent under routine circumstances. However, when

the situation was new or different, they had difficulty adjusting.

5. Resident G enjoys congregate meals in the dining room and is friendly with the other
residents at their table. Recently, they have started to lose weight. They appear to have little
appetite, rarely eat without reminders and willingly give their food to other residents at the
table. Resident G requires frequent cueing from staff to eat and supervision to prevent them
from sharing their food.

Coding: C1000 would be coded 2, moderately impaired.
Rationale: The resident is making poor decisions by giving their food away. They

require cueing to eat and supervision to be sure that they are eating the food on their
plate.

October 2024

Page C-28

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C1310: Signs and Symptoms of Delirium (from CAM©)

D
ra

Item Rationale

Health-related Quality of Life
•

Delirium is associated with:
— increased mortality,
— functional decline,

— development or worsening of incontinence,
— behavior problems,

— withdrawal from activities

— rehospitalizations and increased length of nursing home stay.
•

Delirium can be misdiagnosed as dementia.

•

A recent deterioration in cognitive function may indicate delirium, which may be
reversible if detected and treated in a timely fashion.

Planning for Care
•

Delirium may be a symptom of an acute, treatable illness such as infection or reaction to
medications.

•

Prompt detection is essential in order to identify and treat or eliminate the cause.

October 2024

Page C-29

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C1310: Signs and Symptoms of Delirium (from CAM©) (cont.)
Steps for Assessment

DEFINITION

1. Observe resident behavior during the BIMS items (C0200DELIRIUM
C0400) for the signs and symptoms of delirium. Some
A mental disturbance
experts suggest that increasing the frequency of assessment characterized by new or
(as often as daily for new admissions) will improve the
acutely worsening confusion,
disordered expression of
level of detection.
thoughts, change in level of
2. If the Staff Assessment for Mental Status items (C0700consciousness or
C1000) were completed instead of the BIMS, ask staff
hallucinations.
members who conducted the interview about their
observations of signs and symptoms of delirium.
3. Review medical record documentation during the 7-day look-back period to determine the
resident’s baseline status, fluctuations in behavior, and behaviors that might have occurred
during the 7-day look-back period that were not observed during the BIMS.
4. Observe the resident’s behavior during interactions and consult with other staff, family
members/caregivers, and others in a position to observe the resident’s behavior during the 7day look-back period.

Additional guidance on the signs and symptoms of delirium can be found in Appendix C.

Coding Instructions for C1310A, Acute Mental Status Change
•

Code 0, no: if there is no evidence of acute mental status change from the resident’s

•

Code 1, yes: if resident has an alteration in mental status observed in the observation
period that represents an acute change from baseline.

baseline.

Coding Tips
•

Examples of acute mental status change:

— A resident who is usually noisy or belligerent becomes quiet, lethargic, or inattentive.
— A resident who is normally quiet and content suddenly becomes restless or noisy.
— A resident who is usually able to find their way around their living environment
begins to get lost.

Examples

1. The resident was admitted to the nursing home 4 days ago. Their family reports that they
were alert and oriented prior to admission. During the BIMS interview, they are lethargic and
incoherent.
Coding: Item C1310A would be coded 1, yes.
Rationale: There is an acute change of the resident’s behavior from alert and oriented

(family report) to lethargic and incoherent during interview.

October 2024

Page C-30

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C1310: Signs and Symptoms of Delirium (from CAM©) (cont.)
2. The nurse reports that a resident with poor short-term memory and disorientation to time
suddenly becomes agitated, calling out to their dead spouse, tearing off their clothes, and
being completely disoriented to time, person, and place.
Coding: Item C1310A would be coded 1, yes.
Rationale: The new behaviors represent an acute change in mental status.

Steps for Assessment for C1310B, Inattention

1. Assess attention separately from level of consciousness. Evidence of inattention may be
found during the resident interview, in the medical record, or from family or staff reports of
inattention during the 7-day look-back period.
2. An additional step to identify difficulty with attention is to ask the resident to count
backwards from 20.

Coding Instructions for C1310B, Inattention
•

remains focused during the interview and all other
sources agree that the resident was attentive during
other activities.

Code 1, behavior continuously present, did
not fluctuate: if the resident had difficulty focusing

attention, was easily distracted, or had difficulty
keeping track of what was said AND the inattention did
not vary during the look-back period. All sources must
agree that inattention was consistently present to select
this code.
•

INATTENTION
Reduced ability to maintain
attention to external stimuli
and to appropriately shift
attention to new external
stimuli. Resident seems
unaware or out of touch with
environment (e.g., dazed,
fixated or darting attention).

•

Code 0, behavior not present: if the resident

DEFINITIONS

Code 2, behavior present, fluctuates: if

inattention is noted during the interview or any source
reports that the resident had difficulty focusing
attention, was easily distracted, or had difficulty
keeping track of what was said AND the inattention
varied during interview or during the look-back period
or if information sources disagree in assessing level of
attention.

FLUCTUATION
The behavior tends to come
and go and/or increase or
decrease in severity. The
behavior may fluctuate over
the course of the interview or
during the 7-day look- back
period. Fluctuating behavior
may be noted by the
interviewer, reported by staff
or family or documented in
the medical record.

October 2024

Page C-31

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C1310: Signs and Symptoms of Delirium (from CAM©) (cont.)
Examples
1. The resident tries to answer all questions during the BIMS. Although they answer several
items incorrectly and respond “I don’t know” to others, they pay attention to the interviewer.
Medical record and staff indicate that this is their consistent behavior.
Coding: Item C1310B would be coded 0, behavior not present.
Rationale: The resident remained focused throughout the interview and this was

constant during the look-back period.

2. Questions during the BIMS must be frequently repeated because the resident’s attention
wanders. This behavior occurs throughout the interview and medical records and staff agree
that this behavior is consistently present. The resident has a diagnosis of dementia.

Coding: Item C1310B would be coded 1, behavior continuously present,
does not fluctuate.
Rationale: The resident’s attention consistently wandered throughout the 7-day look-

back period. The resident’s dementia diagnosis does not affect the coding.

3. During the BIMS interview, the resident was not able to focus on all questions asked and
their gaze wandered. However, several notes in the resident’s medical record indicate that the
resident was attentive when staff communicated with them, and family confirmed this.
Coding: Item C1310B would be coded 2, behavior present, fluctuates.
Rationale: Evidence of inattention was found during the BIMS but was noted to be

absent in the medical record. This disagreement shows possible fluctuation in the
behavior. If any information source reports the symptom as present, C1310B cannot be
coded as 0, Behavior not present.

4. The resident is dazedly staring at the television for the first several questions. When you ask
a question, they look at you momentarily but do not answer. Midway through questioning,
they seem to pay more attention and try to answer.

Coding: Item C1310B would be coded 2, behavior present, fluctuates.
Rationale: Resident’s attention fluctuated during the interview. If as few as one source
notes fluctuation, then the behavior should be coded 2.

October 2024

Page C-32

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C1310: Signs and Symptoms of Delirium (from CAM©) (cont.)
Coding Instructions for C1310C, Disorganized Thinking
•

•

Code 0, behavior not present: if all sources
agree that the resident’s thinking was organized and
coherent, even if answers were inaccurate or wrong.
Code 1, behavior continuously present, did
not fluctuate: if, during the interview and according

DEFINITION
DISORGANIZED
THINKING
Evidenced by rambling,
irrelevant, or incoherent
speech.

to other sources, the resident’s responses were
consistently disorganized or incoherent, conversation
was rambling or irrelevant, ideas were unclear or flowed illogically, or the resident
unpredictably switched from subject to subject.

Code 2, behavior present, fluctuates: if, during the interview or according to

•

other data sources, the resident’s responses fluctuated between disorganized/incoherent
and organized/clear. Also code as fluctuating if information sources disagree.

Examples

1. The interviewer asks the resident, who is often confused, to give the date, and the response
is: “Let’s go get the sailor suits!” The resident continues to provide irrelevant or nonsensical
responses throughout the interview, and medical record and staff indicate this is constant.
Coding: C1310C would be coded 1, behavior continuously present, does
not fluctuate.
Rationale: All sources agree that the disorganized thinking is constant.

2. The resident responds that the year is 1837 when asked to give the date. The medical record
and staff indicate that the resident is never oriented to time but has coherent conversations.
For example, staff reports they often discuss their passion for baseball.

Coding: C1310C would be coded 0, behavior not present.
Rationale: The resident’s answer was related to the question, even though it was

incorrect. No other sources report disorganized thinking.

3. The resident was able to tell the interviewer their name, the year and where they were. They
were able to talk about the activity they just attended and the residents and staff that also
attended. Then the resident suddenly asked the interviewer, “Who are you? What are you
doing in my child’s home?”

Coding: C1310C would be coded 2, behavior present, fluctuates.
Rationale: The resident’s thinking fluctuated between coherent and incoherent at least
once. If as few as one source notes fluctuation, then the behavior should be coded 2.

October 2024

Page C-33

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C1310: Signs and Symptoms of Delirium (from CAM©) (cont.)
Coding Instructions for C1310D, Altered Level of Consciousness
•

•

Code 0, behavior not present: if all sources
agree that the resident was alert and maintained
wakefulness during conversation, interview(s), and
activities.
Code 1, behavior continuously present, did
not fluctuate: if, during the interview and according

to other sources, the resident was consistently lethargic
(difficult to keep awake), stuporous (very difficult to
arouse and keep aroused), vigilant (startles easily to any
sound or touch), or comatose.

•

Code 2, behavior present, fluctuates: if,

during the interview or according to other sources, the
resident varied in levels of consciousness. For example,
was at times alert and responsive, while at other times
resident was lethargic, stuporous, or vigilant. Also code
as fluctuating if information sources disagree.

DEFINITIONS
ALTERED LEVEL OF
CONSCIOUSNESS
VIGILANT – startles easily to
any sound or touch;
LETHARGIC – repeatedly
dozes off when you are
asking questions, but
responds to voice or touch;
STUPOR – very difficult to
arouse and keep aroused for
the interview;
COMATOSE – cannot be
aroused despite shaking and
shouting.

Coding Tips
•

A diagnosis of coma or stupor does not have to be present for staff to note the behavior in
this section.

Examples

1. Resident is alert and conversational and answers all questions during the BIMS interview,
although not all answers are correct. Medical record documentation and staff report during
the 7-day look-back period consistently noted that the resident was alert.
Coding: C1310D would be coded 0, behavior not present.
Rationale: All evidence indicates that the resident is alert during conversation,

interview(s) and activities.

2. The resident is lying in bed. They arouse to soft touch but are only able to converse for a
short time before their eyes close, and they appear to be sleeping. Again, they arouse to voice
or touch but only for short periods during the interview. Information from other sources
indicates that this was their condition throughout the look-back period.
Coding: C1310D would be coded 1, behavior continuously present, does
not fluctuate.
Rationale: The resident’s lethargy was consistent throughout the interview, and there is

consistent documentation of lethargy in the medical record during the look-back period.

October 2024

Page C-34

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [C]

C1310: Signs and Symptoms of Delirium (from CAM©) (cont.)
3. Resident is usually alert, oriented to time, place, and person. Today, at the time of the BIMS
interview, resident is conversant at the beginning of the interview but becomes lethargic and
difficult to arouse.
Coding: C1310D would be coded 2, behavior present, fluctuates.
Rationale: The level of consciousness fluctuated during the interview. If as few as one
source notes fluctuation, then the behavior should be coded 2, fluctuating.

CAM Assessment Scoring Methodology
The indication of delirium by the CAM requires the presence of:

Item A = 1 OR Item B, C or D = 2
AND

Item B = 1 OR 2

AND EITHER

Item C = 1 OR 2 OR Item D = 1 OR 2

ft
October 2024

Page C-35

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

SECTION D: MOOD
Intent: The items in this section address mood distress and social isolation. Mood distress is a
serious condition that is underdiagnosed and undertreated in the nursing home and is associated
with significant morbidity. It is particularly important to identify signs and symptoms of mood
distress among nursing home residents because these signs and symptoms can be treatable.
Social isolation refers to an actual or perceived lack of contact with other people and tends to
increase with age. It is a risk factor for physical and mental illness, is a predictor of mortality,
and is important to assess in order to identify engagement strategies.

D0100: Should Resident Mood Interview Be Conducted?

Item Rationale
Health-related Quality of Life
•

Most residents who are capable of communicating can answer questions about how they
feel.

•

Obtaining information about mood directly from the resident, sometimes called “hearing
the resident’s voice,” is more reliable and accurate than observation alone for identifying
a mood disorder.

Planning for Care
•

Symptom-specific information from direct resident interviews will allow for the
incorporation of the resident’s voice in the individualized care plan.

•

If a resident cannot communicate, then Staff Mood Interview (D0500 A-J) should be
conducted, unless the assessment being completed is a stand-alone Part A PPS Discharge;
if that is the case, then skip to D0700. Social Isolation.

October 2024

Page D-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0100: Should Resident Mood Interview Be Conducted? (cont.)
Steps for Assessment
1. Interact with the resident using their preferred language. Be sure they can hear you and/or
have access to their preferred method for communication. If the resident appears unable to
communicate, offer alternatives such as writing, pointing, sign language, or cue cards.
2. Determine whether the resident is rarely/never understood verbally, in writing, or using
another method. If rarely/never understood, skip to D0500, Staff Assessment of Resident
Mood (PHQ-9-OV©), unless the assessment being completed is a stand-alone Part A PPS
Discharge; if that is the case, then skip to D0700. Social Isolation.
3. Review Language item (A1110) to determine if the resident needs or wants an interpreter to
communicate with doctors or health care staff (A1110 = 1).
•

If the resident needs or wants an interpreter, complete the interview with an interpreter.

D
Coding Instructions
•

Code 0, no: if the interview should not be conducted because the resident is

•

Code 1, yes: if the resident interview should be conducted because the resident is at

rarely/never understood or cannot respond verbally, in writing, or using another method,
or an interpreter is needed but not available. Skip to item D0500, Staff Assessment of
Resident Mood (PHQ-9-OV©), unless the assessment being completed is a stand-alone
Part A PPS Discharge; if that is the case, then skip to D0700. Social Isolation.

least sometimes understood verbally, in writing, or using another method, and if an
interpreter is needed, one is available. Continue to item D0150, Resident Mood Interview
(PHQ-2 to 9©).

Coding Tips and Special Populations

Attempt to conduct the interview with ALL residents. This interview is conducted during
the look-back period of the Assessment Reference Date (ARD) and is not contingent
upon item B0700, Makes Self Understood.

•

D0100 serves as a gateway item for the Resident Mood Interview (PHQ-2 to 9©) and
D0500, Staff Assessment of Resident Mood (PHQ-9-OV©). The assessor will complete
the Staff Assessment only when D0100 is coded 0, No. The assessor does not complete
the Staff Assessment based on resident performance during the Resident Mood Interview.

•

If the resident needs an interpreter, every effort should be made to have an interpreter
present for the PHQ-2 to 9© interview. If it is not possible for a needed interpreter to be
present on the day of the interview, code D0100 = 0 to indicate that an interview was not
attempted and complete items D0500-D0600, unless the assessment being completed is a
stand-alone Part A PPS Discharge; if that is the case, then skip to D0700. Social Isolation.

•

Includes residents who use American Sign Language (ASL).

•

October 2024

Page D-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0100: Should Resident Mood Interview Be Conducted? (cont.)
•

If the resident interview was not conducted within the look-back period of the ARD, item
D0100 must be coded 1, Yes, and the standard “no information” code (a dash “-”) entered
in the resident interview items.

•

Do not complete the Staff Assessment of Resident Mood items (D0500) if the resident
interview should have been conducted but was not done, or if the assessment being
completed is a stand-alone Part A PPS Discharge assessment.

•

Resident refusal or unwillingness to participate in the interview would result in Item
D0100 being coded 1, Yes, and code 9, No response being entered in Column 1.
Symptom Presence. Assessors should proceed to Item D0700, Social Isolation in the case
of resident refusal or unwillingness to participate.

D0150: Resident Mood Interview (PHQ-2 to 9©)

October 2024

Page D-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
Item Rationale
Health-related Quality of Life
•

It is important to note that coding the presence of clinical signs and symptoms of
depressed mood does not automatically mean that the resident has a diagnosis of
depression or other mood disorder. Assessors do not make or assign a diagnosis based on
these findings; they simply record the presence or absence of specific clinical signs and
symptoms of depressed mood. Facility staff should recognize these signs and symptoms
and consider them when developing the resident’s individualized care plan.

•

Depression can be associated with:
— psychological and physical distress,

— decreased participation in therapy and activities,

— decreased functional status, and
— poorer outcomes.

•

Mood disorders are common in nursing homes and are
often underdiagnosed and undertreated.

•

PATIENT HEALTH
QUESTIONNAIRE
(PHQ-2 to 9©)
A validated interview that
screens for symptoms of
depression. It provides a
standardized severity score
and a rating for evidence of a
depressive disorder.

Planning for Care

DEFINITION

Findings suggesting mood distress could lead to:

— identifying causes and contributing factors for symptoms and

— identifying interventions (treatment, personal support, or environmental
modifications) that could address symptoms.

Steps for Assessment

1. Interview any resident when D0100 = 1.
2. Conduct the interview in a private setting.
3. If an interpreter is used during resident interviews, the interpreter should not attempt to
determine the intent behind what is being translated, the outcome of the interview, or the
meaning or significance of the resident’s responses.
4. Sit so that the resident can see your face. Minimize glare by directing light sources away
from the resident’s face.
5. Be sure the resident can hear you.
• Residents with a hearing impairment should be interviewed using their usual
communication devices/techniques, as applicable, during the interview.
• Try an external assistive device (headphones or hearing amplifier) if you have any doubt
about hearing ability.
• Minimize background noise.
6. If you are administering the PHQ-2 to 9© in paper form, be sure that the resident can see the
print. Provide large print or assistive device (e.g., page magnifier) if necessary.
7. Explain the reason for the interview before beginning.

October 2024

Page D-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)

Suggested language: “I am going to ask you some questions about your mood and
feelings over the past 2 weeks. I will also ask about some common problems that are
known to go along with feeling down. Some of the questions might seem personal, but
everyone is asked to answer them. This will help us provide you with better care.”
8. Explain and /or show the interview response choices. A cue card with the response choices
clearly written in large print might help the resident comprehend the response choices.
Suggested language: “I am going to ask you how often you have been bothered by a
particular problem over the last 2 weeks. I will give you the choices that you see on this
card.” (Say while pointing to cue card): “0-1 days—never or 1 day, 2-6 days—several
days, 7-11 days—half or more of the days, or 12-14 days—nearly every day.”
9. Ask the first two questions of the Resident Mood Interview (PHQ-2 to 9©).
Suggested language: “Over the last 2 weeks, have you been bothered by any of the
following problems?”
For each of the questions:
• Read the item as it is written.
• Do not provide definitions because the meaning must be based on the resident’s
interpretation. For example, the resident defines for themself what “tired” means; the item
should be scored based on the resident’s interpretation.
• Each question must be asked in sequence to assess Symptom Presence (column 1) and
Symptom Frequency (column 2) before proceeding to the next question.
• Enter code 9 in Column 1 and leave Column 2 blank if the resident was unable or chose
not to complete the assessment or responded nonsensically. A nonsensical response is one
that is unrelated, incomprehensible, or incoherent or if the resident’s response is not
informative with respect to the item being rated (e.g., when asked the question about
“poor appetite or overeating,” the resident answers, “I always win at poker.”).
• For a yes response, ask the resident to tell you how often they were bothered by the
symptom over the last 2 weeks. Use the response choices in D0150 Column 2, Symptom
Frequency. Start by asking the resident the number of days that they were bothered by the
symptom and read and show cue card with frequency categories/descriptions (0-1 days—
never or 1 day, 2-6 days—several days, 7-11 days—half or more of the days, or 12-14
days—nearly every day).
10. Determine whether to ask the remaining seven questions (D0150C to D0150I) of the
Resident Mood Interview (PHQ-2 to 9©). Whether or not further evaluation of a resident’s
mood is needed depends on the resident’s responses to the first two questions (D0150A and
D0150B) of the Resident Mood Interview.
• If both D0150A1 and D0150B1 are coded 9, OR both D0150A2 and D0150B2 are coded
0 or 1, end the PHQ interview; otherwise continue.
— If both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank,
then end the PHQ-2©, leave D0160, Total Severity Score blank, and skip to D0700,
Social Isolation.
— If both D0150A2 and D0150B2 are coded 0 or 1, then end the PHQ-2© and enter the
total score from D0150A2 and D0150B2 in D0160, Total Severity Score.

October 2024

Page D-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
•

For all other scenarios, proceed to ask the remaining seven questions (D0150C to D0150I
of the PHQ-9©) and complete D0160, Total Severity Score.

Coding Instructions for Column 1. Symptom Presence
•

Code 0, no: if resident indicates symptoms listed are not present. Enter 0 in Column 2

•

Code 1, yes: if resident indicates symptoms listed are present. Enter 0, 1, 2, or 3 in

•
•

as well.

Column 2, Symptom Frequency.
Code 9, no response: if the resident was unable or chose not to complete the
assessment or responded nonsensically. Leave Column 2, Symptom Frequency, blank.
Enter a Dash in Column 1 if the symptom presence was not assessed.

Coding Instructions for Column 2. Symptom Frequency
Record the resident’s responses as they are stated, regardless of whether the resident or the
assessor attributes the symptom to something other than mood. Further evaluation of the clinical
relevance of reported symptoms should be explored by the responsible clinician.
•

•
•

have never been bothered by the symptom or have only been bothered by the symptom on
1 day.
Code 1, 2-6 days (several days): if the resident indicates that during the past 2
weeks they have been bothered by the symptom for 2-6 days.
Code 2, 7-11 days (half or more of the days): if the resident indicates during the
past 2 weeks they have been bothered by the symptom for 7-11 days.
Code 3, 12-14 days (nearly every day): if the resident indicates during the past 2
weeks they have been bothered by the symptom for 12-14 days.

•

Code 0, never or 1 day: if the resident indicates that during the past 2 weeks they

Coding Tips and Special Populations
•
•

Attempt to conduct the interview with ALL residents.
If both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank, then
end the PHQ-2©, leave D0160, Total Severity Score blank, and skip to D0700, Social
Isolation.

•

If Column 1 equals 0, enter 0 in Column 2.

•

If Column 1 equals 9 or dash, leave Column 2 blank.

•

For question D0150I, Thoughts That You Would Be Better Off Dead or of Hurting
Yourself in Some Way:
— Beginning interviewers may feel uncomfortable asking this item because they may
fear upsetting the resident or may feel that the question is too personal. Others may
worry that it will give the resident inappropriate ideas. However,

October 2024

Page D-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
○ Experienced interviewers have found that most residents who are having this
feeling appreciate the opportunity to express it.

•

•
•

○ Asking about thoughts of self-harm does not give the person the idea. It does let
the provider better understand what the resident is already feeling.
○ The best interviewing approach is to ask the question openly and without
hesitation.
If the resident uses their own words to describe a symptom, this should be briefly
explored. If you determine that the resident is reporting the intended symptom but using
their own words, ask them to tell you how often they were bothered by that symptom.
Select only one frequency response per item.
If the resident has difficulty selecting between two frequency responses, code for the
higher frequency.
Some items (e.g., item D0150F) contain more than one phrase. If a resident gives
different frequencies for the different parts of a single item, select the highest frequency
as the score for that item.
Residents may respond to questions:
— verbally,
— by pointing to their answers on the cue card, OR
— by writing out their answers.

Interviewing Tips and Techniques
•
•

October 2024

•

Repeat a question if you think that it has been misunderstood or misinterpreted.
Some residents may be eager to talk with you and will stray from the topic at hand. When
a person strays, you should gently guide the conversation back to the topic.
— Example: Say, “That’s interesting, now I need to know…”; “Let’s get back to…”; “I
understand, can you tell me about….”
• Validate your understanding of what the resident is saying by asking for
clarification.
— Example: Say, “I think I hear you saying that…”; “Let’s see if I understood you
correctly.”; “You said…. Is that right?”
If the resident has difficulty selecting a frequency response, start by offering a single
frequency response and follow with a sequence of more specific questions. This is known
as unfolding.
— Example: Say, “Would you say [name symptom] bothered you more than half the
days in the past 2 weeks?”
○ If the resident says “yes,” show the cue card and ask whether it bothered them
nearly every day (12-14 days) or on half or more of the days (7-11 days).
○ If the resident says “no,” show the cue card and ask whether it bothered them
several days (2-6 days) or never or 1 day (0-1 day).

Page D-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
•

•

Noncommittal responses such as “not really” should be explored. Residents may be
reluctant to report symptoms and should be gently encouraged to tell you if the symptom
bothered them, even if it was only some of the time. This is known as probing. Probe by
asking neutral or nondirective questions such as:
— “What do you mean?”
— “Tell me what you have in mind.”
— “Tell me more about that.”
— “Please be more specific.”
— “Give me an example.”
Sometimes respondents give a long answer to interview items. To narrow the answer to
the response choices available, it can be useful to summarize their longer answer and then
ask them which response option best applies. This is known as echoing.
— Example: Item D0150E, Poor Appetite or Overeating. The resident responds “the
food is always cold and it just doesn’t taste like it does at home. The doctor won’t let
me have any salt.”
○ Possible interviewer response: “You’re telling me the food isn’t what you eat at
home and you can’t add salt. How often would you say that you were bothered by
poor appetite or over-eating during the last 2 weeks?”
— Example: Item D0150A, Little Interest or Pleasure in Doing Things. The resident,
when asked how often they have been bothered by little interest or pleasure in doing
things, responds, “There’s nothing to do here, all you do is eat, bathe, and sleep. They
don’t do anything I like to do.”
○ Possible interview response: “You’re saying there isn’t much to do here and I
want to come back later to talk about some things you like to do. Thinking about
how you’ve been feeling over the past 2 weeks, how often have you been bothered
by little interest or pleasure in doing things.”
— Example: Item D0150B, Feeling Down, Depressed, or Hopeless. The resident,
when asked how often they have been bothered by feeling down, depressed, or
hopeless, responds: “How would you feel if you were here?”
○ Possible interview response: “You asked how I would feel, but it is important that
I understand your feelings right now. How often would you say that you have
been bothered by feeling down, depressed, or hopeless during the last 2 weeks?”

October 2024

Page D-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
•

Examples

If the resident has difficulty with longer items, separate the item into shorter parts, and
provide a chance to respond after each part. This method, known as disentangling, is
helpful if a resident has moderate cognitive impairment but can respond to simple, direct
questions.
— Example: Item D0150E, Poor Appetite or Overeating.
○ You can simplify this item by asking: “In the last 2 weeks, how often have you
been bothered by poor appetite?” (pause for a response) “Or overeating?”
— Example: Item D0150C, Trouble Falling or Staying Asleep, or Sleeping Too
Much.
○ You can break the item down as follows: “How often are you having problems
falling asleep?” (pause for response) “How often are you having problems staying
asleep?” (pause for response) “How often do you feel you are sleeping too
much?”
— Example: Item D0150H, 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.
○ You can simplify this item by asking: “How often are you having problems with
moving or speaking so slowly that other people could have noticed?” (pause for
response) “How often have you felt so fidgety or restless that you move around a
lot more than usual?”

1. Assessor: “Over the past 2 weeks, have you been bothered by any of the following problems?
Little interest or pleasure in doing things?”
Resident: “I’m not interested in doing much. I just don’t feel like it. I used to enjoy visiting
with friends, but I don’t do that much anymore. I’m just not interested.”

Resident: “7-11 days.”

Assessor: “In the past 2 weeks, how often would you say you have been bothered by this?
Would you say never or 1 day, 2-6 days, 7-11 days, or 12-14 days?
Coding: D0150A1 (Symptom Presence) would be coded 1, yes and D0150A2
(Symptom Frequency) would be coded 2, 7-11 days.

Rationale: The resident indicates that they have lost interest in activities that they

previously enjoyed. The resident indicates that the symptom has bothered them 7-11 days
in the past 2 weeks.

October 2024

Page D-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0150: Resident Mood Interview (PHQ-2 to 9©) (cont.)
2. Assessor: “Over the past 2 weeks, have you had trouble concentrating on things, such as
reading the newspaper or watching television?”
Resident: “Television? I used to like watching the news. I can’t concentrate on that
anymore.”
Assessor: “In the past 2 weeks, how often have you been bothered by having difficulty
concentrating on things like television? Would you say never or 1 day, 2-6 days, 7-11 days,
or 12-14 days?
Resident: “I’d say every day. It bothers me every day.”
Coding: D0150G1 (Symptom Presence) would be coded 1, yes and D0150G2
(Symptom Frequency) would be coded 3, 12-14 days.

Rationale: The resident states that they have trouble concentrating and that this bothers

them every day.

D0160: Total Severity Score

Item Rationale

Health-related Quality of Life

The Total Severity Score is a summary of the frequency scores on the PHQ-2 to 9© that
indicates the extent of potential depression symptoms.

•

The Total Severity Score does not diagnose a mood disorder or depression but provides
a standard score which can be communicated to the resident’s physician, other clinicians
and mental health specialists for appropriate follow up.

Planning for Care

•

The PHQ-2 to 9© Total Severity Score also provides a way for health care providers and
clinicians to easily identify and track symptoms and how they are changing over time.

•

Responses to PHQ-2 to 9© can indicate possible depression if the full PHQ-2 to 9© is
completed (i.e., interview is not stopped after D0150B due to responses). Responses can
be interpreted as follows:

— Major Depressive Syndrome is suggested if—of the 9 items—5 or more items are
identified at a frequency of half or more of the days (7-11 days) during the assessment
period.

October 2024

Page D-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0160: Total Severity Score (cont.)

— Minor Depressive Syndrome is suggested if, of the 9 items, (1) feeling down,
depressed or hopeless, (2) trouble falling or staying asleep, or sleeping too much, or
(3) feeling tired or having little energy are identified at a frequency of half or more of
the days (7-11 days) during the assessment period.
— In addition, PHQ-2 to 9© Total Severity Score can be used to track changes in
severity over time. Total Severity Score can be interpreted as follows:
1-4: minimal depression
5-9: mild depression
10-14: moderate depression
15-19: moderately severe depression
20-27: severe depression

Steps for Assessment
After completing D0150 A–I

1. Add the numeric scores across all frequency items in Resident Mood Interview (D0150)
Column 2.
2. Do not add up the score while you are interviewing the resident. Instead, focus your full
attention on the interview.
3. The maximum resident score is 27 (3 x 9).

Coding Instructions
•

•
•

October 2024

•

If only the PHQ-2© is completed because both D0150A1 and D0150B1 are coded 9,
leave D0150A2 and D0150B2 blank, then end the PHQ-2©, leave D0160, Total Severity
Score blank, and skip to D0700, Social Isolation.
If only the PHQ-2© is completed because both D0150A2 and D0150B2 are scored 0 or
1, add the numeric scores from these two frequency items and enter the value in D0160.
If the PHQ-9© was completed (that is, D0150C–I were not blank due to the responses in
D0150A and B) and if the resident answered the frequency responses of at least 7 of the
9 items on the PHQ-9©, add the numeric scores from D0150A2–D0150I2, following the
instructions in Appendix E, and enter in D0160.
If symptom frequency in items D0150A2 through D0150I2 is blank for 3 or more items,
the interview is deemed NOT complete. Total Severity Score should be coded as “99,”
do not complete the Staff Assessment of Mood, and skip to D0700, Social Isolation.
Enter the total score as a two-digit number. The Total Severity Score will be between 00
and 27 (or “99” if symptom frequency is blank for 3 or more items).
The software will calculate the Total Severity Score. For detailed instructions on manual
calculations and examples, see Appendix E: PHQ-2 to 9© Total Severity Score Scoring
Rules.

Page D-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0500: Staff Assessment of Resident Mood (PHQ-9-OV©)

D
October 2024

Page D-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0500: Staff Assessment of Resident Mood (PHQ-9-OV©) (cont.)
Item Rationale
Health-related Quality of Life
•
•
•

•

Persons unable to complete the PHQ-2 to 9© Resident Mood Interview may still have a
mood disorder.
The identification of symptom presence and frequency as well as staff observations are
important in the detection of mood distress, as they may inform need for and type of
treatment.
It is important to note that coding the presence of clinical signs and symptoms of
depressed mood does not automatically mean that the resident has a diagnosis of
depression or other mood disorder. Assessors do not make or assign a diagnosis as a
result of the outcomes of the PHQ-2 to 9© or the PHQ-9-OV©; they simply record the
presence or absence of specific clinical signs and symptoms of depressed mood.
Alternate means of assessing mood must be used for residents who cannot communicate
or refuse or are unable to participate in the PHQ-2 to 9© Resident Mood Interview. This
ensures that information about their mood is not overlooked.

Planning for Care
•

When staff determine the resident is not interviewable (i.e., D0100 = 0, No), scripted
interviews with staff who know the resident well should provide critical information for
understanding mood and making care planning decisions.

Steps for Assessment
Conduct the interviews during the 7-day look-back period based on the ARD.
1. Interview staff from all shifts who know the resident best. Conduct the staff interview in a
location that protects resident privacy.
2. Many of the same administration techniques outlined above for the PHQ-2 to 9© Resident
Mood Interview and Interviewing Tips & Techniques can be followed when staff are
interviewed.
3. Encourage staff to report symptom frequency, even if the staff believes the symptom to be
unrelated to depression.
4. Explore unclear responses, focusing the discussion on the specific symptom listed on the
assessment rather than expanding into a lengthy clinical evaluation.
5. If frequency cannot be determined by staff interview because the resident has been in the
facility for less than 2 weeks, talk to family or significant other and review transfer records to
inform the selection of a frequency code.

October 2024

Page D-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0500: Staff Assessment of Resident Mood (PHQ-9-OV©) (cont.)
Examples of Staff Responses That Indicate Need for Follow-up
Questioning with the Staff Member

1. D0500A, Little Interest or Pleasure in Doing Things
• The resident doesn’t really do much here.
• The resident spends most of the time in their room.
2. D0500B, Feeling or Appearing Down, Depressed, or Hopeless
• They’re 95—what can you expect?
• How would you feel if you were here?
3. D0500C, Trouble Falling or Staying Asleep, or Sleeping Too Much
• Their back hurts when they lie down.
• They urinate a lot during the night.
4. D0500D, Feeling Tired or Having Little Energy
• They’re 95—they’re always saying they’re tired.
• They’re having a bad spell with their COPD right now.
5. D0500E, Poor Appetite or Overeating
• They have not wanted to eat much of anything lately.
• They have a voracious appetite, more so than last week.
6. D0500F, Indicating That They Feel Bad about Self, Are a Failure, or Have Let Self or
Family Down
• They do get upset when there’s something they can’t do now because of their stroke.
• They get embarrassed when they can’t remember something they think they should be
able to.
7. D0500G, Trouble Concentrating on Things, Such as Reading the Newspaper or
Watching Television
• They say there’s nothing good on TV.
• They never watch TV.
• They can’t see to read a newspaper.
8. D0500H, Moving or Speaking So Slowly That Other People Have Noticed. Or the
Opposite—Being So Fidgety or Restless That They Have Been Moving Around a Lot
More than Usual
• Their arthritis slows them down.
• They’re bored and always looking for something to do.

October 2024

Page D-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0500: Staff Assessment of Resident Mood (PHQ-9-OV©) (cont.)
9. D0500I, States That Life Isn’t Worth Living, Wishes for Death, or Attempts to Harm
Self
• They say God should take them already.
• They complain that people were not meant to live like this.
10. D0500J, Being Short-Tempered, Easily Annoyed
• They’re OK if you know how to approach them.
• They can snap but usually when their pain is bad.
• Not with me.
• They’re irritable.

Coding Instructions for Column 1. Symptom Presence

Code 0, no: if symptoms listed are not present. Enter 0 in Column 2, Symptom
Frequency.

•

Code 1, yes: if symptoms listed are present. Enter 0, 1, 2, or 3 in Column 2,
Symptom Frequency.

•

Coding Instructions for Column 2. Symptom Frequency

•

Code 0, never or 1 day: if staff indicate that the resident has never or has

•

Code 1, 2-6 days (several days): if staff indicate that the resident has experienced

•

Code 2, 7-11 days (half or more of the days): if staff indicate that the resident

•

Code 3, 12-14 days (nearly every day): if staff indicate that the resident has

experienced the symptom on only 1 day.
the symptom for 2-6 days.

has experienced the symptom for 7-11 days.

experienced the symptom for 12-14 days.

Coding Tips and Special Populations
•

Ask the staff member being interviewed to select how often over the past 2 weeks the
symptom occurred. Use the descriptive and/or numeric categories on the form (e.g.,
“nearly every day” or 3 = 12-14 days) to select a frequency response.

•

If you separated a longer item into its component parts, select the highest frequency
rating that is reported.

•

If the staff member has difficulty selecting between two frequency responses, code for the
higher frequency.

•

If the resident has been in the facility for less than 2 weeks, also talk to the family or
significant other and review transfer records to inform selection of the frequency code.

October 2024

Page D-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0600: Total Severity Score

Item Rationale
•
•

•

Health-related Quality of Life

Review Item Rationale for D0160, Total Severity Score.
The PHQ-9-OV© is adapted to allow the assessor to interview staff and identify a Total
Severity Score for potential depressive symptoms.

Planning for Care

The score can be communicated among health care providers and used to track symptoms
and how they are changing over time.
The score is useful for knowing when to request additional assessment by providers or
mental health specialists for underlying depression.

•

Steps for Assessment

After completing the Staff Assessment of Resident Mood:

1. Add the numeric scores across all frequency items for Staff Assessment of Mood, Symptom
Frequency (D0500) Column 2.
2. Maximum score is 30 (3 × 10).

Coding Instructions

The interview is successfully completed if the staff members were able to answer the frequency
responses of at least 8 out of 10 items on the PHQ-9-OV©.

•

The software will calculate the Total Severity Score. For detailed instructions on manual
calculations and examples, see Appendix E: PHQ-9-OV© Total Severity Score Scoring
Rules.

October 2024

Page D-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0600: Total Severity Score (cont.)
Coding Tips and Special Populations
•

Responses to PHQ-9-OV© can indicate possible depression. Responses can be interpreted
as follows:
— Major Depressive Syndrome is suggested if—of the 10 items, 5 or more items are
identified at a frequency of half or more of the days (7-11 days) during the look-back
period and at least one of these, (1) little interest or pleasure in doing things, or (2)
feeling down, depressed, or hopeless is identified at a frequency of half or more of the
days (7-11 days) during the look-back period.

— Minor Depressive Syndrome is suggested if—of the 10 items, (1) feeling down,
depressed or hopeless, (2) trouble falling or staying asleep, or sleeping too much, or
(3) feeling tired or having little energy are identified at a frequency of half or more of
the days (7-11 days) during the look-back period and at least one of these, (1) little
interest or pleasure in doing things, or (2) feeling down, depressed, or hopeless is
identified at a frequency of half or more of the days (7-11 days).

— In addition, PHQ-9-OV© Total Severity Score can be used to track changes in
severity over time. Total Severity Score can be interpreted as follows:
minimal depression

5-9:

mild depression

1-4:

10-14: moderate depression

15-19: moderately severe depression
20-30: severe depression

D0700: Social Isolation

ft
October 2024

Page D-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0700: Social Isolation (cont.)
Item Rationale
•

•

Social isolation tends to increase with age and is a risk
factor for physical and mental illness and a predictor of
mortality.

Planning for Care

DEFINITION
SOCIAL ISOLATION
Refers to an actual or
perceived lack of contact with
other people, such as living
alone or residing in a remote
area.

Programs to increase residents’ social engagement
should be designed and implemented, while also taking
into account individual needs (e.g., disability, language)
and preferences (e.g., cultural practices).
Assessing social isolation can facilitate the identification of residents who may feel
lonely and therefore may benefit from engagement efforts.
Resident engagement in social interactions and activities of interest can greatly enhance
quality of life. A resident’s individualized care plan should address activity planning if
the resident states that they sometimes, often, or always feel lonely or isolated.

•

Health-related Quality of Life

•

Steps for Assessment

This item is intended to be a resident self-report item. No other source should be used to
identify the response.
1. Ask the resident, “How often do you feel lonely or isolated from those around you?”

Coding Instructions

Code 0, Never: if the resident indicates never feeling lonely or isolated from others.

•

Code 1, Rarely: if the resident indicates rarely feeling lonely or isolated from others.

•

Code 2, Sometimes: if the resident indicates sometimes feeling lonely or isolated

•

Code 3, Often: if the resident indicates often feeling lonely or isolated from others.

•

Code 4, Always: if the resident indicates always feeling lonely or isolated from

•

Code 7, Resident declines to respond: if the resident declines to respond.

•

Code 8, Resident unable to respond: if the resident is unable to respond.

from others.

others.

October 2024

•

Page D-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [D]

D0700: Social Isolation (cont.)
Examples
1. The resident is speaking with the social worker about being admitted for extended
rehabilitation and is hoping to see their family later on in the day. When asked how often the
resident feels lonely or isolated from those around them, the resident replies that they live
with their child and their child’s family but don’t always feel like being around so much
activity and stay in their room alone. As a result, they report that they sometimes feel lonely
or isolated even though others are almost always home.
Coding: D0700 would be coded 2, Sometimes.
Rationale: The resident states they sometimes feel lonely or isolated from those around

them because they sometimes stay alone in their room.

2. The resident, upon being admitted to the facility, is asked about how often they feel lonely or
isolated from those around them. They state that because they don’t have many family
members left who live close by and they see their friends only a couple of times a month,
they often feel isolated. They are hoping that being in the facility will help them feel less
isolated and plan to attend activities regularly.

Coding: D0700 would be coded 3, Often.

Rationale: The resident states that because the family members they have don’t live

close by and their friends only visit a couple of times a month that they often feel
isolated.

3. During the observation period of resident F’s annual assessment, they are asked how often
they feel lonely or isolated from those around them. Resident F responds that, even though
they go to activities and have a few friends, they still feel alone. When asked how often they
feel alone, Resident F responds every day.

Coding: D0700 would be coded 4, Always.

Rationale: Resident F stated that they feel alone (i.e., lonely) every day when asked.

October 2024

Page D-19

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

SECTION E: BEHAVIOR
Intent: The items in this section identify behavioral symptoms in the last seven days that may
cause distress to the resident, or may be distressing or disruptive to facility residents, staff
members or the care environment. These behaviors may place the resident at risk for injury,
isolation, and inactivity and may also indicate unrecognized needs, preferences or illness.
Behaviors include those that are potentially harmful to the resident themself. The emphasis is
identifying behaviors, which does not necessarily imply a medical diagnosis. Identification of the
frequency and the impact of behavioral symptoms on the resident and on others is critical to
distinguish behaviors that constitute problems from those that are not problematic. Once the
frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation
and care plan interventions can be developed to improve the symptoms or reduce their impact.

This section focuses on the resident’s actions, not the intent of their behavior. Because of their
interactions with residents, staff may have become used to the behavior and may underreport or
minimize the resident’s behavior by presuming intent (e.g., “Resident A doesn’t really mean to
hurt anyone. They’re just frightened.”). Resident intent should not be taken into account when
coding for items in this section.

E0100: Potential Indicators of Psychosis

Item Rationale

•

DEFINITIONS

Psychotic symptoms may be associated with
— delirium,
— dementia,
— adverse drug effects,
— psychiatric disorders, and
— hearing or vision impairment.
Hallucinations and delusions may
— be distressing to residents and families,
— cause disability,
— interfere with delivery of medical, nursing,
rehabilitative and personal care, and
— lead to dangerous behavior or possible harm.

HALLUCINATION
The perception of the
presence of something that is
not actually there. It may be
auditory or visual or involve
smells, tastes or touch.

October 2024

•

Health-related Quality of Life

DELUSION
A fixed, false belief not
shared by others that the
resident holds even in the
face of evidence to the
contrary.

Page E-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0100: Potential Indicators of Psychosis (cont.)
Planning for Care
•

Reversible and treatable causes should be identified and addressed promptly. When
the cause is not reversible, the focus of management strategies should be to minimize
the amount of disability and distress.

Steps for Assessment
1. Review the resident’s medical record for the 7-day look-back period.
2. Interview staff members and others who have had the opportunity to observe the resident in a
variety of situations during the 7-day look-back period.
3. Observe the resident during conversations and the structured interviews in other assessment
sections and listen for statements indicating an experience of hallucinations, or the
expression of false beliefs (delusions).
4. Clarify potentially false beliefs:
•

When a resident expresses a belief that is plausible but alleged by others to be false (e.g.,
history indicates that the resident’s spouse died 20 years ago, but the resident states their
spouse has been visiting them every day), try to verify the facts to determine whether
there is reason to believe that it could have happened or whether it is likely that the belief
is false.

•

When a resident expresses a clearly false belief, determine if it can be readily corrected
by a simple explanation of verifiable (real) facts (which may only require a simple
reminder or reorientation) or demonstration of evidence to the contrary. Do not, however,
challenge the resident.

•

The resident’s response to the offering of a potential alternative explanation is often
helpful in determining whether the false belief is held strongly enough to be considered
fixed.

Coding Instructions
Code based on behaviors observed and/or thoughts expressed in the last 7 days rather than the
presence of a medical diagnosis. Check all that apply.
•

Check E0100A, hallucinations: if hallucinations were present in the last 7 days. A
hallucination is the perception of the presence of something that is not actually there. It
may be auditory or visual or involve smells, tastes or touch.

•

Check E0100B, delusions: if delusions were present in the last 7 days. A delusion
is a fixed, false belief not shared by others that the resident holds true even in the face of
evidence to the contrary.

•

Check E0100Z, none of the above: if no hallucinations or delusions were present

in the last 7 days.

October 2024

Page E-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0100: Potential Indicators of Psychosis (cont.)
Coding Tips and Special Populations
•

If a belief cannot be objectively shown to be false, or it is not possible to determine
whether it is false, do not code it as a delusion.

•

If a resident expresses a false belief but easily accepts a reasonable alternative
explanation, do not code it as a delusion. If the resident continues to insist that the belief
is correct despite an explanation or direct evidence to the contrary, code as a delusion.

Examples

1. A resident carries a doll, which they believe is their baby, and the resident appears upset.
When asked about this, they report they are distressed from hearing their baby crying and
think that the baby is hungry and they want to get the baby a bottle.
Coding: E0100A would be checked and E0100B would be checked.
Rationale: The resident believes the doll is a baby, which is a delusion, and they hear

the doll crying, which is an auditory hallucination.

2. A resident reports that they heard a gunshot. In fact, there was a loud knock on the door.
When this is explained to them, they accept the alternative interpretation of the loud noise.

Coding: E0100Z would be checked.
Rationale: They misinterpreted a real sound in the external environment. Because they

are able to accept the alternative explanation for the cause of the sound, their report of a
gunshot is not a fixed false belief and is therefore not a delusion.

3. A resident is found speaking aloud in their room. When asked about this, they state that they
are answering a question posed to them by an individual in front of them. Staff note that no
one is present and that no other voices can be heard in the environment.

Coding: E0100A would be checked.
Rationale: The resident reports auditory and visual sensations that occur in the absence

of any external stimulus. Therefore, this is a hallucination.

4. A resident announces that they must leave to go to work, because they are needed in their
office right away. In fact, they have been retired for 15 years. When reminded of this, they
continue to insist that they must get to their office.
Coding: E0100B would be checked.
Rationale: The resident adheres to the belief that they still work, even after being

reminded about their retirement status. Because the belief is held firmly despite an
explanation of the real situation, it is a delusion.

October 2024

Page E-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0100: Potential Indicators of Psychosis (cont.)
5. A resident believes they must leave the facility immediately because their parents are waiting
for them to return home. Staff know that, in reality, their parents are deceased and gently
remind them that their parents are no longer living. In response to this reminder, the resident
acknowledges, “Oh yes, I remember now. My parents passed away years ago.”
Coding: E0100Z would be checked.
Rationale: The resident’s initial false belief is readily altered with a simple reminder,

suggesting that their mistaken belief is due to forgetfulness (i.e., memory loss) rather than
psychosis. Because it is not a firmly held false belief, it does not fit the definition of a
delusion.

E0200: Behavioral Symptom—Presence & Frequency

D
Item Rationale

Health-related Quality of Life

New onset of behavioral symptoms warrants prompt evaluation, assurance of resident
safety, relief of distressing symptoms, and compassionate response to the resident.

•

Reversible and treatable causes should be identified and addressed promptly. When the
cause is not reversible, the focus of management strategies should be to minimize the
amount of disability and distress.

Planning for Care

•

Identification of the frequency and the impact of behavioral symptoms on the resident
and on others is critical to distinguish behaviors that constitute problems—and may
therefore require treatment planning and intervention—from those that are not
problematic.

•

These behaviors may indicate unrecognized needs, preferences, or illness.

•

Once the frequency and impact of behavioral symptoms are accurately determined,
follow-up evaluation and interventions can be developed to improve the symptoms or
reduce their impact.

October 2024

Page E-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0200: Behavioral Symptom—Presence & Frequency (cont.)
•

Subsequent assessments and documentation can be compared to baseline to identify
changes in the resident’s behavior, including response to interventions.

Steps for Assessment
1. Review the medical record for the 7-day look-back period.
2. Interview staff, across all shifts and disciplines, as well as others who had close interactions
with the resident during the 7-day look-back period, including family or friends who visit
frequently or have frequent contact with the resident.
3. Observe the resident in a variety of situations during the 7-day look-back period.

Coding Instructions
Code 0, behavior not exhibited: if the behavioral symptoms were not present in

•

the last 7 days. Use this code if the symptom has never been exhibited or if it previously
has been exhibited but has been absent in the last 7 days.

•

Code 1, behavior of this type occurred 1-3 days: if the behavior was exhibited

•

Code 2, behavior of this type occurred 4-6 days, but less than daily: if

•

1-3 days of the last 7 days, regardless of the number or severity of episodes that occur on
any one of those days.

the behavior was exhibited 4-6 of the last 7 days, regardless of the number or severity of
episodes that occur on any of those days.
Code 3, behavior of this type occurred daily: if the behavior was exhibited

daily, regardless of the number or severity of episodes that occur on any of those days.

Coding Tips and Special Populations

Code based on whether the symptoms occurred and not based on an interpretation of the
behavior’s meaning, cause or the assessor’s judgment that the behavior can be explained
or should be tolerated.

•

Code as present, even if staff have become used to the behavior or view it as typical or
tolerable.

•

Behaviors in these categories should be coded as present or not present, whether or not
they might represent a rejection of care.

•

Item E0200C does not include wandering.

October 2024

•

Page E-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0200: Behavioral Symptom—Presence & Frequency (cont.)
Examples
1. Every morning, a nursing assistant tries to help a resident who is unable to dress themself. On
the last 4 out of 6 mornings, the resident has hit or scratched the nursing assistant during
attempts to dress them.
Coding: E0200A would be coded 2, behavior of this type occurred 4-6
days, but less than daily.
Rationale: Scratching the nursing assistant was a physical behavior directed toward

others.

2. A resident has previously been found rummaging through the clothes in their roommate’s
dresser drawer. This behavior has not been observed by staff or reported by others in the last
7 days.
Coding: E0200C would be coded 0, behavior not exhibited.
Rationale: The behavior did not occur during the look-back period.

3. A resident throws their dinner tray at another resident who repeatedly spit food at them
during dinner. This is a single, isolated incident.

Coding: E0200A would be coded 1, behavior of this type occurred 1-3 days
of the last 7 days.
Rationale: Throwing a tray was a physical behavior directed toward others.

Although a possible explanation exists, the behavior is noted as present because it
occurred.

ft
October 2024

Page E-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0300: Overall Presence of Behavioral Symptoms

Item Rationale
To determine whether or not additional items E0500, Impact on Resident, and E0600, Impact
on Others, are required to be completed.

Steps for Assessment
1. Review coding for item E0200 and follow these coding instructions:

Coding Instructions
•

Code 0, no: if E0200A, E0200B, and E0200C all are coded 0, not present. Skip to

•

Code 1, yes: if any of E0200A, E0200B, or E0200C were coded 1, 2, or 3. Proceed to
complete Impact on Resident item (E0500), and Impact on Others item (E0600).

Rejection of Care—Presence & Frequency item (E0800).

ra
October 2024

Page E-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0500: Impact on Resident

Item Rationale
Health-related Quality of Life
Behaviors identified in item E0200 impact the resident’s risk for significant injury,
interfere with care or their participation in activities or social interactions.

•

Planning for Care

•

Identification of the impact of the behaviors noted in E0200 may require treatment
planning and intervention.
Subsequent assessments and documentation can be compared to a baseline to identify
changes in the resident’s behavior, including response to interventions.

Steps for Assessment

1. Consider the previous review of the medical record, staff interviews across all shifts and
disciplines, interviews with others who had close interactions with the resident and previous
observations of the behaviors identified in E0200 for the 7-day look-back period.
2. Code E0500A, E0500B, and E0500C based on all of the behavioral symptoms coded in
E0200.
3. Determine whether those behaviors put the resident at significant risk of physical illness or
injury, whether the behaviors significantly interfered with the resident’s care, and/or whether
the behaviors significantly interfered with the resident’s participation in activities or social
interactions.

Coding Instructions for E0500A. Did Any of the Identified Symptom(s)
Put the Resident at Significant Risk for Physical Illness or
Injury?
•

Code 0, no: if none of the identified behavioral symptom(s) placed the resident at

•

Code 1, yes: if any of the identified behavioral symptom(s) placed the resident at
clinically significant risk for a physical illness or injury, even if no injury occurred.

clinically significant risk for a physical illness or injury.

October 2024

Page E-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0500: Impact on Resident (cont.)
Coding Instructions for E0500B. Did Any of the Identified Symptom(s)
Significantly Interfere with the Resident’s Care?
•

Code 0, no: if none of the identified behavioral symptom(s) significantly interfered

•

Code 1, yes: if any of the identified behavioral symptom(s) impeded the delivery of
essential medical, nursing, rehabilitative or personal care, including but not limited to
assistance with activities of daily living, such as bathing, dressing, feeding, or toileting.

with the resident’s care.

Coding Instructions for E0500C. Did Any of the Identified Symptom(s)
Significantly Interfere with the Resident’s Participation in
Activities or Social Interactions?
•

Code 0, no: if none of the identified symptom(s) significantly interfered with the

•

Code 1, yes: if any of the identified behavioral symptom(s) significantly interfered
with or decreased the resident’s participation or caused staff not to include residents in
activities or social interactions.

resident’s participation in activities or social interactions.

Coding Tips and Special Populations

For E0500A, code based on whether the risk for physical injury or illness is known to
occur commonly under similar circumstances (i.e., with residents who exhibit similar
behavior in a similar environment). Physical injury is trauma that results in pain or other
distressing physical symptoms, impaired organ function, physical disability, or other
adverse consequences, regardless of the need for medical, surgical, nursing, or
rehabilitative intervention.

•

For E0500B, code if the impact of the resident’s behavior is impeding the delivery of care
to such an extent that necessary or essential care (medical, nursing, rehabilitative or
personal that is required to achieve the resident’s goals for health and well-being) cannot
be received safely, completely, or in a timely way without more than a minimal
accommodation, such as simple change in care routines or environment.

•

For E0500C, code if the impact of the resident’s behavior is limiting or keeping the
resident from engaging in solitary activities or hobbies, joining groups, or attending
programmed activities or having positive social encounters with visitors, other residents,
or staff.

•

Examples
1. A resident frequently grabs and scratches staff when they attempt to change their soiled brief,
digging their nails into staff members’ skin. This makes it difficult to complete the care task.
Coding: E0500B would be coded 1, yes.
Rationale: This behavior interfered with delivery of essential personal care.
October 2024

Page E-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0500: Impact on Resident (cont.)
2. During the last 7 days, a resident with vascular dementia and severe hypertension, hits staff
during incontinent care making it very difficult to change them. Six out of the last seven days
the resident refuses all their medication including their antihypertensive. The resident closes
their mouth and shakes their head and will not take it even if re-approached multiple times.
Coding: E0500A and E0500B would both be coded 1, yes.
Rationale: The behavior interfered significantly with delivery of their medical and

nursing care and put them at clinically significant risk for physical illness.

3. A resident paces incessantly. When staff encourage them to sit at the dinner table, they return
to pacing after less than a minute, even after cueing and reminders. They are so restless that
they cannot sit still long enough to feed themself or receive assistance in obtaining adequate
nutrition.
Coding: E0500A and E0500B would both be coded 1, yes.
Rationale: This behavior significantly interfered with personal care (i.e., feeding) and
put the resident at risk for malnutrition and physical illness.
4. A resident repeatedly throws their markers and card on the floor during bingo.

Coding: E0500C would be coded 1, yes.
Rationale: This behavior interfered with their ability to participate in the activity.

5. A resident with severe dementia has continuous outbursts while awake despite all efforts
made by staff to address the issue, including trying to involve the resident in prior activities
of choice.
Coding: E0500C would be coded 1, yes.
Rationale: The staff determined the resident’s behavior interfered with the ability to

participate in any activities.

October 2024

E0600: Impact on Others

Page E-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0600: Impact on Others (cont.)
Item Rationale
Health-related Quality of Life
•

Behaviors identified in item E0200 put others at risk for significant injury, intrude on
their privacy or activities and/or disrupt their care or living environments. The impact on
others is coded here in item E0600.

Planning for Care
Identification of the behaviors noted in E0200 that have an impact on others may require
treatment planning and intervention.

•

Subsequent assessments and documentation can be compared with a baseline to identify
changes in the resident’s behavior, including response to interventions.

•

Steps for Assessment

1. Consider the previous review of the clinical record, staff interviews across all shifts and
disciplines, interviews with others who had close interactions with the resident and previous
observations of the behaviors identified in E0200 for the 7-day look-back period.

2. To code E0600, determine if the behaviors identified put others at significant risk of physical
illness or injury, intruded on their privacy or activities, and/or interfered with their care or
living environments.

Coding Instructions for E0600A. Did Any of the Identified Symptom(s)
Put Others at Significant Risk for Physical Injury?
•

Code 0, no: if none of the identified behavioral symptom(s) placed staff, visitors, or

•

Code 1, yes: if any of the identified behavioral symptom(s) placed staff, visitors, or

other residents at significant risk for physical injury.

Coding Instructions for E0600B. Did Any of the Identified Symptom(s)
Significantly Intrude on the Privacy or Activity of Others?
•

Code 0, no: if none of the identified behavioral symptom(s) significantly intruded on

•

Code 1, yes: if any of the identified behavioral symptom(s) kept other residents from
enjoying privacy or engaging in informal activities (not organized or run by staff).
Includes coming in uninvited, invading, or forcing oneself on others’ private activities.

the privacy or activity of others.

October 2024

Page E-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0600: Impact on Others (cont.)
Coding Instructions for E0600C. Did Any of the Identified Symptom(s)
Significantly Disrupt Care or the Living Environment?
•

Code 0, no: if none of the identified behavioral symptom(s) significantly disrupted

•

Code 1, yes: if any of the identified behavioral symptom(s) created a climate of
excessive noise or interfered with the receipt of care or participation in organized
activities by other residents.

delivery of care or the living environment.

Coding Tips and Special Populations
•

For E0600A, code based on whether the behavior placed others at significant risk for
physical injury. Physical injury is trauma that results in pain or other distressing physical
symptoms, impaired organ function, physical disability or other adverse consequences,
regardless of the need for medical, surgical, nursing, or rehabilitative intervention.
For E0600B, code based on whether the behavior violates other residents’ privacy or
interrupts other residents’ performance of activities of daily living or limits engagement
in or enjoyment of informal social or recreational activities to such an extent that it
causes the other residents to experience distress (e.g., displeasure or annoyance) or
inconvenience, whether or not the other residents complain.

•

For E0600C, code based on whether the behavior interferes with staff ability to deliver
care or conduct organized activities, interrupts receipt of care or participation in
organized activities by other residents, and/or causes other residents to experience
distress or adverse consequences.

Examples

•

1. A resident appears to intentionally stick their cane out when another resident walks by.

Coding: E0600A would be coded 1, yes; E0600B and E0600C would be coded 0,
no.
Rationale: The behavior put the other resident at risk for falling and physical injury.

You may also need to consider coding B and C depending on the specific situation in the
environment or care setting.

2. A resident, when sitting in the hallway outside the community activity room, continually
yells, repeating the same phrase. The yelling can be heard by other residents in hallways and
activity/recreational areas but not in their private rooms.

Coding: E0600A would be coded 0, no; E0600B and E0600C would be coded 1,
yes.
Rationale: The behavior does not put others at risk for significant injury. The behavior

does create a climate of excessive noise, disrupting the living environment and the
activity of others.

October 2024

Page E-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0600: Impact on Others (cont.)
3. A resident repeatedly enters the rooms of other residents and rummages through their
personal belongings. The other residents do not express annoyance.
Coding: E0600A and E0600C would be coded 0, no; E0600B would be coded 1,
yes.
Rationale: This is an intrusion and violates other residents’ privacy regardless of

whether they complain or communicate their distress.

4. When eating in the dining room, a resident frequently grabs food off the plates of other
residents. Although the other resident’s food is replaced, and the behavior does not
compromise their nutrition, other residents become anxious in anticipation of this recurring
behavior.

Coding: E0600A would be coded 0, no; E0600B and E0600C would be coded 1,
yes.
Rationale: This behavior violates other residents’ privacy as it is an intrusion on the

personal space and property (food tray). In addition, the behavior is pervasive and disrupts
the staff’s ability to deliver nutritious meals in dining room (an organized activity).

5. A resident tries to seize the telephone out of the hand of another resident who is attempting to
complete a private conversation. Despite being asked to stop, the resident persists in grabbing
the telephone and insisting that they want to use it.
Coding: E0600A and E0600C would be coded 0, no; E0600B would be coded 1,
yes.
Rationale: This behavior is an intrusion on another resident’s private telephone

conversation.

6. A resident begins taunting two residents who are playing an informal card game, yelling that
they will “burn in hell” if they don’t stop “gambling.”

Coding: E0600A and E0600C would be coded 0, no; E0600B would be coded 1,
yes.
Rationale: The behavior is intruding on the other residents’ game. The game is not an

organized facility event and does not involve care. It is an activity in which the two
residents wanted to engage.

7. A resident yells continuously during an exercise group, diverting staff attention so that others
cannot participate in and enjoy the activity.
Coding: E0600A and E0600B would be coded 0, no; E0600C would be coded 1,
yes.
Rationale: This behavior disrupts the delivery of physical care (exercise) to the group

participants and creates an environment of excessive noise.

October 2024

Page E-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0600: Impact on Others (cont.)
8. A resident becomes verbally threatening in a group discussion activity, frightening other
residents. In response to this disruption, staff terminate the discussion group early to avoid
eliciting the behavioral symptom.
Coding: E0600A and E0600B would be coded 0, no; E0600C would be coded 1,
yes.
Rationale: This behavior does not put other residents at risk for significant injury.

However, the behavior restricts full participation in the organized activity, and limits the
enjoyment of other residents. It also causes fear, thereby disrupting the living
environment.

E0800: Rejection of Care—Presence & Frequency

D
ra

Item Rationale

Health-related Quality of Life

Goals for health and well-being reflect the resident’s wishes and objectives for health,
function, and life satisfaction that define an acceptable quality of life for that individual.

•

The resident’s care preferences reflect desires, wishes, inclinations, or choices for care.
Preferences do not have to appear logical or rational to the clinician. Similarly,
preferences are not necessarily informed by facts or scientific knowledge and may not be
consistent with “good judgment.”

•

It is really a matter of resident choice. When rejection/decline of care is first identified,
the team then investigates and determines the rejection/decline of care is really a matter
of resident’s choice. Education is provided and the resident’s choices become part of the
plan of care. On future assessments, this behavior would not be coded in this item.

•

A resident might reject/decline care because the care conflicts with their preferences and
goals. In such cases, care rejection behavior is not considered a problem that warrants
treatment to modify or eliminate the behavior.

•

Care rejection may be manifested by verbally declining, statements of refusal, or through
physical behaviors that convey aversion to, result in avoidance of, or interfere with the
receipt of care.

•

October 2024

Page E-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0800: Rejection of Care—Presence & Frequency (cont.)
•

•

This type of behavior interrupts or interferes with the
delivery or receipt of care by disrupting the usual
routines or processes by which care is given, or by
exceeding the level or intensity of resources that are
usually available for the provision of care.
A resident’s rejection of care might be caused by an
underlying neuropsychiatric, medical, or dental
problem. This can interfere with needed care that is
consistent with the resident’s preferences or established
care goals. In such cases, care rejection behavior may
be a problem that requires assessment and intervention.

Planning for Care

•

Evaluation of rejection of care assists the nursing home
in honoring the resident’s care preferences in order to
meet their desired health care goals.

•

Follow-up assessment should consider:

— whether alternative approaches could be used to
achieve the resident’s care goals.
•

REJECTION OF CARE
Behavior that interrupts or
interferes with the delivery or
receipt of care. Care rejection
may be manifested by
verbally declining or
statements of refusal or
through physical behaviors
that convey aversion to or
result in avoidance of or
interfere with the receipt of
care.
INTERFERENCE WITH
CARE
Hindering the delivery or
receipt of care by disrupting
the usual routines or
processes by which care is
given, or by exceeding the
level or intensity of resources
that are usually available for
the provision of care.

— whether established care goals clearly reflect the
resident’s preferences and goals and

DEFINITIONS

Determine whether a previous discussion identified an
objection to the type of care or the way in which the care was provided. If so, determine
approaches to accommodate the resident’s preferences.

Steps for Assessment

1. Review the medical record.
2. Interview staff, across all shifts and disciplines, as well as others who had close interactions
with the resident during the 7-day look-back period.
3. Review the record and consult staff to determine whether the rejected care is needed to
achieve the resident’s preferences and goals for health and well-being.
4. Review the medical record to find out whether the care rejection behavior was previously
addressed and documented in discussions or in care planning with the resident, family, or
significant other and determined to be an informed choice consistent with the resident’s
values, preferences, or goals; or whether that the behavior represents an objection to the way
care is provided, but acceptable alternative care and/or approaches to care have been
identified and employed.
5. If the resident exhibits behavior that appears to communicate a rejection of care (and that
rejection behavior has not been previously determined to be consistent with the resident’s
values or goals), ask them directly whether the behavior is meant to decline or refuse care.

October 2024

Page E-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0800: Rejection of Care—Presence & Frequency (cont.)
•

If the resident indicates that the intention is to decline or refuse, then ask them about the
reasons for rejecting care and about their goals for health care and well-being.

•

If the resident is unable or unwilling to respond to questions about their rejection of care
or goals for health care and well-being, then interview the family or significant other to
ascertain the resident’s health care preferences and goals.

Coding Instructions
•
•

Code 0, behavior not exhibited: if rejection of care consistent with goals was not

exhibited in the last 7 days.

Code 1, behavior of this type occurred 1-3 days: if the resident rejected care

consistent with goals 1-3 days during the 7-day look-back period, regardless of the
number of episodes that occurred on any one of those days.

•
•

Code 2, behavior of this type occurred 4-6 days, but less than daily: if
the resident rejected care consistent with goals 4-6 days during the 7-day look-back
period, regardless of the number of episodes that occurred on any one of those days.
Code 3, behavior of this type occurred daily: if the resident rejected care
consistent with goals daily in the 7-day look-back period, regardless of the number of
episodes that occurred on any one of those days.

Coding Tips and Special Populations

The intent of this item is to identify potential behavioral problems, not situations in which
care has been rejected based on a choice that is consistent with the resident’s preferences
or goals for health and well-being or a choice made on behalf of the resident by a family
member or other proxy decision maker.

•

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 the resident’s
values, preferences, or goals. Residents who have made an informed choice about not
wanting a particular treatment, procedure, etc., should not be identified as “rejecting
care.”

Examples

•

1. A resident with heart failure who recently returned to the nursing home after surgical repair
of a hip fracture is offered physical therapy and declines. They say that they get too short of
breath when they try to walk even a short distance, making physical therapy intolerable. They
do not expect to walk again and does not want to try. Their physician has discussed this with
them and has indicated that their prognosis for regaining ambulatory function is poor.
Coding: E0800 would be coded 0, behavior not exhibited.
Rationale: This resident has communicated that they consider physical therapy to be

both intolerable and futile. The resident discussed this with their physician. Their choice
to not accept physical therapy treatment is consistent with their values and goals for
health care. Therefore, this would not be coded as rejection of care.

October 2024

Page E-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0800: Rejection of Care—Presence & Frequency (cont.)
2. A resident informs the staff that they would rather receive care at home, and the next day
they call for a taxi and exits the nursing facility. When staff try to persuade them to return,
they firmly state, “Leave me alone. I always swore I’d never go to a nursing home. I’ll get by
with my visiting nurse service at home again.” They are not exhibiting signs of
disorientation, confusion, or psychosis and has never been judged incompetent.
Coding: E0800 would be coded 0, behavior not exhibited.
Rationale: Their departure is consistent with their stated preferences and goals for

health care. Therefore, this is not coded as care rejection.

3. A resident goes to bed at night without changing out of the clothes they wore during the day.
When a nursing assistant offers to help them get undressed, they decline, stating that they
prefer to sleep in their clothes tonight. The clothes are wet with urine. This has happened 2 of
the past 7 days. The resident was previously fastidious, recently has expressed
embarrassment at being incontinent, and has care goals that include maintaining personal
hygiene and skin integrity.
Coding: E0800 would be coded 1, behavior of this type occurred 1-3 days.
Rationale: The resident’s care rejection behavior is not consistent with their values and

goals for health and well-being. Therefore, this is classified as care rejection that
occurred twice.

4. A resident chooses not to eat supper one day, stating that the food causes them diarrhea. They
say they know they need to eat and do not wish to compromise their nutrition, but they are
more distressed by the diarrhea than by the prospect of losing weight.
Coding: E0800 would be coded 1, behavior of this type occurred 1-3 days.
Rationale: Although choosing not to eat is consistent with the resident’s desire to avoid

diarrhea, it is also in conflict with their stated goal to maintain adequate nutrition.

5. A resident is given their antibiotic medication prescribed for treatment of pneumonia and
immediately spits the pills out on the floor. This resident’s assessment indicates that they do
not have any swallowing problems. This happened on each of the last 4 days. The resident’s
advance directive indicates that they would choose to take antibiotics to treat a potentially
life-threatening infection.

Coding: E0800 would be coded 2, behavior of this type occurred 4-6 days,
but less than daily.
Rationale: The behavioral rejection of antibiotics prevents the resident from achieving

their stated goals for health care listed in their advance directives. Therefore, the behavior
is coded as care rejection.

October 2024

Page E-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0800: Rejection of Care—Presence & Frequency (cont.)
6. A resident who recently returned to the nursing home after surgery for a hip fracture is
offered physical therapy and declines. They state that they want to walk again but is afraid of
falling. This occurred on 4 days during the look-back period.
Coding: E0800 would be coded 2, behavior of this type occurred 4-6 days.
Rationale: Even though the resident’s health care goal is to regain their ambulatory

status, their fear of falling results in rejection of physical therapy and interferes with their
rehabilitation. This would be coded as rejection of care.

7. A resident who previously ate well and prided themself on following a healthy diet has been
refusing to eat every day for the past 2 weeks. They complain that the food is boring and that
they feel full after just a few bites. They say they want to eat to maintain their weight and
avoid getting sick, but they cannot push themself to eat anymore.

Coding: E0800 would be coded 3, behavior of this type occurred daily.
Rationale: The resident’s choice not to eat is not consistent with their goal of weight

maintenance and health. Choosing not to eat may be related to a medical condition such
as a disturbance of taste sensation, gastrointestinal illness, endocrine condition,
depressive disorder, or medication side effects.

E0900: Wandering—Presence & Frequency

Item Rationale

Health-related Quality of Life

•

Wandering may be a pursuit of exercise or a pleasurable leisure activity, or it may be
related to tension, anxiety, agitation, or searching.

Planning for Care
•

It is important to assess for reason for wandering. Determine the frequency of its
occurrence, and any factors that trigger the behavior or that decrease the episodes.

•

Assess for underlying tension, anxiety, psychosis, drug-induced psychomotor
restlessness, agitation, or unmet need (e.g., for food, fluids, toileting, exercise, pain relief,
sensory or cognitive stimulation, sense of security, companionship) that may be
contributing to wandering.

October 2024

Page E-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E0900: Wandering—Presence & Frequency (cont.)
Steps for Assessment
1. Review the medical record and interview staff to determine whether wandering occurred
during the 7-day look-back period.
•

Wandering is the act of moving (walking or locomotion in a wheelchair) from place to
place with or without a specified course or known direction. Wandering may or may not
be aimless. The wandering resident may be oblivious to their physical or safety needs.
The resident may have a purpose such as searching to find something, but they persist
without knowing the exact direction or location of the object, person or place. The
behavior may or may not be driven by confused thoughts or delusional ideas (e.g., when a
resident believes they must find their parent, who staff know is deceased).

2. If wandering occurred, determine the frequency of the wandering during the 7-day look-back
period.

Coding Instructions for E0900
•

Code 0, behavior not exhibited: if wandering was not exhibited during the 7-day

look-back period. Skip to Change in Behavior or Other Symptoms item (E1100).

Code 1, behavior of this type occurred 1-3 days: if the resident wandered on

•

Code 2, behavior of this type occurred 4-6 days, but less than daily: if
the resident wandered on 4-6 days during the 7-day look-back period, regardless of the
number of episodes that occurred on any one of those days. Proceed to answer
Wandering—Impact item (E1000).

•

Code 3, behavior of this type occurred daily: if the resident wandered daily

•

1-3 days during the 7-day look-back period, regardless of the number of episodes that
occurred on any one of those days. Proceed to answer Wandering—Impact item
(E1000).

during the 7-day look-back period, regardless of the number of episodes that occurred on
any one of those days. Proceed to answer Wandering—Impact item (E1000).

Coding Tips and Special Populations
•

Pacing (repetitive walking with a driven/pressured quality) within a constrained space is
not included in wandering.

•

Wandering may occur even if resident is in a locked unit.

•

Traveling via a planned course to another specific place (such as going to the dining
room to eat a meal or to an activity) is not considered wandering.

October 2024

Page E-19

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E1000: Wandering—Impact
Answer this item only if E0900, Wandering—Presence & Frequency, was coded 1 (behavior of
this type occurred 1-3 days), 2 (behavior of this type occurred 4-6 days, but less than daily), or 3
(behavior of this type occurred daily).

Item Rationale

Health-related Quality of Life

•
•
•

Not all wandering is harmful.
Some residents who wander are at potentially higher risk for entering an unsafe situation.
Some residents who wander can cause significant disruption to other residents.

•

Care plans should consider the impact of wandering on resident safety and disruption to
others.
Care planning should be focused on minimizing these issues.
Determine the need for environmental modifications (door alarms, door barriers, etc.) that
enhance resident safety if wandering places the resident at risk.
Determine when wandering requires interventions to reduce unwanted intrusions on other
residents or disruption of the living environment.

•

•
•

Planning for Care

Steps for Assessment

1. Consider the previous review of the resident’s wandering behaviors identified in E0900 for
the 7-day look-back period.
2. Determine whether those behaviors put the resident at significant risk of getting into
potentially dangerous places and/or whether wandering significantly intrudes on the privacy
or activities of others based on clinical judgment for the individual resident.

Coding Instructions for E1000A. Does the Wandering Place the
Resident at Significant Risk of Getting to a Potentially
Dangerous Place?
•

Code 0, no: if wandering does not place the resident at significant risk.

•

Code 1, yes: if the wandering places the resident at significant risk of getting to a

dangerous place (e.g., wandering outside the facility where there is heavy traffic) or
encountering a dangerous situation (e.g., wandering into the room of another resident
with dementia who is known to become physically aggressive toward intruders).

October 2024

Page E-20

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E1000: Wandering—Impact (cont.)
Coding Instructions for E1000B. Does the Wandering Significantly
Intrude on the Privacy or Activities of Others?
•

Code 0, no: if the wandering does not intrude on the privacy or activity of others.

•

Code 1, yes: if the wandering intrudes on the privacy or activities of others (i.e., if the
wandering violates other residents’ privacy or interrupts other residents’ performance of
activities of daily living or limits engagement in or enjoyment of social or recreational
activities), whether or not the other resident complains or communicates displeasure or
annoyance.

Examples

1. A resident wanders away from the nursing home in their pajamas at 3 a.m. When staff
members talk to them, they insist they looking for their spouse. This elopement behavior had
occurred when they were living at home, and on one occasion they became lost and were
missing for 3 days, leading their family to choose nursing home admission for their personal
safety.
Coding: E1000A would be coded 1, yes.
Rationale: Wandering that results in elopement from the nursing home places the

resident at significant risk of getting into a dangerous situation.

2. A resident wanders away from the nursing facility at 7 a.m. Staff find them crossing a busy
street against a red light. When staff try to persuade them to return, they become angry and
say, “My boss called, and I have to get to the office.” When staff remind them that they have
been retired for many years, they continue to insist that they must get to work.
Coding: E1000A would be coded 1, yes.
Rationale: This resident’s wandering is associated with elopement from the nursing

home and into a dangerous traffic situation. Therefore, this is coded as placing the
resident at significant risk of getting to a place that poses a danger. In addition, delusions
would be checked in item E0100.

3. A resident propels themself in their wheelchair into the room of another resident, blocking
the door to the other resident’s bathroom.
Coding: E1000B would be coded 1, yes.
Rationale: Moving about in this manner with the use of a wheelchair meets the

definition of wandering, and the resident has intruded on the privacy of another resident
and has interfered with that resident’s ability to use the bathroom.

E1100: Change in Behavior or Other Symptoms

October 2024

Page E-21

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E1100: Change in Behavior or Other Symptoms (cont.)
Item Rationale
Health-related Quality of Life
•

Change in behavior may be an important indicator of
— a change in health status or a change in environmental stimuli,
— positive response to treatment, and
— adverse effects of treatment.

Planning for Care
•

If behavior is worsening, assessment should consider whether it is related to

— new health problems, psychosis, or delirium;
— worsening of pre-existing health problems;
— a change in environmental stimuli or caregivers that influences behavior; and
— adverse effects of treatment.
If behaviors are improved, assessment should consider what interventions should be
continued or modified (e.g., to minimize risk of relapse or adverse effects of treatment).

•

Steps for Assessment

1. Review responses provided to items E0100-E1000 on the current MDS assessment.
2. Compare with responses provided on prior MDS assessment.
3. Taking all of these MDS items into consideration, make a global assessment of the change in
behavior from the most recent to the current MDS.
4. Rate the overall behavior as same, improved, or worse.

Coding Instructions

Code 0, same: if overall behavior is the same (unchanged).

•

Code 1, improved: if overall behavior is improved.

•

Code 2, worse: if overall behavior is worse.

•

Code 3, N/A: if there was no prior MDS assessment of this resident.

Coding Tips
•

•

For residents with multiple behavioral symptoms, it is possible that different behaviors
will vary in different directions over time. That is, one behavior may improve while
another worsens or remains the same. Using clinical judgment, this item should be rated
to reflect the overall direction of behavior change, estimating the net effects of multiple
behaviors.

October 2024

Page E-22

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [E]

E1100: Change in Behavior or Other Symptoms (cont.)
Examples

1. On the prior assessment, the resident was reported to wander on 4 out of 7 days. Because of
elopement, the behavior placed the resident at significant risk of getting to a dangerous place.
On the current assessment, the resident was found to wander on the unit 2 of the last 7 days
but has not attempted to exit the unit. Because the resident is no longer attempting to exit the
unit, they are at decreased risk for elopement and getting to a dangerous place. However, the
resident is now wandering into the rooms of other residents, intruding on their privacy. This
requires occasional redirection by staff.
Coding: E1100 would be coded 1, improved.
Rationale: Although one component of this resident’s wandering behavior is worse
because it has begun to intrude on the privacy of others, it is less frequent and less
dangerous (without recent elopement) and is therefore improved overall since the last
assessment. The fact that the behavior requires less intense surveillance or intervention
by staff also supports the decision to rate the overall behavior as improved.

2. At the time of the last assessment, the resident was ambulatory and would threaten and hit
other residents daily. They recently suffered a hip fracture and is not ambulatory. They are
not approaching, threatening, or assaulting other residents. However, the resident is now
combative when staff try to assist with dressing and bathing, and is hitting staff members
daily.
Coding: E1100 would be coded 0, same.
Rationale: Although the resident is no longer assaulting other residents, they have
begun to assault staff. Because the danger to others and the frequency of these behaviors
is the same as before, the overall behavior is rated as unchanged.

3. On the prior assessment, a resident with Alzheimer’s disease was reported to wander on 2 out
of 7 days and has responded well to redirection. On the most recent assessment, it was noted
that the resident has been wandering more frequently for 5 out of 7 days and has also
attempted to elope from the building on two occasions.
This behavior places the resident at significant risk of personal harm. The resident has
been placed on more frequent location checks and has required additional redirection
from staff. They were also provided with an elopement bracelet so that staff will be
alerted if the resident attempts to leave the building. The intensity required of staff
surveillance because of the dangerousness and frequency of the wandering behavior has
significantly increased.

Coding: E1100 would be coded 2, worse.
Rationale: Because the danger and the frequency of the resident’s wandering behavior

have increased and there were two elopement attempts, the overall behavior is rated as
worse.

October 2024

Page E-23

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

SECTION F: PREFERENCES FOR CUSTOMARY ROUTINE
AND ACTIVITIES
Intent: The intent of items in this section is to obtain information regarding the resident’s
preferences for their daily routine and activities. This is best accomplished when the information
is obtained directly from the resident or through family or significant other, or staff interviews if
the resident cannot report preferences. The information obtained during this interview is just a
portion of the assessment. Nursing homes should use this as a guide to create an individualized
plan based on the resident’s preferences and is not meant to be all-inclusive.

F0300: Should Interview for Daily and Activity Preferences Be
Conducted?

Item Rationale
Health-related Quality of Life

•

Planning for Care

Quality of life can be greatly enhanced when care respects the resident’s choice regarding
anything that is important to the resident.
Interviews allow the resident’s voice to be reflected in the care plan.
Information about preferences that comes directly from the resident provides specific
information for individualized daily care and activity planning.

Steps for Assessment

•
•

Most residents capable of communicating can answer questions about what they like.
Obtaining information about preferences directly from the resident, sometimes called
“hearing the resident’s voice,” is the most reliable and accurate way of identifying
preferences.
If a resident cannot communicate, then family or significant other who knows the resident
well may be able to provide useful information about preferences.

•
•

1. Interact with the resident using their preferred language. Be sure they can hear you and/or has
access to their preferred method for communication. If the resident appears unable to
communicate, offer alternatives such as writing, pointing, sign language, or cue cards.
2. There may be times when, due to medical or psychiatric conditions, a resident has difficulty
communicating and understanding. When conducting resident interviews, providers are to
assess and use their clinical judgment to determine the best time in which to attempt to
conduct the resident interview. Providers are to attempt to conduct the interview with all
conscious residents.

October 2024

Page F-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0300: Should Interview for Daily and Activity Preferences Be
Conducted? (cont.)

The determination as to whether or not a resident interview is conducted is not based on the
response to item B0700, Makes Self Understood. Instead, the resident interview is attempted,
and is only terminated based on the response or lack of response to the resident interview
questions/statements according to the coding instructions provided for the interview which
would render the interview incomplete.
3. If the resident is unable to complete the resident interview, attempt to conduct the interview
with a family member or significant other. If neither a family member nor significant other is
available, skip to item F0800, Staff Assessment of Daily and Activity Preferences.
4. Conduct the interview during the observation period.
5. Review Language item (A1110) to determine whether or not the resident needs or wants an
interpreter.
• If the resident needs or wants an interpreter, complete the interview with an interpreter.

Coding Instructions
•

should be selected for residents who are rarely/never understood, who need an interpreter
but one was not available, and who do not have a family member or significant other
available for interview. Skip to F0800, (Staff Assessment of Daily and Activity
Preferences).

•

Code 0, no: if the interview should not be conducted with the resident. This option

Code 1, yes: if the resident interview should be conducted. This option should be
selected for residents who are able to be understood, for whom an interpreter is not
needed or is present, or who have a family member or significant other available for
interview. Continue to F0400 (Interview for Daily Preferences) and F0500 (Interview for
Activity Preferences).

Coding Tips and Special Populations
•

If the resident needs an interpreter, every effort should be made to have an interpreter
present for the MDS clinical interview. If it is not possible for a needed interpreter to be
present on the day of the interview, and a family member or significant other is not
available for interview, code F0300 = 0 to indicate interview not attempted, and complete
the Staff Assessment of Daily and Activity Preferences (F0800) instead of the interview
with the resident (F0400 and F0500).

•

If the resident interview was not conducted within the look-back period of the ARD, item
F0300 must be coded 1, Yes, and the standard “no information” code (a dash “-”) entered
in the resident interview items.

•

Do not complete the Staff Assessment of Daily and Activity Preferences items (F0700–
F0800) if the resident interview should have been conducted, but was not done.

October 2024

Page F-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0400: Interview for Daily Preferences

D
•
•
•

•

Individuals who live in nursing homes continue to have distinct lifestyle preferences.
A lack of attention to lifestyle preferences can contribute to depressed mood and
increased behavior symptoms.
Resident responses that something is important but that they can’t do it or have no choice
can provide clues for understanding pain, perceived functional limitations, and perceived
environmental barriers.

Planning for Care

Care planning should be individualized and based on the resident’s preferences.
Care planning and care practices that are based on resident preferences can lead to
— improved mood,
— enhanced dignity, and
— increased involvement in daily routines and activities.
Incorporating resident preferences into care planning is a dynamic, collaborative process.
Because residents may adjust their preferences in response to events and changes in
status, the preference assessment tool is intended as a first step in an ongoing dialogue
between care providers and the residents. Care plans should be updated as residents’
preferences change, paying special attention to preferences that residents state are
important.

•
•

Item Rationale
Health-related Quality of Life

Steps for Assessment: Interview Instructions

1. Interview any resident not screened out by the Should Interview for Daily and Activity
Preferences Be Conducted? item (F0300).
2. Conduct the interview in a private setting.
October 2024

Page F-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0400: Interview for Daily Preferences (cont.)

3. Sit so that the resident can see your face. Minimize glare by directing light sources away
from the resident’s face.
4. Be sure the resident can hear you.
• Residents with hearing impairment should be interviewed using their usual
communication devices/techniques, as applicable.
• Try an external assistive device (headphones or hearing amplifier) if you have any doubt
about hearing ability.
• Minimize background noise.
5. Explain the reason for the interview before beginning.
Suggested language: “I’d like to ask you a few questions about your daily routines. The
reason I’m asking you these questions is that the staff here would like to know what’s
important to you. This helps us plan your care around your preferences so that you can have a
comfortable stay with us. Even if you’re only going to be here for a few days, we want to
make your stay as personal as possible.”
6. Explain the interview response choices. While explaining, also show the resident a clearly
written list of the response options, for example a cue card.

Suggested language: “I am going to ask you how important various activities and routines
are to you while you are in this home. I will ask you to answer using the choices you see on
this card [read the answers while pointing to cue card]: ‘Very Important,’ ‘Somewhat
important,’ ‘Not very important,’ ‘Not important at all,’ or ‘Important, but can’t do or no
choice.’”
Explain the “Important, but can’t do or no choice” response option.

7. Residents may respond to questions

Suggested language: “Let me explain the ‘Important, but can’t do or no choice’ answer. You
can select this answer if something would be important to you, but because of your health or
because of what’s available in this nursing home, you might not be able to do it. So, if I ask
you about something that is important to you, but you don’t think you’re able to do it now,
answer ‘Important, but can’t do or no choice.’ If you choose this option, it will help us to
think about ways we might be able to help you do those things.”
•

verbally,

•

by pointing to their answers on the cue card, OR

•

by writing out their answers.

8. If resident cannot report preferences, then interview family or significant others.

October 2024

Page F-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0400: Interview for Daily Preferences (cont.)
Coding Instructions
•

•

Code 1, very important: if resident, family, or

significant other indicates that the topic is “very
important.”

Code 2, somewhat important: if resident, family,

or significant other indicates that the topic is
“somewhat important.”

Code 3, not very important: if resident, family, or

significant other indicates that the topic is “not very
important.”

DEFINITION
NONSENSICAL
RESPONSE
Any unrelated,
incomprehensible, or
incoherent response that is
not informative with respect
to the item being rated.

D
•

Code 4, not important at all: if resident, family, or significant other indicates that

•

Code 5, important, but can’t do or no choice: if resident, family, or significant

•

Code 9, no response or non-responsive:

the topic is “not important at all.”

other indicates that the topic is “important,” but that they are physically unable to
participate, or have no choice about participating while staying in nursing home because
of nursing home resources or scheduling.

— If resident, family, or significant other refuses to answer or says they do not know.
— If resident does not give an answer to the question for several seconds and does not
appear to be formulating an answer.
— If resident provides an incoherent or nonsensical answer that does not correspond to
the question.

Coding Tips and Special Populations
•

The interview is considered incomplete if the resident gives nonsensical responses or fails
to respond to 3 or more of the 16 items in F0400 and F0500. If the interview is stopped
because it is considered incomplete, and there is no family member or significant other to
assist in completing the interview, fill the remaining F0400 and F0500 items with a 9 and
proceed to F0600, Daily Activity Preferences Primary Respondent.

•

The resident, family member or significant other is being asked about current preferences
while in the nursing home but is not limited to a 7-day period to convey what these
preferences are.

•

The facility is still obligated to complete the interview within the observation period.

October 2024

Page F-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0400: Interview for Daily Preferences (cont.)
Interviewing Tips and Techniques
•

Sometimes respondents give long or indirect answers to interview items. To narrow the
answer to the response choices available, it can be useful to summarize their longer
answer and then ask them which response option best applies. This is known as echoing.

•

For these questions, it is appropriate to explore resident, family and/or significant other’s
answers and try to understand the reason.

Examples for F0400A, How Important Is It to You to Choose What
Clothes to Wear (including hospital gowns or other garments
provided by the facility)?

1. Resident answers, “It’s very important. I’ve always paid attention to my appearance.”
Coding: F0400A would be coded 1, very important.

2. Resident replies, “I leave that up to the nurse. You have to wear what you can handle if you
have a stiff leg.”

Interviewer echoes, “You leave it up to the nurses. Would you say that, while you are here,
choosing what clothes to wear is [pointing to cue card] very important, somewhat important,
not very important, not important at all, or that it’s important, but you can’t do it because of
your leg?”
Resident responds, “Well, it would be important to me, but I just can’t do it.”
Coding: F0400A would be coded 5, important, but can’t do or no choice.

Examples for F0400B, How Important Is It to You to Take Care of Your
Personal Belongings or Things?
DEFINITION

1. Resident answers, “It’s somewhat important. I’m not a
perfectionist, but I don’t want to have to look for things.”
Coding: F0400B would be coded 2, somewhat
important.

2. Resident answers, “All my important things are at home.”

Interviewer clarifies, “Your most important things are at
home. Do you have any other things while you’re here that
you think are important to take care of yourself?”

PERSONAL
BELONGINGS OR
THINGS
Possessions such as
eyeglasses, hearing aids,
clothing, jewelry, books,
toiletries, knickknacks,
pictures.

Resident responds, “Well, my son brought me this CD
player so that I can listen to music. It is very important to me to take care of that.”
Coding: F0400B would be coded 1, very important.

October 2024

Page F-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0400: Interview for Daily Preferences (cont.)
Examples for F0400C, How Important Is It to You to Choose between a
Tub Bath, Shower, Bed Bath, or Sponge Bath?
1. Resident answers, “I like showers.”
Interviewer clarifies, “You like showers. Would you say that choosing a shower instead of
other types of bathing is very important, somewhat important, not very important, not
important at all, or that it’s important, but you can’t do it or have no choice?”
The resident responds, “It’s very important.”
Coding: F0400C would be coded 1, very important.

2. Resident answers, “I don’t have a choice. I like only sponge baths, but I have to take shower
two times a week.”
The interviewer says, “So how important is it to you to be able to choose to have a sponge
bath while you’re here?”
The resident responds, “Well, it is very important, but I don’t always have a choice because
that’s the rule.”

Coding: F0400C would be coded 5, important, but can’t do or no choice.

Example for F0400D, How Important Is It to You to Have Snacks
Available between Meals?
1. Resident answers, “I’m a diabetic, so it’s very important that I get snacks.”
Coding: F0400D would be coded 1, very important.

ft
October 2024

Page F-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0400: Interview for Daily Preferences (cont.)
Example for F0400E, How Important Is It to You to Choose Your Own
Bedtime?
1. Resident answers, “At home I used to stay up and watch TV. But here I’m usually in bed by
8. That’s because they get me up so early.”
Interviewer echoes and clarifies, “You used to stay up later, but now you go to bed before 8
because you get up so early. Would you say it’s [pointing to cue card] very important,
somewhat important, not very important, not important at all, or that it’s important, but you
don’t have a choice about your bedtime?”
Resident responds, “I guess it would be important, but I can’t do it because they wake me up so
early in the morning for therapy and by 8 o’clock at night, I’m tired.”

Coding: F0400E would be coded 5, important, but can’t do or no choice.

Example for F0400F, How Important Is It to You to Have Your Family
or a Close Friend Involved in Discussions about Your Care?
1. Resident responds, “They’re not involved. They live in the city. They’ve got to take care of
their own families.”

Interviewer replies, “You said that your family and close friends aren’t involved right now.
When you think about what you would prefer, would you say that it’s very important,
somewhat important, not very important, not important at all, or that it is important but you
have no choice or can’t have them involved in decisions about your care?”
Resident responds, “It’s somewhat important.”

Coding: F0400F would be coded 2, somewhat important.

Example for F0400G, How Important Is It to You to Be Able to Use the
Phone in Private?
1. Resident answers “That’s not a problem for me, because I
have my own room. If I want to make a phone call, I just
shut the door.”
Interviewer echoes and clarifies, “So, you can shut your
door to make a phone call. If you had to rate how important
it is to be able to use the phone in private, would you say
it’s very important, somewhat important, not very
important, or not important at all?”
Resident responds, “Oh, it’s very important.”

DEFINITION

PRIVATE TELEPHONE
CONVERSATION

A telephone conversation on
which no one can listen in,
other than the resident.

Coding: F0400G would be coded 1, very important.

October 2024

Page F-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0400: Interview for Daily Preferences (cont.)
Example for F0400H, How Important Is It to You to Have a Place to
Lock Your Things to Keep Them Safe?
1. Resident answers, “I have a safe deposit box at my bank, and that’s where I keep family
heirlooms and personal documents.”
Interviewer says, “That sounds like a good service. While you are staying here, how
important is it to you to have a drawer or locker here?”
Resident responds, “It’s not very important. I’m fine with keeping all my valuables at the
bank.”
Coding: F0400H would be coded 3, not very important.

F0500: Interview for Activity Preferences

ra
Item Rationale

Health-related Quality of Life
•

Activities are a way for individuals to establish meaning in their lives, and the need for
enjoyable activities and pastimes does not change on admission to a nursing home.

•

A lack of opportunity to engage in meaningful and enjoyable activities can result in
boredom, depression, and behavior disturbances.

•

Individuals vary in the activities they prefer, reflecting unique personalities, past
interests, perceived environmental constraints, religious and cultural background, and
changing physical and mental abilities.

October 2024

Page F-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0500: Interview for Activity Preferences (cont.)
Planning for Care
•

These questions will be useful for designing individualized care plans that facilitate
residents’ participation in activities they find meaningful.

•

Preferences may change over time and extend beyond those included here. Therefore, the
assessment of activity preferences is intended as a first step in an ongoing informal
dialogue between the care provider and resident.

•

As with daily routines, responses may provide insights into perceived functional,
emotional, and sensory support needs.

Coding Instructions

•

DEFINITIONS

See Coding Instructions on page F-4.

Coding approach is identical to that for daily
preferences.

Coding Tips and Special Populations
•

See Coding Tips on page F-5.

•

Include Braille and or audio recorded material when
coding items in F0500A.

Interviewing Tips and Techniques
•

NEWS
News about local, state,
national, or international
current events.

Coding tips include those for daily preferences.

READ
Script, Braille, or audio
recorded written material.

See Interview Tips and Techniques on
page F-5.

NEWSPAPERS AND
MAGAZINES
Any type, such as
journalistic, professional, and
trade publications in script,
Braille, or audio recorded
format.

Coding tips and techniques are identical to those for
daily preferences.

KEEP UP WITH THE
NEWS
Stay informed by reading,
watching, or listening.

October 2024

Page F-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0500: Interview for Activity Preferences (cont.)
Examples for F0500A, How Important Is It to You to Have Books
(Including Braille and Audio-recorded Format), Newspapers, and
Magazines to Read?

1. Resident answers, “Reading is very important to me.”
Coding: F0500A would be coded 1, very important.
2. Resident answers, “They make the print so small these days. I guess they are just trying to
save money.”
Interviewer replies, “The print is small. Would you say that having books, newspapers, and
magazines to read is very important, somewhat important, not very important, not important
at all, or that it is important but you can’t do it because the print is so small?”
Resident answers: “It would be important, but I can’t do it because of the print.”
Coding: F0500A would be coded 5, important, but can’t do or no choice.

Example for F0500B, How Important Is It to You to Listen to Music
You Like?

1. Resident answers, “It’s not important, because all we have in here is TV. They keep it blaring
all day long.”
Interviewer echoes, “You’ve told me it’s not important because all you have is a TV. Would
you say it’s not very important or not important at all to you to listen to music you like while
you are here? Or are you saying that it’s important, but you can’t do it because you don’t
have a radio or CD player?”
Resident responds, “Yeah. I’d enjoy listening to some jazz if I could get a radio.”
Coding: F0500B would be coded 5, important, but can’t do or no choice.

Examples for F0500C, How Important Is It to You to Be Around
Animals Such as Pets?

1. Resident answers, “It’s very important for me NOT to be around animals. You get hair all
around and I might inhale it.”
Coding: F0500C would be coded 4, not important at all.

2. Resident answers, “I’d love to go home and be around my own animals. I’ve taken care of
them for years and they really need me.”
Interviewer probes, “You said you’d love to be at home with your own animals. How
important is it to you to be around pets while you’re staying here? Would you say it is [points
to card] very important, somewhat important, not very important, not important at all, or is it
important, but you can’t do it or don’t have a choice about it.”
Resident responds, “Well, it’s important to me to be around my own dogs, but I can’t be
around them. I’d say important but can’t do.”
Coding: F0500C would be coded 5, Important, but can’t do or no choice.
Rationale: Although the resident has access to therapeutic dogs brought to the nursing
home, they do not have access to the type of pet that is important to them.
October 2024

Page F-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0500: Interview for Activity Preferences (cont.)
Example for F0500D, How Important Is It to You to Keep Up with the
News?
1. Resident answers, “Well, they are all so liberal these days, but it’s important to hear what
they are up to.”
Interviewer clarifies, “You think it is important to hear the news. Would you say it is [points
to card] very important, somewhat important, or it’s important but you can’t do it or have no
choice?”
Resident responds, “I guess you can mark me somewhat important on that one.”
Coding: F0500D would be coded 2, somewhat important.

Example for F0500E, How Important Is It to You to Do Things with
Groups of People?
1. Resident answers, “I’ve never really liked groups of people. They make me nervous.”

Interviewer echoes and clarifies, “You’ve never liked groups. To help us plan your activities,
would you say that while you’re here, doing things with groups of people is very important,
somewhat important, not very important, not important at all, or would it be important to you
but you can’t do it because you feel nervous about it?”
Resident responds, “At this point I’d say it’s not very important.”

Coding: F0500E would be coded 3, not very important.

Examples for F0500F, How Important Is It to You to Do Your Favorite
Activities?

1. Resident answers, “Well, it’s very important, but I can’t really do my favorite activities while
I’m here. At home, I used to like to play board games, but you need people to play and make
it interesting. I also like to sketch, but I don’t have the supplies I need to do that here. I’d say
important but no choice.”
Coding: F0500F would be coded 5, important, but can’t do or no choice.

2. Resident answers, “I like to play bridge with my bridge club.”

Interviewer probes, “Oh, you like to play bridge with your bridge club. How important is it to
you to play bridge while you are here in the nursing home?”
Resident responds, “Well, I’m just here for a few weeks to finish my rehabilitation. It’s not
very important.”
Coding: F0500F would be coded 3, not very important.

October 2024

Page F-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0500: Interview for Activity Preferences (cont.)
Example for F0500G, How Important Is It to You to Go Outside to Get
Fresh Air When the Weather Is Good (Includes Less Temperate
Weather if Resident Has Appropriate Clothing)?
1. Resident answers, “They have such a nice garden here. It’s very important to me to go out
there.”
Coding: F0500G would be coded 1, very important.

Examples for F0500H, How Important Is It to
You to Participate in Religious Services
or Practices?

1. Resident answers, “I’m Jewish. I’m Orthodox, but they
have Reform services here. So I guess it’s not important.”

OUTSIDE
Any outdoor area in the
proximity of the facility,
including patio, porch,
balcony, sidewalk, courtyard,
or garden.
PARTICIPATE IN
RELIGIOUS SERVICES
Any means of taking part in
religious services or
practices, such as listening to
services on the radio or
television, attending services
in the facility or in the
community, or private prayer
or religious study.

Interviewer clarifies, “You’re Orthodox, but the services
offered here are Reform. While you are here, how
important would it be to you to be able to participate in
religious services? Would you say it is very important,
somewhat important, not very important, not important at
all, or would it be important to you but you can’t or have no
choice because they don’t offer Orthodox services.”

DEFINITIONS

Resident responds, “It’s important for me to go to Orthodox
services if they were offered, but they aren’t. So, can’t do
or no choice.”
Coding: F0500I would be coded 5, important,
but can’t do or no choice.

2. Resident answers “My pastor sends taped services to me
that I listen to in my room on Sundays. I don’t participate in
the services here.”

RELIGIOUS PRACTICES
Rituals associated with
various religious traditions or
faiths, such as washing
rituals in preparation for
prayer, following kosher
dietary laws, honoring
holidays and religious
festivals, and participating in
communion or confession.

Interviewer probes, “You said your pastor sends you taped
services. Would you say that it is very important, somewhat
important, not very important, or not important at all, to
you that you are able to listen to those tapes from your
pastor?”
Resident responds, “Oh, that’s very important.”

Coding: F0500I would be coded 1, very important.

October 2024

Page F-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0600: Daily and Activity Preferences Primary Respondent

Item Rationale
•

This item establishes the source of the information regarding the resident’s preferences.

Coding Instructions
•

Code 1, resident: if resident was the primary source for the preference questions in

F0400 and F0500.

Code 2, family or significant other: if a family member or significant other was
the primary source of information for F0400 and F0500.

•

Code 9, interview could not be completed: if F0400 and F0500 could not be

•

completed by the resident, a family member, or a representative of the resident.

F0700: Should the Staff Assessment of Daily and Activity
Preferences Be Conducted?

Item Rationale

Health-related Quality of Life

Resident interview is preferred as it most accurately reflects what the resident views as
important. However, a small percentage of residents are unable or unwilling to complete
the interview for Daily and Activity Preferences.

•

Persons unable to complete the preference interview should still have preferences
evaluated and considered.

Planning for Care
•

•

Even though the resident was unable to complete the interview, important insights may
be gained from the responses that were obtained, observing behaviors, and observing the
resident’s affect during the interview.

Steps for Assessment
1.

Review resident, family, or significant other responses to F0400A-H and F0500A-H.

October 2024

Page F-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0700: Should the Staff Assessment of Daily and Activity
Preferences Be Conducted? (cont.)
Coding Instructions
•

•

Code 0, no: if Interview for Daily and Activity Preferences items (F0400 and

F0500) was completed by resident, family or significant other. Skip to and complete
GG0100, Prior Functioning: Everyday Activities.
Code 1, yes: if Interview for Daily and Activity Preferences items (F0400 through

F0500) were not completed because the resident, family, or significant other was unable
to answer 3 or more items (i.e. 3 or more items in F0400 through F0500 were coded as 9
or “-“).

Coding Tips and Special Populations
•

If the total number of unanswered questions in F0400 through F0500 is equal to 3 or
more, the interview is considered incomplete.

F0800: Staff Assessment of Daily and Activity Preferences

ra
October 2024

Page F-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0800: Staff Assessment of Daily and Activity Preferences (cont.)
Item Rationale
Health-related Quality of Life
•

Alternate means of assessing daily preferences must be used for residents who cannot
communicate. This ensures that information about their preferences is not overlooked.

•

Activities allow residents to establish meaning in their lives. A lack of meaningful and
enjoyable activities can result in boredom, depression, and behavioral symptoms.

Planning for Care
•

Caregiving staff should use observations of resident behaviors to understand resident
likes and dislikes in cases where the resident, family, or significant other cannot report
the resident’s preferences. This allows care plans to be individualized to each resident.

Steps for Assessment

1. Observe the resident when the care, routines, and activities specified in these items are made
available to the resident.
2. Observations should be made by staff across all shifts and departments and others with close
contact with the resident.
3. If the resident appears happy or content (e.g., is involved, pays attention, smiles) during an
activity listed in Staff Assessment of Daily and Activity Preferences item (F0800), then
that item should be checked.
If the resident seems to resist or withdraw when these are made available, then do not check
that item.

Coding Instructions

Check all that apply in the last 7 days based on staff observation of resident preferences.

•

F0800A. Choosing clothes to wear

•

F0800B. Caring for personal belongings

•

F0800C. Receiving tub bath

•

F0800D. Receiving shower

•

F0800E. Receiving bed bath

•

F0800F. Receiving sponge bath

•

F0800G. Snacks between meals

•

F0800H. Staying up past 8:00 p.m.

•

F0800I. Family or significant other involvement in care discussions

•

F0800J. Use of phone in private

•

F0800K. Place to lock personal belongings

October 2024

Page F-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [F]

F0800: Staff Assessment of Daily and Activity Preferences (cont.)
F0800L. Reading books, newspapers, or magazines

•

F0800M. Listening to music

•

F0800N. Being around animals such as pets

•

F0800O. Keeping up with the news

•

F0800P. Doing things with groups of people

•

F0800Q. Participating in favorite activities

•

F0800R. Spending time away from the nursing home

•

F0800S. Spending time outdoors

•

F0800T. Participating in religious activities or practices

•

F0800Z. None of the above

•

October 2024

Page F-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

SECTION GG: FUNCTIONAL ABILITIES
Intent: This section includes items about functional abilities. It includes items focused on prior

function, admission and discharge performance, performance throughout a resident’s stay,
mobility device use, and range of motion. Functional status is assessed based on the need for
assistance when performing self-care and mobility activities.

GG0100. Prior Functioning: Everyday Activities

D
Item Rationale
•

Knowledge of the resident’s functioning prior to the current illness, exacerbation, or
injury may inform treatment goals.

Steps for Assessment

Coding Instructions

1. Ask the resident or their family about, or review the resident’s medical records
describing, the resident’s prior functioning with everyday activities.

•

Code 3, Independent: if the resident completed the activities by themself, with or

•

Code 2, Needed Some Help: if the resident needed partial assistance from another

•

Code 1, Dependent: if the helper completed the activities for the resident, or the

•

Code 8, Unknown: if the resident’s usual ability prior to the current illness,

•

Code 9, Not Applicable: if the activities were not applicable to the resident prior to

without an assistive device, with no assistance from a helper.
person to complete the activities.

assistance of two or more helpers was required for the resident to complete the activities.

exacerbation, or injury is unknown.

the current illness, exacerbation, or injury.

October 2024

Page GG-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0100: Prior Functioning: Everyday Activities (cont.)
Coding Tips
Record the resident’s usual ability to perform self-care, indoor mobility (ambulation),
stairs, and functional cognition prior to the current illness, exacerbation, or injury.

•

If no information about the resident’s ability is available after attempts to interview the
resident or their family and after reviewing the resident’s medical record, code as 8,
Unknown.

•

Completing the stair activity for GG0100C indicates that a resident went up and down the
stairs, by any safe means, with or without handrails or assistive devices or equipment
(such as a cane, crutch, walker, or stair lift) and/or with or without some level of
assistance.

•

Going up and down a ramp is not considered going up and down stairs for coding
GG0100C.

•

Examples for Coding Prior Functioning: Everyday Activities

1. Self-Care: Resident T was admitted to an acute care facility after sustaining a stroke and
subsequently admitted to the SNF for rehabilitation. Prior to the stroke, Resident T was
independent in eating and using the toilet; however, Resident T required assistance for
bathing and putting on and taking off their shoes and socks. The assistance needed was due
to severe arthritic lumbar pain upon bending, which limited their ability to access their feet.
Coding: GG0100A would be coded 2, Needed Some Help.
Rationale: Resident T needed partial assistance from a helper to complete the activities

of bathing and dressing. While Resident T did not need help for all self-care activities,
they did need some help. Code 2 is used to indicate that Resident T needed some help for
self-care.

2. Self-Care: Resident R was diagnosed with a progressive neurologic condition five years ago.
They live in a long-term nursing facility and were recently hospitalized for surgery and have
now been admitted to the SNF for skilled services. According to Resident R’s spouse, prior
to the surgery, Resident R required complete assistance with self-care activities, including
eating, bathing, dressing, and using the toilet.
Coding: GG0100A would be coded 1, Dependent.
Rationale: Resident R’s spouse has reported that Resident R was completely dependent

in self-care activities that included eating, bathing, dressing, and using the toilet. Code 1,
Dependent, is appropriate based upon this information.

3. Indoor Mobility (Ambulation): Approximately three months ago, Resident K had a cardiac
event that resulted in anoxia, and subsequently a swallowing disorder. Resident K has been
living at home with their spouse and developed aspiration pneumonia. After this most recent
hospitalization, they were admitted to the SNF for a diagnosis of aspiration pneumonia and
severe deconditioning. Prior to the most recent acute care hospitalization, Resident K needed
some assistance when walking.

October 2024

Page GG-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0100: Prior Functioning: Everyday Activities (cont.)
Coding: GG0100B would be coded 2, Needed Some Help.
Rationale: While the resident experienced a cardiac event three months ago, they

recently had an exacerbation of a prior condition that required care in an acute care
hospital and skilled nursing facility. The resident’s prior functioning is based on the time
immediately before their most recent condition exacerbation that required acute care.

4. Indoor Mobility (Ambulation): Resident L had a stroke one year ago that resulted in their
using a wheelchair to self-mobilize, as they were unable to walk. Resident L subsequently
had a second stroke and was transferred from an acute care unit to the SNF for skilled
services.
Coding: GG0100B would be coded 9, Not Applicable.
Rationale: The resident did not ambulate immediately prior to the current illness,

injury, or exacerbation (the second stroke).

5. Stairs: Prior to admission to the hospital for bilateral knee surgery, followed by their recent
admission to the SNF for rehabilitation, Resident V experienced severe knee pain upon
ascending and particularly descending their internal and external stairs at home. Resident V
required assistance from their spouse when using the stairs to steady them in the event their
left knee would buckle. Resident V’s spouse was interviewed about their spouse’s
functioning prior to admission, and the therapist noted Resident V’s prior functional level
information in their medical record.
Coding: GG0100C would be coded 2, Needed Some Help.
Rationale: Prior to admission, Resident V required some help in order to manage

internal and external stairs.

6. Stairs: Resident P has expressive aphasia and difficulty communicating. SNF staff have not
received any response to their phone messages to Resident P’s family members requesting a
return call. Resident P has not received any visitors since their admission. The medical record
from their prior facility does not indicate Resident P’s prior functioning. There is no
information to code item GG0100C, but there have been attempts at seeking this information.
Coding: GG0100C would be coded 8, Unknown.
Rationale: Attempts were made to seek information regarding Resident P’s prior

functioning; however, no information was available.

7. Functional Cognition: Resident K has mild dementia and recently sustained a fall resulting
in complex multiple fractures requiring multiple surgeries. Resident K has been admitted to
the SNF for rehabilitation. Resident K’s caregiver reports that when living at home,
Resident K needed reminders to take their medications on time, manage their money, and
plan tasks, especially when they were fatigued.
Coding: GG0100D would be coded 2, Needed Some Help.
Rationale: Resident K required some help to recall, perform, and plan regular daily

activities as a result of cognitive impairment.

October 2024

Page GG-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0100: Prior Functioning: Everyday Activities (cont.)
8. Functional Cognition: Resident R had a stroke, resulting in a severe communication
disorder. Their family members have not returned phone calls requesting information about
Resident R’s prior functional status, and their medical records do not include information
about their functional cognition prior to the stroke.
Coding: GG0100D would be coded 8, Unknown.
Rationale: Attempts to seek information regarding Resident R’s prior functioning were

made; however, no information was available.

GG0110. Prior Device Use

D
Item Rationale
•

Knowledge of the resident’s routine use of devices and aids immediately prior to the
current illness, exacerbation, or injury may inform treatment goals.

Steps for Assessment

1. Ask the resident or their family or review the resident’s medical records to determine the
resident’s use of prior devices and aids.

Coding Instructions
•

Check all devices that apply.

•

Check Z, None of the above: if the resident did not use any of the listed devices or

aids immediately prior to the current illness, exacerbation, or injury.

Coding Tips
•

For GG0110D, Prior Device Use - Walker: “Walker” refers to all types of walkers (for
example, pickup walkers, hemi-walkers, rolling walkers, and platform walkers).

•

GG0110C, Mechanical lift, includes sit-to-stand, stand assist, stair lift, and full-bodystyle lifts.

October 2024

Page GG-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0110: Prior Device Use (cont.)
Example for Coding Prior Device Use
1. Resident M is a bilateral lower extremity amputee and has multiple diagnoses, including
diabetes, obesity, and peripheral vascular disease. They are unable to walk and did not walk
prior to the current episode of care, which started because of a pressure ulcer and respiratory
infection. They use a motorized wheelchair to mobilize.
Coding: GG0110B would be checked.
Rationale: Resident M used a motorized wheelchair prior to the current illness/injury.

GG0115: Functional Limitation in Range of Motion

D
Intent: The intent of GG0115 is to determine whether
functional limitation in range of motion (ROM) interferes with
the resident’s activities of daily living or places them at risk of
injury. When completing this item, staff members should refer
to items in GG0130 and GG0170 and view the limitation in
ROM, taking into account activities the resident is able to
perform.

Health-related Quality of Life
•

Functional impairment could place the resident at risk of injury or interfere with
performance of activities of daily living.

Planning for Care
•

FUNCTIONAL
LIMITATION IN RANGE
OF MOTION
Limited ability to move a joint
that interferes with daily
functioning (particularly with
activities of daily living) or
places the resident at risk of
injury.

Item Rationale

DEFINITION

Individualized care plans should address possible reversible causes such as
deconditioning and adverse side effects of medications or other treatments.

October 2024

Page GG-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0115: Functional Limitation in Range of Motion (cont.)
Steps for Assessment
1. Review the medical record for references to functional range-of-motion limitation during the
7-day observation period.
2. Talk with staff members who work with the resident as well as family/significant others
about any impairment in functional ROM.
3. Coding for functional ROM limitations is a three-step process:
Test the resident’s upper and lower extremity ROM (See item 6 below for examples).

•

If the resident is noted to have limitation of upper- and/or lower-extremity ROM, review
GG0130 and GG0170 and/or directly observe the resident to determine whether the
limitation interferes with function or places the resident at risk for injury.

•

Code GG0115A and GG0115B as appropriate based on the above assessment.

•

4. Assess the resident’s ROM bilaterally at the shoulder, elbow, wrist, hand, hip, knee, ankle,
foot, and other joints unless contraindicated (e.g., recent fracture, joint replacement or pain).
5. Staff member observations of various activities, including ADLs, may be used to determine
whether any ROM limitations have an impact on the resident’s functional abilities.
6. Although this item codes for the presence or absence of functional limitation related to ROM,
thorough assessment ought to be comprehensive and follow standards of practice for
evaluating ROM impairment. Below are some suggested assessment strategies:
•
•

Ask the resident to follow your verbal instructions for each movement.
Demonstrate each movement (e.g., ask the resident to do what you are doing).

•

Actively assist the resident with the movements by supporting their extremity and
guiding it through the joint ROM.

Lower Extremity—includes hip, knee, ankle, and foot

While resident is lying supine in a flat bed, instruct the resident to flex (pull toes up toward
head) and extend (push toes down away from head) each foot. Then ask the resident to lift
their leg one at a time, bending it at the knee to a right angle (90 degrees). Then ask the
resident to slowly lower their leg and extend it flat on the mattress. If assessing lowerextremity ROM by observing the resident, the flexion and extension of the foot mimics the
motion on the pedals of a bicycle. Extension might also be needed to don a shoe. If assessing
bending at the knee, the motion would be similar to lifting of the leg when donning lowerbody clothing.

October 2024

Page GG-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0115: Functional Limitation in Range of Motion (cont.)
Upper Extremity—includes shoulder, elbow, wrist, and fingers
For each hand, instruct the resident to make a fist and then open the hand. With resident
seated in a chair, instruct them to reach with both hands and touch palms to back of head.
Then ask resident to touch each shoulder with the opposite hand. Alternatively, observe the
resident donning or removing a shirt over the head. If assessing upper-extremity ROM by
observing the resident, making a fist mimics useful actions for grasping and letting go of
utensils. When an individual reaches both hands to the back of the head, this mimics the
action needed to comb hair.

Coding Tips
•

Do not look at limited ROM in isolation. You must determine whether the limited ROM
has an impact on functional ability or places the resident at risk for injury. For example, if
the resident has an amputation, it does not automatically mean that they are limited in
function. A resident with an amputation may not have a particular joint in which a certain
range of motion can be tested, however, that does not mean that the resident necessarily
has a limitation in completing activities of daily living, nor does it mean that the resident
is automatically at risk of injury. There are many amputees who function extremely well
and can complete all activities of daily living either with or without the use of prosthetics.
If a resident with an amputation does indeed have difficulty completing ADLs and is at
risk for injury, the facility should code this item as appropriate. This item is coded in
terms of function and risk of injury, not by diagnosis or lack of a limb or digit.

Coding Instructions for GG0115A, Upper Extremity (Shoulder, Elbow,
Wrist, Hand); GG0115B, Lower Extremity (Hip, Knee, Ankle, Foot)
•

Code 0, no impairment: if resident has full functional range of motion on the right

•

Code 1, impairment on one side: if resident has an upper- and/or lower-extremity

•

and left side of upper/lower extremities.

impairment on one side that interferes with daily functioning or places the resident at risk
of injury.
Code 2, impairment on both sides: if resident has an upper- and/or lower-

extremity impairment on both sides that interferes with daily functioning or places the
resident at risk of injury.

October 2024

Page GG-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0115: Functional Limitation in Range of Motion (cont.)
Examples for GG0115A, Upper Extremity (Shoulder, Elbow, Wrist,
Hand); GG0115B, Lower Extremity (Hip, Knee, Ankle, Foot)
1. The resident can perform all arm, hand, and leg motions on the right side, with smooth
coordinated movements. They are able to perform grooming activities (e.g., brush their teeth,
comb their hair) with their right upper extremity and are also able to pivot to their wheelchair
with the assistance of one person. They are, however, unable to voluntarily move their left
side (limited arm, hand, and leg motion), as they have a flaccid left hemiparesis from a prior
stroke.
Coding: GG0115A would be coded 1, upper-extremity impairment on one side.

GG0115B would be coded 1, lower-extremity impairment on one side.
Rationale: Impairment due to left hemiparesis affects both upper and lower extremities
on one side. Even though this resident has limited ROM that impairs function on the left
side, as indicated above, the resident can perform ROM fully on the right side. Even though
there is impairment on one side, the facility should always attempt to provide the resident
with assistive devices or physical assistance that allows the resident to be as independent as
possible.

2. The resident had shoulder surgery and can’t brush their hair with their right arm or raise their
right arm above their head. The resident can brush their hair with their left arm and has no
impairment on the lower extremities.
Coding: GG0115A would be coded 1, upper-extremity impairment on one side.
GG0115B would be coded 0, no impairment.
Rationale: Impairment due to shoulder surgery affects only one side of their upper
extremities.

3. The resident has a diagnosis of Parkinson’s and ambulates with a shuffling gait. The resident
has had three falls in the past quarter and often forgets their walker, which they need to
ambulate. They have tremors of both upper extremities that make it very difficult for them to
feed themself, brush their teeth, or write.
Coding: GG0115A would be coded 2, upper-extremity impairment on both sides.

GG0115B would be coded 2, lower-extremity impairment on both sides.

Rationale: Impairment due to Parkinson’s disease affects the resident’s upper and

lower extremities on both sides.

October 2024

Page GG-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0120: Mobility Devices

Item Rationale
Health-related Quality of Life
•

Maintaining independence is important to an individual’s feelings of autonomy and selfworth. The use of devices may assist the resident in maintaining that independence.

Planning for Care

•

A resident’s ability to move about their room, unit or nursing home may be directly
related to the use of devices. It is critical that staff members assure that the resident’s
independence is optimized by making mobility devices available on a daily basis, if
needed.

Steps for Assessment

1. Review the medical record for references to locomotion during the 7-day observation period.
2. Talk with staff members who work with the resident as well as family/significant others
about devices the resident used for mobility during the observation period.
3. Observe the resident during locomotion.

Coding Instructions

Record the type(s) of mobility devices the resident normally uses for locomotion (in room and in
facility). Check all that apply:
•

Check GG0120A, Cane/crutch: if the resident used a cane or crutch, including

•

Check GG0120B, Walker: if the resident used a walker or hemi-walker, including an
enclosed frame-wheeled walker with or without a posterior seat and lap cushion. Also
check this item if the resident walks while pushing a wheelchair for support.

•

Check GG0120C, Wheelchair (manual or electric): if the resident normally

•

Check GG0120D, Limb prosthesis: if the resident used an artificial limb to replace

single-prong, tripod, quad cane, etc.

sits in a wheelchair when moving about. Include wheelchairs that are hand propelled,
motorized, or pushed by another person. Do not include geri-chairs, reclining chairs with
wheels, positioning chairs, scooters, and other types of specialty chairs.
a missing extremity.

October 2024

Page GG-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0120: Mobility Devices (cont.)
•

Check GG0120Z, None of the above: if the resident used none of the mobility

devices listed in GG0120 or locomotion did not occur during the observation period.

Examples
1. The resident uses a quad cane daily to walk in the room and on the unit. The resident uses
a standard push wheelchair that they self-propel when leaving the unit because of their
issues with endurance.
Coding: GG0120A, Cane/crutch, and GG0120C, Wheelchair, would be checked.
Rationale: The resident uses a quad cane in their room and on the unit and a

wheelchair off the unit.

2. The resident has an artificial leg that is applied each morning and removed each evening.
Once the prosthesis is applied, the resident is able to ambulate independently.
Coding: GG0120D, Limb prosthesis, would be checked.
Rationale: The resident uses a leg prosthesis for ambulating.

ra
October 2024

Page GG-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (3-day assessment period) Admission

D
October 2024

Page GG-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (3-day assessment period) Discharge

D
October 2024

Page GG-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (OBRA/Interim)

D
October 2024

Page GG-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Item Rationale
Health-related Quality of Life
•

Residents may have self-care limitations on admission.
In addition, residents may be at risk of further
functional decline during their stay in the facility.

DEFINITION
ADL
Tasks related to personal
care, such as any of the
tasks listed in GG0130 and
GG0170.

Most nursing home residents need some physical
assistance and are at risk of further physical decline.
The amount of assistance needed and the risk of decline
vary from resident to resident.

•

A wide range of physical, neurological, and psychological conditions and cognitive
factors can adversely affect physical function.

•

Dependence on others for ADL assistance can lead to feelings of helplessness, isolation,
diminished self-worth, and loss of control over one’s destiny.

•

As inactivity increases, complications such as pressure ulcers, falls, contractures,
depression, and muscle wasting may occur.

Planning for Care

Individualized care plans should address strengths and weaknesses, possible reversible
causes such as deconditioning, and adverse side effects of medications or other
treatments. These may contribute to loss of self-sufficiency. In addition, some neurologic
injuries such as stroke may continue to improve for months after an acute event.

•

For some residents, cognitive deficits can limit ability or willingness to initiate or
participate in self-care or restrict understanding of the tasks required to complete ADLs.

•

Individualized care plans should be based on an accurate assessment of the resident’s
self-performance and the amount and type of support being provided to the resident.

•

Many residents may require lower levels of assistance if they are provided with
appropriate devices and aids, assisted with segmenting tasks, or given adequate time to
complete a task while being provided with graduated prompting and assistance. This type
of supervision requires skill, time, and patience.

•

Most residents are candidates for nursing-based rehabilitative care that focuses on
maintaining and expanding self-involvement in ADLs.

•

Graduated prompting/task segmentation (helping the resident break tasks down into
smaller components) and allowing the resident time to complete an activity can often
increase functional independence.

October 2024

•

Page GG-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Steps for Assessment
1. Assess the resident’s self-care performance based on direct
observation, incorporating resident self-reports and reports
from qualified clinicians, care staff, or family documented
in the resident’s medical record during the assessment
period. CMS anticipates that an interdisciplinary team of
qualified clinicians is involved in assessing the resident
during the assessment period.
•

For residents in a Medicare Part A stay, the admission
assessment period is the first 3 days of the Part A stay
starting with the date in A2400B, the Start of Most
Recent Medicare Stay. The admission assessment
period for residents who are not in a Medicare Part A
stay is the first 3 days of their stay starting with the date
in A1600, Entry Date.
•

For residents in a Medicare Part A stay, the assessment
period for the Interim Payment Assessment
(A0310B = 08) is the last 3 days (i.e., the ARD plus 2
previous calendar days).

•

For residents in a Medicare Part A stay, the discharge
assessment period is the End Date of Most Recent
Medicare Stay (A2400C) plus 2 previous calendar days.
For all other Discharge assessments, the assessment
period is A2000, Discharge Date plus 2 previous
calendar days.

QUALIFIED CLINICIAN
Healthcare professionals
practicing within their scope
of practice and consistent
with Federal, State, and local
law and regulations.

•

USUAL PERFORMANCE
A resident’s functional status
can be impacted by the
environment or situations
encountered 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 functional status. 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.

Note: If A0310B = 01 and A0310A = 01 – 06
indicating a 5-day PPS assessment combined with
an OBRA assessment, the assessment period is the
first 3 days of the stay beginning on A2400B and
both columns are required. In these scenarios, do
not complete Column 5. OBRA/Interim
Performance.

DEFINITIONS

PRIOR TO THE BENEFIT
OF SERVICES means prior
to provision of any care by
facility staff that would result
in more independent coding.

When completing an OBRA-required assessment other
than an Admission assessment (i.e., A0310A = 02 –
06), the assessment period is the ARD plus 2 previous calendar days.

2. Residents should be allowed to perform activities as independently as possible, as long as
they are safe.

October 2024

Page GG-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
3. For the purposes of completing Section GG, a “helper” is defined as facility staff who are
direct employees and facility-contracted employees (e.g., rehabilitation staff, nursing agency
staff). Thus, “helper” does not include individuals hired, compensated or not, by individuals
outside of the facility’s management and administration such as hospice staff,
nursing/certified nursing assistant students, etc. Therefore, when helper assistance is required
because a resident’s performance is unsafe or of poor quality, consider only facility staff
when scoring according to the amount of assistance provided.
4. Activities may be completed with or without assistive device(s). Use of assistive device(s) to
complete an activity should not affect coding of the activity.

5. For residents in a Medicare Part A stay, the admission functional assessment, when possible,
should be conducted prior to the benefit of services in order to reflect the resident’s true
admission baseline functional status. If treatment has started, for example, on the day of
admission, a baseline functional status assessment can still be conducted. Treatment should
not be withheld in order to conduct the functional assessment.
6. Refer to facility, Federal, and State policies and procedures to determine which staff
members may complete an assessment. Resident assessments are to be done in compliance
with facility, Federal, and State requirements.

Coding Instructions
•

When coding the resident’s usual performance, use the six-point scale, or use one of the four
“activity was not attempted” codes to specify the reason why an activity was not attempted.

•

Code 06, Independent: if the resident completes the activity by themself with no

assistance from a helper.

•

Code 05, Setup or clean-up assistance: if the helper sets up or cleans up; resident

•

Code 04, Supervision or touching assistance: if the helper provides verbal cues or

completes activity. Helper assists only prior to or following the activity, but not during the
activity. For example, the resident requires assistance cutting up food or opening container,
or requires setup of hygiene item(s) or assistive device(s).

touching/steadying/contact guard assistance as resident completes activity. Assistance may
be provided throughout the activity or intermittently. For example, the resident requires
verbal cueing, coaxing, or general supervision for safety to complete activity; or resident may
require only incidental help such as contact guard or steadying assist during the activity.
o Code 04, Supervision or touching assistance: if the resident requires only verbal
cueing to complete the activity safely.

•

Code 03, Partial/moderate assistance: if the helper does LESS THAN HALF the

•

Code 02, Substantial/maximal assistance: if the helper does MORE THAN HALF

effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.
the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.

October 2024

Page GG-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
•

Code 01, Dependent: if the helper does ALL of the effort. Resident does none of the

effort to complete the activity; or the assistance of two or more helpers is required for the
resident to complete the activity.
o Code 01, Dependent: if two helpers are required for the safe completion of an
activity, even if the second helper provides supervision/stand-by assist only and does
not end up needing to provide hands-on assistance.
o Code 01, Dependent: if a resident requires the assistance of two helpers to complete
an activity (one to provide support to the resident and a second to manage the
necessary equipment to allow the activity to be completed).

Code 07, Resident refused: if the resident refused to complete the activity.

•

Code 09, Not applicable: if the activity was not attempted and the resident did not

•

Code 10, Not attempted due to environmental limitations: if the resident did

•

Code 88, Not attempted due to medical condition or safety concerns: if the

•

perform this activity prior to the current illness, exacerbation, or injury.

not attempt this activity due to environmental limitations. Examples include lack of
equipment and weather constraints.

activity was not attempted due to medical condition or safety concerns.

October 2024

Page GG-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Decision Tree
Use this decision tree to code the resident’s performance on the assessment instrument. If helper
assistance is required because the resident’s performance is unsafe or of poor quality, score
according to the amount of assistance provided. Only use the “activity not attempted codes” if
the activity did not occur; that is, the resident did not perform the activity and a helper did not
perform that activity for the resident.

D
October 2024

Page GG-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Assessment Period
•

•
•

For the 5-Day PPS assessment, code the resident’s functional status based on a
clinical assessment of the resident’s performance that occurs soon after the resident’s
admission. This functional assessment must be completed within the first three days
(3 calendar days) of the Medicare Part A stay, starting with the date in A2400B, Start
of Most Recent Medicare Stay, and the following two days, ending at 11:59 PM on
day 3. The admission function scores are to reflect the resident’s admission baseline
status and are to be based on an assessment. The scores should reflect the resident’s
status prior to any benefit from interventions. The assessment should occur, when
possible, prior to the resident benefitting from treatment interventions in order to
determine the resident’s true admission baseline status. Even if treatment started on
the day of admission, a baseline functional status assessment can still be conducted.
Treatment should not be withheld in order to conduct the functional assessment.
For an OBRA Admission assessment, code the resident’s usual performance during
first 3 days of their stay starting with the date in A1600, Entry Date.

OBRA/Interim: The Interim Payment Assessment (IPA) (A0310B = 08) is an optional
assessment that may be completed by providers in order to report a change in the
resident’s PDPM classification. OBRA assessments (A0310A = 01 – 06) are required for
residents in Medicare-certified, Medicaid-certified, or dually certified nursing homes and
are outlined in Chapter 2 of this Manual.
For Section GG on the IPA or an OBRA assessment, providers will use the same 6point scale and activity not attempted codes to assess the resident’s usual functional
performance during the 3-day assessment period.

•

The ARD for the IPA is determined by the provider, and the assessment period is the
last 3 days (i.e., the ARD plus 2 previous calendar days). It is important to note that
the IPA changes payment beginning on the ARD and continues until the end of the
Medicare Part A stay or until another IPA is completed. The IPA does not affect the
variable per diem schedule.

•

For Section GG on OBRA assessments other than the Admission assessment (i.e.,
A0310A = 02 – 06), the assessment period is the last 3 days (i.e., the ARD plus 2
previous calendar days).

•

October 2024

Page GG-19

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
•

Discharge: The Part A PPS Discharge assessment is required to be completed as a
standalone assessment when the resident’s Medicare Part A Stay ends (as documented in
A2400C, End of Most Recent Medicare Stay) and the resident remains in the facility. The
Part A PPS Discharge assessment must be combined with an OBRA Discharge if the
Medicare Part A stay ends on the day of, or one day before, the resident’s Discharge Date
(A2000). An OBRA Discharge assessment is required when the resident is discharged
from the facility. Please see Chapter 2 and Section A of the RAI Manual for additional
details regarding Discharge assessments.
•

For the PPS Discharge assessment (i.e., standalone Part A PPS or combined
OBRA/Part A PPS), code the resident’s discharge functional status, based on a
clinical assessment of the resident’s performance that occurs as close to the time of
the resident’s discharge from Medicare Part A as possible. This functional assessment
must be completed within the last 3 calendar days of the resident’s Medicare Part A
stay, which includes the day of discharge from Medicare Part A plus 2 previous
calendar days prior to the day of discharge from Medicare Part A.

•

On standalone OBRA Discharge assessments (i.e., A0310F = 10 or 11 AND
A0310H = 0), code the resident’s usual performance during last 3 days of their stay
(i.e., A2000, Discharge Date plus 2 previous calendar days).

Coding Tips

General Coding Tips

When reviewing the medical record, interviewing staff, and observing the resident, be
familiar with the definition for each activity (e.g., eating, oral hygiene). For example,
when assessing Eating (item GG0130A), determine the type and amount of assistance
required to bring food and/or liquid to the mouth and swallow food and/or liquid once the
meal is placed before the resident.

•

Residents with cognitive impairments/limitations may need physical and/or verbal
assistance when completing an activity. Code based on the resident’s need for assistance
to perform the activity safely (for example, choking risk due to rate of eating, amount of
food placed into mouth, risk of falling).

•

If the resident does not attempt the activity and a helper does not complete the activity for
the resident during the entire assessment period, code the reason the activity was not
attempted. For example, code as 07 if the resident refused to attempt the activity; code as
09 if the activity is not applicable for the resident (the activity did not occur at the time of
the assessment and prior to the current illness, injury, or exacerbation); code as 10 if the
resident was not able to attempt the activity due to environmental limitations; or code as
88 if the resident was not able to attempt the activity due to medical condition or safety
concerns.

•

An activity can be completed independently with or without devices. If the resident uses
adaptive equipment and uses the device independently when performing an activity, enter
code 06, Independent.

•

October 2024

Page GG-20

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
If two or more helpers are required to assist the resident to complete the activity, code as
01, Dependent.

•

To clarify your own understanding of the resident’s performance of an activity, ask
probing questions to the care staff about the resident, beginning with the general and
proceeding to the more specific. See examples of probing questions at the end of this
section.

•

A dash (“-”) indicates “No information.” CMS expects dash use to be a rare occurrence.

•

Documentation in the medical record is used to support assessment coding of Section
GG. Data entered should be consistent with the clinical assessment documentation in the
resident’s medical record. This assessment can be conducted by appropriate healthcare
personnel as defined by facility policy and in accordance with State and Federal
regulations.

•

CMS does not provide an exhaustive list of assistive devices that may be used when
coding self-care and mobility activities. Clinical assessments may include any device or
equipment that the resident can use to allow them to safely complete the activity as
independently as possible.

•

Do not code self-care and mobility activities with use of a device that is restricted to
resident use during therapy sessions (e.g., parallel bars, exoskeleton, or overhead track
and harness systems).

•

Tips for Coding the Resident’s Usual Performance

When coding the resident’s usual performance, “effort” refers to the type and amount of
assistance a helper provides in order for the activity to be completed. The six-point rating
scale definitions include the following types of assistance: setup/cleanup, touching
assistance, verbal cueing, and lifting assistance.

•

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 during the assessment
period.

•

Code based on the resident’s performance. Do not record the staff’s assessment of the
resident’s potential capability to perform the activity.

•

If the resident performs the activity more than once during the assessment period and the
resident’s performance varies, coding in Section GG should be based on the resident’s
“usual performance,” which is identified as the resident’s usual activity/performance for
any of the Self-Care or Mobility activities, not the most independent or dependent
performance over the assessment period. Therefore, if the resident’s Self-Care
performance varies during the assessment period, report the resident’s usual performance,
not the resident’s most independent performance and not the resident’s most dependent
performance. A provider may need to use the entire assessment period to obtain the
resident’s usual performance.

October 2024

•

Page GG-21

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Coding Tips for GG0130A, Eating
•

The intent of GG0130A, Eating is to assess the resident’s 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.

•

The administration of tube feedings and parenteral nutrition is not considered when
coding this activity.

•

The following is guidance for some situations in which a resident receives tube feedings
or parenteral nutrition:

•

o If the resident does not eat or drink by mouth and relies solely on nutrition and liquids
through tube feedings or total parenteral nutrition (TPN) because of a new (recentonset) medical condition, code GG0130A as 88, Not attempted due to medical
condition or safety concerns.
o If the resident does not eat or drink by mouth at the time of the assessment, and the
resident did not eat or drink by mouth prior to the current illness, injury, or
exacerbation, code GG0130A as 09, Not applicable - Not attempted and the resident
did not perform this activity prior to the current illness, exacerbation, or injury.
o If the resident eats and drinks by mouth, and relies partially on obtaining nutrition
and liquids via tube feedings or parenteral nutrition, code Eating based on the amount
of assistance the resident requires to eat and drink by mouth.
o Assistance with tube feedings or parenteral nutrition is not considered when coding
the item Eating.
If a resident requires assistance (e.g., supervision or cueing) to swallow safely, code
based on the type and amount of assistance required for feeding and safe swallowing.
If a resident swallows safely without assistance, exclude swallowing from consideration
when coding GG0130A, Eating.

•

If the resident eats finger foods using their hands, then code Eating based upon the
amount of assistance provided. If the resident eats finger foods with their hands
independently, for example, the resident would be coded as 06, Independent.

•

For a resident taking only fluids by mouth, the item may be coded based on ability to
bring liquid to the mouth and swallow liquid, once the drink is placed in front of the
resident.

•

Examples for Coding Performance

Note: The following are coding examples for each Self-Care item. Some examples describe a
single observation of the person completing the activity; other examples describe a summary of
several observations of the resident completing an activity across different times of the day and
different days.

October 2024

Page GG-22

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Examples for GG0130A, Eating
1. Eating: Resident S has multiple sclerosis, affecting their endurance and strength. Resident S
prefers to feed themself as much as they are capable. During all meals, after eating threefourths of the meal by themself, Resident S usually becomes extremely fatigued and requests
assistance from the certified nursing assistant to feed them the remainder of the meal.
Coding: GG0130A would be coded 03, Partial/moderate assistance.
Rationale: The certified nursing assistant provides less than half the effort for the

resident to complete the activity of eating for all meals.

2. Eating: Resident M has upper extremity weakness and fine motor impairments. The
occupational therapist places an adaptive device onto Resident M’s hand that supports the
eating utensil within their hand. At the start of each meal Resident M can bring food and
liquids to their mouth. Resident M then tires and the certified nursing assistant feeds them
more than half of each meal.
Coding: GG0130A would be coded 02, Substantial/maximal assistance.
Rationale: The helper provides more than half the effort for the resident to complete

the activity of eating at each meal.

3. Eating: The dietary aide opens all of Resident S’s cartons and containers on their food tray
before leaving the room. There are no safety concerns regarding Resident S’s ability to eat.
Resident S eats the food themself, bringing the food to their mouth using appropriate utensils
and swallowing the food safely.
Coding: GG0130A would be coded 05, Setup or clean-up assistance.
Rationale: The helper provided setup assistance prior to the eating activity.

4. Eating: Resident H does not have any food consistency restrictions, but often needs to
swallow 2 or 3 times so that the food clears their throat due to difficulty with pharyngeal
peristalsis. They require verbal cues from the certified nursing assistant to use the
compensatory strategy of extra swallows to clear the food.

Coding: GG0130A would be coded 04, Supervision or touching assistance.
Rationale: Resident H swallows all types of food consistencies and requires verbal

cueing (supervision) from the helper.

5. Eating: Resident R is unable to eat by mouth since they had a stroke one week ago. They
receive nutrition through a gastrostomy tube (G-tube), which is administered by nurses.
Coding: GG0130A would be coded 88, Not attempted due to medical condition or

safety concerns.

Rationale: The resident does not eat or drink by mouth at this time due to their recent-

onset stroke. This item includes eating and drinking by mouth only. Since eating and
drinking did not occur due to their recent-onset medical condition, the activity is coded as
88, Not attempted due to medical condition and safety concerns. Assistance with G-tube
feedings is not considered when coding this item.

October 2024

Page GG-23

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Coding Tips for GG0130B, Oral hygiene
•

If a resident does not perform oral hygiene during therapy, determine the resident’s
abilities based on performance on the nursing care unit.

•

For a resident who is edentulous, code Oral hygiene based on the type and amount of
assistance required from a helper to clean the resident’s gums.

Examples for GG0130B, Oral hygiene

1. Oral hygiene: Before bedtime, the nurse provides steadying assistance to Resident S as they
walk to the bathroom. The nurse applies toothpaste onto Resident S’s toothbrush. Resident S
then brushes their teeth at the sink in the bathroom without physical assistance or
supervision. Once Resident S is done brushing their teeth and washing their hands and face,
the nurse returns and provides steadying assistance as the resident walks back to their bed.
Coding: GG0130B would be coded 05, Setup or clean-up assistance.
Rationale: The helper provides setup assistance (putting toothpaste on the toothbrush)

every evening before Resident S brushes their teeth. Do not consider assistance provided
to get to or from the bathroom to score Oral hygiene.

2. Oral hygiene: At night, the certified nursing assistant provides Resident K water and
toothpaste to clean their dentures. Resident K cleans their upper denture plate. Resident K
then cleans half of their lower denture plate, but states they are tired and unable to finish
cleaning their lower denture plate. The certified nursing assistant finishes cleaning the lower
denture plate and Resident K replaces the dentures in their mouth.
Coding: GG0130B would be coded 03, Partial/moderate assistance.
Rationale: The helper provided less than half the effort to complete oral hygiene.

3. Oral hygiene: Resident W is edentulous (without teeth) and their dentures no longer fit their
gums. In the morning and evening, Resident W begins to brush their upper gums after the
helper applies toothpaste onto their toothbrush. Resident W brushes their upper gums, but
cannot finish due to fatigue. The certified nursing assistant completes the activity of oral
hygiene by brushing their back upper gums and their lower gums.
Coding: GG0130B would be coded 02, Substantial/maximal assistance.
Rationale: The resident begins the activity. The helper completes the activity by

performing more than half the effort.

4. Oral hygiene: Resident D has experienced a stroke. They can brush their teeth while sitting
on the side of the bed, but when the certified nursing assistant hands them the toothbrush and
toothpaste, they look up at them puzzled what to do next. The certified nursing assistant cues
Resident D to put the toothpaste on the toothbrush and instructs them to brush their teeth.
Resident D then completes the task of brushing their teeth.
Coding: GG0130B would be coded 04, Supervision or touching assistance.
Rationale: The helper provides verbal cues to assist the resident in completing the

activity of brushing their teeth.
October 2024

Page GG-24

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Coding Tips for GG0130C, Toileting hygiene
•

Toileting hygiene (managing clothing and perineal cleansing) takes place before and after
use of the toilet, commode, bedpan, or urinal. If the resident completes a bowel toileting
program in bed, code the item Toileting hygiene based on the resident’s need for
assistance managing clothing and perineal cleansing.

•

Includes:
o Performing perineal hygiene.

o Managing clothing (including undergarments and incontinence products, such as
incontinence briefs or pads) before and after voiding or having a bowel movement.

o Adjusting clothing relevant to the individual resident.

•

If the resident has an indwelling urinary catheter and has bowel movements, code the
Toilet hygiene item based on the amount of assistance needed by the resident before and
after moving their bowels.
When the resident requires different levels of assistance to perform toileting hygiene after
voiding versus after a bowel movement, code based on the type and amount of assistance
required to complete the ENTIRE activity.

•

If a resident manages an ostomy, toileting hygiene includes wiping the opening of the
ostomy or colostomy bag, but not management of the equipment.

•

If a resident has an indwelling catheter, toileting hygiene includes perineal hygiene to the
indwelling catheter site, but not management of the equipment.

•

o For example, if the resident has an indwelling urinary catheter and has bowel
movements, code Toileting hygiene based on the type and amount of assistance
needed by the resident before and after moving their bowels. This may include the
need to perform perineal hygiene to the indwelling urinary catheter site after the
bowel movement.

Examples for GG0130C, Toileting hygiene

1. Toileting hygiene: Resident J uses a bedside commode. The certified nursing assistant
provides steadying (touching) assistance as Resident J pulls down their pants and underwear
before sitting down on the commode. When Resident J is finished voiding or having a bowel
movement, the certified nursing assistant provides steadying assistance as Resident J wipes
their perineal area and pulls up their pants and underwear without assistance.
Coding: GG0130C would be coded 04, Supervision or touching assistance.
Rationale: The helper provides steadying (touching) assistance to the resident to

complete toileting hygiene.

October 2024

Page GG-25

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
2. Toileting hygiene: Resident J is morbidly obese and has a diagnosis of debility. They
request the use of a bedpan when voiding or having bowel movements and require two
certified nursing assistants to pull down their pants and underwear and mobilize them onto
and off the bedpan. Resident J is unable to complete any of their perineal/perianal hygiene.
Both certified nursing assistants help Resident J pull up their underwear and pants.
Coding: GG0130C would be coded 01, Dependent.
Rationale: The assistance of two helpers was needed to complete the activity of

toileting hygiene.

3. Toileting hygiene: Resident C has Parkinson’s disease and significant tremors that cause
intermittent difficulty for them to perform perineal hygiene after having a bowel movement
in the toilet. They walk to the bathroom with close supervision and lower their pants, but ask
the certified nursing assistant to help them with perineal hygiene after moving their bowels.
They then pull up their pants without assistance.
Coding: GG0130C would be coded 03, Partial/moderate assistance.
Rationale: The helper provides less than half the effort. The resident performs two of

the three toileting hygiene tasks by themself. Walking to the bathroom is not considered
when scoring toileting hygiene.

4. Toileting hygiene: Resident Q has a progressive neurological disease that affects their fine
and gross motor coordination, balance, and activity tolerance. They wear a hospital gown and
underwear during the day. Resident Q uses a bedside commode as they steady themself in
standing with one hand and initiates pulling down their underwear with the other hand but
need assistance to complete this activity due to their coordination impairment. After voiding,
Resident Q wipes their perineal area without assistance while sitting on the commode. When
Resident Q has a bowel movement, a certified nursing assistant performs perineal hygiene as
Resident Q needs to steady themself with both hands to stand for this activity. Resident Q is
usually too fatigued at this point and requires full assistance to pull up their underwear.

Coding: GG0130C would be coded 02, Substantial/maximal assistance.
Rationale: The helper provided more than half the effort needed for the resident to

complete the activity of toileting hygiene.

Coding Tips for GG0130E, Shower/bathe self
•

Shower/bathe self includes the ability to wash, rinse, and dry the face, upper and lower
body, perineal area, and feet. Do not include washing, rinsing, and drying the resident’s
back or hair. Shower/bathe self does not include transferring in/out of a tub/shower.

•

Assessment of Shower/bathe self can take place in any location including a shower or
bath or at a sink or in bed (i.e., full body sponge bath). Bathing can be assessed with the
resident seated on a tub bench.

•

Code 05, Setup or clean-up assistance, if the resident can complete bathing tasks only
after a helper retrieves or sets up supplies necessary to perform the included tasks.

October 2024

Page GG-26

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
•

Code 05, Setup or clean-up assistance, if the only help the resident requires is assistance
before the bathing activity to cover wounds or devices for water protection during
bathing.

•

If the resident cannot bathe their entire body because of a medical condition (e.g., a cast
or a nonremovable dressing), then code Shower/bathe self based on the amount of
assistance needed to complete the activity.

Examples for GG0130E, Shower/bathe self

1. Shower/bathe self: Resident J sits on a tub bench as they wash, rinse, and dry themself. A
certified nursing assistant stays with them to ensure their safety, as Resident J has had
instances of losing their sitting balance. The certified nursing assistant also provides lifting
assistance as Resident J gets onto and off of the tub bench.
Coding: GG0130E would be coded 04, Supervision or touching assistance.
Rationale: The helper provides supervision as Resident J washes, rinses, and dries

themself. The transfer onto or off of the tub bench is not considered when coding the
Shower/bathe self activity.

2. Shower/bathe self: Resident E has a severe and progressive neurological condition that has
affected their endurance as well as their fine and gross motor skills. They are transferred to
the shower bench with partial/moderate assistance. Resident E showers while sitting on a
shower bench and washes their arms and chest using a wash mitt. A certified nursing
assistant then must help wash the remaining parts of their body, as a result of Resident E’s
fatigue, to complete the activity. Resident E uses a hand-held showerhead to rinse themself
but tires halfway through the task. The certified nursing assistant dries Resident E’s entire
body.

Coding: GG0130E would be coded 02, Substantial/maximal assistance.
Rationale: The helper assists Resident E with more than half of the task of

showering, which includes bathing, rinsing, and drying their body. The transfer onto the
shower bench is not considered in coding this activity.

3. Shower/bathe self: Resident Y has limited mobility resulting from their multiple and
complex medical conditions. They prefer to wash their body while sitting in front of the sink
in their bathroom. A helper assists with washing, rinsing, and drying Resident Y’s
arms/hands, upper legs, lower legs, buttocks, and back.
Coding: GG0130E would be coded 02, Substantial/maximal assistance.
Rationale: The helper completed more than half the activity. Bathing may occur at

the sink. When coding this activity, do not include assistance provided with washing,
rinsing, or drying the resident’s back.

October 2024

Page GG-27

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Coding Tips for GG0130F, Upper body dressing, GG0130G, Lower
body dressing, and GG0130H, Putting on/taking off footwear
•

For upper body dressing, lower body dressing, and putting on/taking off footwear, if the
resident dresses themself and a helper retrieves or puts away the resident’s clothing, then
code 05, Setup or clean-up assistance.

•

If donning and doffing an elastic bandage, elastic stockings, or an orthosis or prosthesis
occurs while the resident is dressing/undressing, then count the elastic bandage/elastic
stocking/orthotic/prosthesis as a piece of clothing when determining the amount of
assistance the resident needs when coding the dressing item.

•

The following items are considered a piece of clothing when coding the dressing items:

o Upper body dressing examples: thoracic-lumbar-sacrum orthosis (TLSO), abdominal
binder, back brace, stump sock/shrinker, upper body support device, neck support,
hand or arm prosthetic/orthotic.
o Lower body dressing examples: knee brace, elastic bandage, stump sock/shrinker,
lower-limb prosthesis.

o Footwear examples: ankle-foot orthosis (AFO), elastic bandages, foot orthotics,
orthopedic walking boots, compression stockings (considered footwear because of
dressing don/doff over foot).
Upper body dressing items used for coding include bra, undershirt, T-shirt, button-down
shirt, pullover shirt, dresses, sweatshirt, sweater, nightgown (not hospital gown), and
pajama top. Upper body dressing cannot be assessed based solely on donning/doffing a
hospital gown.

•

If a resident requires assistance with dressing, including assistance with buttons, fasteners
and/or fastening a bra, code based on the type and amount of assistance required to
complete the entire dressing activity.

•

Lower body dressing items used for coding include underwear, incontinence brief, slacks,
shorts, capri pants, pajama bottoms, and skirts.

•

Footwear dressing items used for coding include socks, shoes, boots, and running shoes.

•

For residents with bilateral lower extremity amputations with or without use of
prostheses, the activity of putting on/taking off footwear may not occur. For example, the
socks and shoes may be attached to the prosthesis associated with the upper or lower leg.

•

o If the resident performed the activity of putting on/taking off footwear immediately
prior to the current illness, exacerbation, or injury, code as 88, Not attempted due to
medical condition or safety concerns.

October 2024

Page GG-28

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
o If the resident did not perform the activity of putting on/taking off footwear
immediately prior to the current illness, exacerbation, or injury because the resident
had bilateral lower-extremity amputations and the activity of putting on/taking off
footwear was not performed during the assessment period, code as 09, Not applicable
- Not attempted and the resident did not perform this activity prior to the current
illness, exacerbation, or injury.
•

For residents with a single lower extremity amputation with or without use of a
prosthesis, the activity of putting on/taking off footwear could apply to the intact limb or
both the limb with the prosthesis and the intact limb.

o If the resident performed the activity of putting on/taking off footwear for the intact
limb only, then code based upon the amount of assistance needed to complete the
activity.
o If the resident performed the activity of putting on/taking off footwear for both the
intact limb and the prosthetic limb, then code based upon the amount of assistance
needed to complete the activity.

Examples for GG0130F, Upper body dressing

1. Upper body dressing: Resident Y has right-side upper extremity weakness as a result of a
stroke and has worked in therapy to relearn how to dress their upper body. During the day,
they require a certified nursing assistant only to place their clothing next to their bedside.
Resident Y can now use compensatory strategies to put on their bra and top without any
assistance. At night they remove their top and bra independently and put the clothes on the
nightstand, and the certified nursing assistant puts them away in their dresser.
Coding: GG0130F would be coded 05, Setup or clean-up assistance.
Rationale: Resident Y dresses and undresses their upper body and requires a helper

only to retrieve and put away their clothing, that is, setting up the clothing for their use.
The description refers to Resident Y as “independent” (when removing clothes), but
they need setup assistance, so they are not independent with regard to the entire activity
of upper body dressing.

2. Upper body dressing: Resident Z wears a bra and a sweatshirt most days while in the SNF.
They require assistance from a certified nursing assistant to initiate the threading of their
arms into their bra. Resident Z completes the placement of the bra over their chest. The
helper hooks the bra clasps. Resident Z pulls the sweatshirt over their arms, head, and trunk.
When undressing, Resident Z removes the sweatshirt, with the helper assisting them with one
sleeve. Resident Z slides the bra off, once it has been unclasped by the helper.
Coding: GG0130F would be coded 03, Partial/moderate assistance.
Rationale: The helper provides assistance with threading Resident Z’s arms into their

bra and hooking and unhooking their bra clasps and assistance with removing one
sleeve of the sweatshirt. Resident Z performs more than half of the effort.

October 2024

Page GG-29

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
3. Upper body dressing: Resident K sustained a spinal cord injury that has affected both
movement and strength in both upper extremities. They place their left hand into one-third of
their left sleeve of their shirt with much time and effort and are unable to continue with the
activity. A certified nursing assistant then completes the remaining upper body dressing for
Resident K.
Coding: GG0130F would be coded 02, Substantial/maximal assistance.
Rationale: Resident K can perform a small portion of the activity of upper body

dressing but requires assistance by a helper for more than half of the effort of upper
body dressing.

Examples for GG0130G, Lower body dressing

1. Lower body dressing: Resident D is required to follow hip precautions as a result of recent
hip surgery. The occupational therapist in the acute care hospital instructed them in the use of
adaptive equipment to facilitate lower body dressing. They require a helper to retrieve their
clothing from the closet. Resident D uses their adaptive equipment to assist in threading their
legs into their pants. Because of balance issues, Resident D needs the helper to steady them
when standing to manage pulling on or pulling down their pants/undergarments. Resident D
also needs some assistance to put on and take off their socks and shoes.
Coding: GG0130G would be coded 04, Supervision or touching assistance.
Rationale: A helper steadies Resident D when they are standing and performing the

activity of lower body dressing, which is supervision or touching assistance. Putting on
and taking off socks and shoes is not considered when coding lower body dressing.
2.

Lower body dressing: Resident M has severe rheumatoid arthritis and multiple fractures
and sprains due to a fall. They have been issued a knee brace, to be worn during the day.
Resident M threads their legs into their garments and pulls up and down their clothing to
and from just below their hips. Only a little assistance from a helper is needed to pull up
their garments over their hips. Resident M requires the helper to fasten their knee brace
because of grasp and fine motor weakness.
Coding: GG0130G would be coded 03, Partial/moderate assistance.
Rationale: A helper provides only a little assistance when Resident M is putting on

their lower extremity garments and fastening the knee brace. The helper provides less
than half of the effort. Assistance putting on and removing the knee brace they wear is
considered when determining the help needed when coding lower body dressing.

October 2024

Page GG-30

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
3. Lower body dressing: Resident R has peripheral neuropathy in their upper and lower
extremities. Each morning, Resident R needs assistance from a helper to place their lower
limb into, or to take it out of (don/doff), their lower limb prosthesis. They need no assistance
to put on and remove their underwear or slacks.
Coding: GG0130G would be coded 03, Partial/moderate assistance.
Rationale: A helper performs less than half the effort of lower body dressing (with a

prosthesis considered a piece of clothing). The helper lifts, holds, or supports
Resident R’s trunk or limbs, but provides less than half the effort for the task of lower
body dressing.

Examples for GG0130H, Putting on/taking off footwear

1. Putting on/taking off footwear: Resident M is undergoing rehabilitation for right-side upper
and lower body weakness following a stroke. They have made significant progress toward
their independence and will be discharged to home tomorrow. Resident M wears an anklefoot orthosis that they put on their foot and ankle after they put on their socks but before they
put on their shoes. They always place their AFO, socks, and shoes within easy reach of their
bed. While sitting on the bed, they need to bend over to put on and take off their AFO, socks,
and shoes, and they occasionally lose their sitting balance, requiring staff to place their hands
on them to maintain their balance while performing this task.
Coding: GG0130H would be coded 04, Supervision or touching assistance.
Rationale: Resident M puts on and takes off their AFO, socks, and shoes by themself;

however, because of occasional loss of balance, they need a helper to provide touching
assistance when they are bending over.

2. Putting on/taking off footwear: Resident F was admitted to the SNF for a neurologic
condition and experiences visual impairment and fine motor coordination and endurance
issues. They require setup for retrieving their socks and shoes, which they prefer to keep in
the closet. Resident F often drops their shoes and socks as they attempt to put them onto their
feet or as they take them off. Often a certified nursing assistant must first thread their socks
or shoes over their toes, and then Resident F can complete the task. Resident F needs the
certified nursing assistant to initiate taking off their socks and unstrapping the fasteners on
their shoes.
Coding: GG0130H would be coded 02, Substantial/maximal assistance.
Rationale: A helper provides Resident F with assistance in initiating putting on and

taking off their footwear because of their limitations regarding fine motor coordination
when putting on/taking off footwear. The helper completes more than half of the effort
with this activity.

October 2024

Page GG-31

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Coding Tips for GG0130I, Personal hygiene
•

Complete GG0130I when A0310A = 01 – 06 or A0310F = 10 or 11.

•

Personal hygiene involves the ability to maintain personal hygiene, including combing
hair, shaving, applying makeup, and washing and drying face and hands (excludes baths,
showers, and oral hygiene).

Examples for GG0130I, Personal hygiene

1. A certified nursing assistant takes Resident L’s comb, razor, and shaving cream from the
drawer and places them at the bathroom sink. Resident L combs their hair and shaves daily.
During the observation period, they required cueing to complete their shaving tasks.
Coding: GG01301 would be coded 04, Supervision or touching assistance.
Rationale: A certified nursing assistant placed grooming devices at sink for the
resident’s use and provided cueing during the observation period.

2. Resident J is unable to brush and style their hair or wash and dry their face due to elbow pain.
A certified nursing assistant completes these tasks for them.
Coding: GG0130I would be coded 02, Substantial/moderate assistance.
Rationale: Resident J was unable to complete their personal hygiene and required a
certified nursing assistant to complete their personal hygiene tasks during the assessment
period. The certified nursing assistant provided more than half the effort to complete the
personal hygiene tasks.

October 2024

Page GG-32

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0130: Self-Care (cont.)
Examples of Probing Conversations with Staff
1. Eating: Example of a probing conversation between a nurse and a certified nursing assistant
regarding the resident’s eating abilities:
Nurse: “Please describe to me how Resident S eats their meals. Once the food and liquid
are presented to them, do they use utensils to bring food to their mouth and swallow?”
Certified nursing assistant: “No, I have to feed them.”
Nurse: “Do you always have to physically feed them or can they sometimes do some
aspect of the eating activity with encouragement or cues to feed themself?”

Certified nursing assistant: “No, they can’t do anything by themself. I scoop up each
portion of the food and bring the fork or spoon to their mouth. I try to encourage them to
feed themself or to help guide the spoon to their mouth but they can’t hold the fork. I
even tried encouraging them to eat food they could pick up with their fingers, but they
will not eat unless they are completely assisted for food and liquid.”

In this example, the nurse inquired specifically how Resident S requires assistance to eat their
meals. The nurse asked about instructions and physical assistance. If this nurse had not asked
probing questions, they may not have received enough information to make an accurate
assessment of the assistance Resident S received. Accurate coding is important for reporting
on the type and amount of care provided. Be sure to consider each activity definition fully.
Coding: GG0130A would be coded 01, Dependent.
Rationale: The resident requires complete assistance from the certified nursing

assistant to eat their meals.

2. Oral hygiene: Example of a probing conversation between a nurse determining a resident’s
oral hygiene score and a certified nursing assistant regarding the resident’s oral hygiene
routine:

Nurse: “Does Resident K help with brushing their teeth?”

Certified nursing assistant: “They can help clean their teeth.”
Nurse: “How much help do they need to brush their teeth?”

Certified nursing assistant: “They usually get tired after starting to brush their upper
teeth. I have to brush most of their teeth.”

In this example, the nurse inquired specifically how Resident K manages their oral hygiene.
The nurse asked about physical assistance and how the resident performed the activity. If this
nurse had not asked probing questions, they would not have received enough information to
make an accurate assessment of the actual assistance Resident K received.

Coding: GG0130B would be coded 02, Substantial/maximal assistance.
Rationale: The certified nursing assistant provides more than half the effort to complete

Resident K’s oral hygiene.

October 2024

Page GG-33

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (3-day assessment period) Admission

D
October 2024

Page GG-34

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (3-day assessment period) Admission (cont.)

D
October 2024

Page GG-35

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (3-day assessment period) Discharge

D
October 2024

Page GG-36

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (3-day assessment period) Discharge (cont.)

D
October 2024

Page GG-37

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (OBRA/Interim)

D
October 2024

Page GG-38

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (OBRA/Interim) (cont.)

D
October 2024

Page GG-39

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Item Rationale
•

Residents may have mobility limitations on admission. In addition, residents may be at
risk of further functional decline during their stay in the facility. Please review the item
rationale for GG0130, Self-Care, for additional information about the importance of
assessing ADLs, including information about health-related quality of life and planning
for care.

Steps for Assessment

1. Assess the resident’s mobility performance based on direct
observation, incorporating resident self-reports and reports from
qualified clinicians, care staff, or family documented in the
resident’s medical record during the assessment period. CMS
anticipates that a multidisciplinary team of qualified clinicians
is involved in assessing the resident during the assessment
period.
•

•

USUAL PERFORMANCE
A resident’s functional status
can be impacted by the
environment or situations
encountered 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 functional status. 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.

For residents in a Medicare Part A stay, the admission
assessment period is the first 3 days of the Part A stay
starting with the date in A2400B, the Start of Most Recent
Medicare Stay. The admission assessment period for
residents who are not in a Medicare Part A stay is the first 3
days of their stay starting with the date in A1600, Entry
Date.

DEFINITION

Note: If A0310B = 01 and A0310A = 01 – 06 indicating
a 5-day PPS assessment combined with an OBRA
assessment, the assessment period is the first 3 days of
the stay beginning on A2400B and both columns are
required. In these scenarios, do not complete Column 5.
OBRA/Interim Performance.

•

For residents in a Medicare Part A stay, the assessment
period for the Interim Payment Assessment (A0310B = 08)
is the last 3 days (i.e., the ARD plus 2 previous calendar days).

•

For residents in a Medicare Part A stay, the discharge assessment period is the End Date
of Most Recent Medicare Stay (A2400C) plus 2 previous calendar days. For all other
Discharge assessments, the assessment period is A2000, Discharge Date plus 2 previous
calendar days.

•

When completing an OBRA-required assessment other than an Admission assessment
(i.e., A0310A = 02 – 06), the assessment period is the ARD plus 2 previous calendar
days.

2. Residents should be allowed to perform activities as independently as possible, as long as
they are safe.

October 2024

Page GG-40

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
3. For the purposes of completing Section GG, a “helper” is defined as facility staff who are
direct employees and facility-contracted employees (e.g., rehabilitation staff, nursing agency
staff). Thus, does not include individuals hired, compensated or not, by individuals outside of
the facility’s management and administration, such as hospice staff, nursing/certified nursing
assistant students, etc. Therefore, when helper assistance is required because a resident’s
performance is unsafe or of poor quality, only consider facility staff when scoring according
to amount of assistance provided.
4. Activities may be completed with or without assistive device(s). Use of assistive device(s) to
complete an activity should not affect coding of the activity.

5. For residents in a Medicare Part A stay, the admission functional assessment, when possible,
should be conducted prior to the resident benefitting from treatment interventions in order to
reflect the resident’s true admission baseline functional status. If treatment has started, for
example, on the day of admission, a baseline functional status assessment can still be
conducted. Treatment should not be withheld in order to conduct the functional assessment.
6. Refer to facility, Federal, and State policies and procedures to determine which SNF staff
members may complete an assessment. Resident assessments are to be done in compliance
with facility, Federal, and State requirements.

•

•
•

•

When coding the resident’s usual performance, use the six-point scale, or one of the four
“activity was not attempted” codes (07, 09, 10, and 88), to specify the reason why an
activity was not attempted.
Code 06, Independent: if the resident completes the activity by themself with no

assistance from a helper.

Code 05, Setup or clean-up assistance: if the helper sets up or cleans up;

resident completes activity. Helper assists only prior to or following the activity, but not
during the activity. For example, the resident requires placement of a bed rail to facilitate
rolling, or requires setup of a leg lifter or other assistive devices.

•

Coding Instructions

Code 04, Supervision or touching assistance: if the helper provides verbal

cues or touching/steadying/contact guard assistance as resident completes activity.
Assistance may be provided throughout the activity or intermittently. For example, the
resident requires verbal cueing, coaxing, or general supervision for safety to complete the
activity; or resident may require only incidental help such as contact guard or steadying
assistance during the activity.
Code 03, Partial/moderate assistance: if the helper does LESS THAN HALF

the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the
effort. For example, the resident requires assistance such as partial weight-bearing
assistance, but HELPER does LESS THAN HALF the effort.

October 2024

Page GG-41

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
•

Code 02, Substantial/maximal assistance: if the helper does MORE THAN

•

Code 01, Dependent: if the helper does ALL of the effort. Resident does none of the

•

Code 07, Resident refused: if the resident refused to complete the activity.

•

Code 09, Not applicable: if the activity was not attempted and the resident did not

•

Code 10, Not attempted due to environmental limitations: if the resident

•

Code 88, Not attempted due to medical condition or safety concerns: if

•

For additional information on coding the resident’s performance on the assessment
instrument, refer to the Decision Tree on page GG-18.

HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the
effort.

effort to complete the activity. Or the assistance of two or more helpers is required for the
resident to complete the activity.

perform this activity prior to the current illness, exacerbation, or injury.

did not attempt this activity due to environmental limitations. Examples include lack of
equipment and weather constraints.
the activity was not attempted due to medical condition or safety concerns.

Coding Tips
•

Admission: The 5-Day PPS assessment (A0310B = 01) is the first Medicare-required
assessment to be completed when the resident is admitted for a SNF Part A stay.
Additionally, an OBRA Admission assessment (A0310A = 1) is required for a new
resident and, under some circumstances, a returning resident and must be completed by
the end of day 14. Please refer to Section 2.6 of this Manual for additional information
about the OBRA Admission assessment.
For the 5-Day PPS assessment, code the resident’s functional status based on a
clinical assessment of the resident’s performance that occurs soon after the resident’s
admission. This functional assessment must be completed within the first three days
(3 calendar days) of the Medicare Part A stay, starting with the date in A2400B, Start
of Most Recent Medicare Stay, and the following two days, ending at 11:59 PM on
day 3. The admission function scores are to reflect the resident’s admission baseline
status and are to be based on an assessment. The scores should reflect the resident’s
status prior to any benefit from interventions. The assessment should occur prior to
the resident benefitting from treatment interventions in order to determine the
resident’s true admission baseline status. Even if treatment started on the day of
admission, a baseline functional status assessment can still be conducted. Treatment
should not be withheld in order to conduct the functional assessment.

•

For an OBRA Admission assessment, code the resident’s usual performance during
first 3 days of their stay starting with the date in A1600, Entry Date.

•

October 2024

Page GG-42

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
•

OBRA/Interim:
The Interim Payment Assessment (IPA) (A0310B = 08) is an optional assessment that
may be completed by providers in order to report a change in the resident’s PDPM
classification.

•

OBRA assessments (A0310A = 01 – 06) are required for residents in Medicarecertified, Medicaid-certified, or dually certified nursing homes and are outlined in
Chapter 2 of this Manual.

•

For Section GG on the IPA or an OBRA assessment, providers will use the same 6point scale and activity not attempted codes to assess the resident’s usual functional
status during the 3-day assessment period.

•

For Section GG on OBRA assessments other than the Admission assessment (i.e.,
A0310A = 02 – 06), the assessment period is the last 3 days (i.e., the ARD plus 2
previous calendar days).

•

Discharge: The Part A PPS Discharge assessment is required to be completed as a
standalone assessment when the resident’s Medicare Part A stay ends (as documented in
A2400C, End of Most Recent Medicare Stay) and the resident remains in the facility. The
Part A PPS Discharge assessment must be combined with an OBRA Discharge if the
Medicare Part A stay ends on the day of, or one day before, the resident’s Discharge Date
(A2000). An OBRA Discharge assessment is required when the resident is discharged
from the facility. Please see Chapter 2 and Section A of the RAI Manual for additional
details regarding Discharge assessments.

•

For the Discharge assessment, (i.e., standalone Part A PPS or combined OBRA/Part
A PPS), code the resident’s discharge functional status, based on a clinical assessment
of the resident’s performance that occurs as close to the time of the resident’s
discharge from Medicare Part A as possible. This functional assessment must be
completed within the last three calendar days of the resident’s Medicare Part A stay,
which includes the day of discharge from Medicare Part A and the two days prior to
the day of discharge from Medicare Part A.

•

October 2024

Page GG-43

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Coding Tips
General Coding Tips
When reviewing the medical record, interviewing staff, and observing the resident, be
familiar with the definition for each activity. For example, when assessing GG0170J,
Walk 50 feet with two turns, determine the type and amount of assistance required as the
resident walks 50 feet and negotiates two turns.

•

An activity can be completed independently with or without devices. If the resident has
adaptive equipment, retrieves the equipment without assistance, and performs the activity
independently using the device, enter code 06, Independent.

•

If two or more helpers are required to assist the resident to complete the activity, code as
01, Dependent.

•

To clarify your own understanding and observations about a resident’s performance of an
activity, ask probing questions, beginning with the general and proceeding to the more
specific. See examples of using probes when talking with staff at the end of this section.

•

A dash (“-”) indicates “No information.” CMS expects dash use to be a rare occurrence.

•

Documentation in the medical record is used to support assessment coding of Section GG
and should be consistent with the clinical assessment documentation in the resident’s
medical record. This assessment can be conducted by appropriate healthcare personnel as
defined by facility policy and in accordance with local, State, and Federal regulations.

•

October 2024

•

Page GG-44

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Tips for Coding the Resident’s Usual Performance
When coding the resident’s usual performance, “effort” refers to the type and amount of
assistance a helper provides in order for the activity to be completed. The six-point rating
scale definitions include the following types of assistance: setup/cleanup, touching
assistance, verbal cueing, and lifting assistance.

•

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 during the assessment
period.

•

Code based on the resident’s performance. Do not record the staff’s assessment of the
resident’s potential capability to perform the activity.

•

If the resident performs the activity more than once during the assessment period and the
resident’s performance varies, coding in Section GG is based on the resident’s “usual
performance,” which is identified as the resident’s usual activity/performance for any of
the Self-Care or Mobility activities, not the most independent or dependent performance
over the assessment period. A provider may need to use the entire assessment period to
obtain the resident’s usual performance.

•

October 2024

Page GG-45

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Examples and Coding Tips
Note: The following are coding examples and coding tips for mobility items. Some examples
describe a single observation of the person completing the activity; other examples describe a
summary of several observations of the resident completing an activity across different times of
the day and different days.

Coding Tip for GG0170A, Roll left and right
•

If the resident does not sleep in a bed, clinicians should assess bed mobility activities
using the alternative furniture on which the resident sleeps (for example, a recliner).

Examples for GG0170A, Roll left and right

1. Roll left and right: Resident R has a history of skin breakdown. A nurse instructs them to
turn onto their right side, providing step-by-step instructions to use the bedrail, bend their left
leg, and then roll onto their right side. Resident R attempts to roll with the use of the bedrail,
but indicates they cannot perform the task. The nurse then rolls them onto their right side.
Next, Resident R is instructed to return to lying on their back, which they successfully
complete. Resident R then requires physical assistance from the nurse to roll onto their left
side and to return to lying on their back to complete the activity.
Coding: GG0170A would be coded 02, Substantial/maximal assistance.
Rationale: The nurse provides more than half of the effort needed for the resident to

complete the activity of rolling left and right. This is because the nurse provides physical
assistance to move Resident R’s body weight to turn onto their right side. The nurse
provides the same assistance when Resident R turns to their left side and when they return
to their back. Resident R is able to return to lying on their back from their right side by
themself.

2. Roll left and right: A physical therapist helps Resident K turn onto their right side by
instructing them to bend their left leg and roll onto their right side. The physical therapist
then instructs them on how to position their limbs to return to lying on their back and then to
repeat a similar process for rolling onto their left side and then return to lying on their back.
Resident K completes the activity without physical assistance from the physical therapist.

Coding: GG0170A would be coded 04, Supervision or touching assistance.
Rationale: The physical therapist provides verbal cues (i.e., instructions) to Resident K

as they roll from their back to their right side and return to lying on their back, and then
again as they perform the same activities with respect to their left side. The physical
therapist does not provide any physical assistance.

October 2024

Page GG-46

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
3. Roll left and right: Resident Z had a stroke that resulted in paralysis on their right side and
is recovering from cardiac surgery. They require the assistance of two certified nursing
assistants when rolling onto their right side and returning to lying on their back and also
when rolling onto their left side and returning to lying on their back.
Coding: GG0170A would be coded 01, Dependent.
Rationale: Two certified nursing assistants are needed to help Resident Z roll onto their

left and right side and back while in bed.

4. Roll left and right: Resident M fell and sustained left shoulder contusions and a fractured
left hip and underwent an open reduction internal fixation of the left hip. A physician’s order
allows them to roll onto their left hip as tolerated. A certified nursing assistant assists
Resident M in rolling onto their right side by instructing them to bend their left leg while
rolling to their right side. Resident M needs physical assistance from the certified nursing
assistant to initiate their rolling right because of their left arm weakness when grasping the
right bedrail to assist in rolling. Resident M returns to lying on their back without assistance
and uses their right arm to grasp the left bedrail to slowly roll onto their left hip and then
return to lying on their back.

Coding: GG0170A would be coded 03, Partial/moderate assistance.
Rationale: The helper provides less than half the effort needed for the resident to

complete the activity of rolling left and right.

Examples for GG0170B, Sit to lying

1. Sit to lying: Resident H requires assistance from a nurse to transfer from sitting at the edge
of the bed to lying flat on the bed because of paralysis on their right side. The helper lifts and
positions Resident H’s right leg. Resident H uses their arms to position their upper body and
lowers themself to a lying position flat on their back.

Coding: GG0170B would be coded 03, Partial/moderate assistance.
Rationale: A helper lifts Resident H’s right leg and helps them position it as they move

from a seated to a lying position; the helper performs less than half of the effort.

2. Sit to lying: Resident F requires assistance from a certified nursing assistant to get from a
sitting position to lying flat on the bed because of postsurgical open reduction internal
fixation healing fractures of their right hip and left and right wrists. The certified nursing
assistant cradles and supports their trunk and right leg to transition Resident F from sitting at
the side of the bed to lying flat on the bed. Resident F assists themself a small amount by
bending their elbows and left leg while pushing their elbows and left foot into the mattress
only to straighten their trunk while transitioning into a lying position.
Coding: GG0170B would be coded 02, Substantial/maximal assistance.
Rationale: The helper provided more than half the effort for the resident to complete

the activity of sit to lying.

October 2024

Page GG-47

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
3. Sit to lying: Resident H requires assistance from two certified nursing assistants to transfer
from sitting at the edge of the bed to lying flat on the bed due to paralysis on their right side,
obesity, and cognitive limitations. One of the certified nursing assistants explains to
Resident H each step of the sitting to lying activity. Resident H is then fully assisted to get
from sitting to a lying position on the bed. Resident H makes no attempt to assist when asked
to perform the incremental steps of the activity.
Coding: GG0170B would be coded 01, Dependent.
Rationale: The assistance of two certified nursing assistants was needed to complete

the activity of sit to lying. If two or more helpers are required to assist the resident to
complete an activity, code as 01, Dependent.

4. Sit to lying: Resident F had a stroke about 2 weeks ago and is unable to sequence the
necessary movements to complete an activity (apraxia). They can maneuver themself when
transitioning from sitting on the side of the bed to lying flat on the bed if the certified nursing
assistant provides verbal instructions as to the steps needed to complete this task.
Coding: GG0170B would be coded 04, Supervision or touching assistance.
Rationale: A helper provides verbal cues in order for the resident to complete the

activity of sit to lying flat on the bed.

5. Sit to lying: Resident A suffered multiple vertebral fractures due to a fall off a ladder. They
require assistance from a therapist to get from a sitting position to lying flat on the bed
because of significant pain in their lower back. The therapist supports their trunk and lifts
both legs to assist Resident A from sitting at the side of the bed to lying flat on the bed.
Resident A assists themself a small amount by raising one leg onto the bed and then bending
both knees while transitioning into a lying position.
Coding: GG0170B would be coded 02, Substantial/maximal assistance.
Rationale: The helper provided more than half the effort for the resident to complete

the activity of sit to lying.

Coding Tips for GG0170C, Lying to sitting on side of bed
•

The activity includes resident transitions from lying on their back to sitting on the side of
the bed without back support. The residents’ ability to perform each of the tasks within
this activity and how much support the residents require to complete the tasks within this
activity is assessed.

•

For item GG0170C, Lying to sitting on side of bed, clinical judgment should be used to
determine what is considered a “lying” position for a particular resident.

•

Back support refers to an object or person providing support for the resident’s back.

•

If the qualified clinician determines that bed mobility cannot be assessed because of the
degree to which the head of the bed must be elevated because of a medical condition,
then code the activities GG0170A, Roll left and right, GG0170B, Sit to lying, and
GG0170C, Lying to sitting on side of bed, as 88, Not attempted due to medical condition
or safety concern.

October 2024

Page GG-48

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Examples for GG0170C, Lying to sitting on side of bed
1. Lying to sitting on side of bed: Resident B pushes up from the bed to get themself from a
lying to a seated position. The certified nursing assistant provides steadying (touching)
assistance as Resident B scoots themself to the edge of the bed and lowers their feet onto the
floor.
Coding: GG0170C would be coded 04, Supervision or touching assistance.
Rationale: The helper provides touching assistance as the resident moves from a lying

to sitting position.

2. Lying to sitting on side of bed: Resident B pushes up on the bed to attempt to get themself
from a lying to a seated position as the occupational therapist provides much of the lifting
assistance necessary for them to sit upright. The occupational therapist provides additional
lifting assistance as Resident B scoots themself to the edge of the bed and lowers their feet to
the floor.
Coding: GG0170C would be coded 02, Substantial/maximal assistance.
Rationale: The helper provides lifting assistance (more than half the effort) as the

resident moves from a lying to sitting position.

3. Lying to sitting on side of bed: Resident P is being treated for sepsis and has multiple
infected wounds on their lower extremities. Full assistance from the certified nursing
assistant is needed to move Resident P from a lying position to sitting on the side of their bed
because they usually have pain in their lower extremities upon movement.
Coding: GG0170C would be coded 01, Dependent.
Rationale: The helper fully completed the activity of lying to sitting on the side of bed

for the resident.

4. Lying to sitting on side of bed: Resident P is recovering from Guillain-Barre Syndrome
with residual lower body weakness. The certified nursing assistant steadies Resident P’s
trunk as they get to a fully upright sitting position on the bed and lifts each leg toward the
edge of the bed. Resident P then scoots toward the edge of the bed and places both feet flat
on the floor. Resident P completes most of the effort to get from lying to sitting on the side of
the bed.
Coding: GG0170C would be coded 03, Partial/moderate assistance.
Rationale: The helper provided lifting assistance and less than half the effort for the

resident to complete the activity of lying to sitting on side of bed.

October 2024

Page GG-49

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Coding Tips for GG0170D, Sit to stand
The activity includes the resident coming to a standing position from any sitting surface.

•

If a sit-to-stand (stand assist) lift is used and two helpers are needed to assist with the sit-tostand lift, then code as 01, Dependent.

•

If a full-body mechanical lift is used to assist in transferring a resident for a chair/bed-tochair transfer, code GG0170D, Sit to stand with the appropriate “activity not attempted”
code.

•

Code as 05, Setup or clean-up assistance, if the only help a resident requires to complete the
sit-to-stand activity is for a helper to retrieve an assistive device or adaptive equipment, such
as a walker or ankle-foot orthosis.

•

Examples for GG0170D, Sit to stand
1. Sit to stand: Resident M has osteoarthritis and is recovering from sepsis. Resident M
transitions from a sitting to a standing position with the steadying (touching) assistance of the
nurse’s hand on Resident M’s trunk.

Coding: GG0170D would be coded 04, Supervision or touching assistance.
Rationale: The helper provides touching assistance only.

2. Sit to stand: Resident L has multiple healing fractures and multiple sclerosis, requiring two
certified nursing assistants to assist them to stand up from sitting in a chair.
Coding: GG0170D would be coded 01, Dependent.
Rationale: Resident L requires the assistance of two helpers to complete the activity.

3. Sit to stand: Resident B has complete tetraplegia and is currently unable to stand when
getting out of bed. They transfer from their bed into a wheelchair with assistance. The
activity of sit to stand is not attempted due to their medical condition.
Coding: GG0170D would be coded 88, Not attempted due to medical condition or

safety concerns.
Rationale: The activity is not attempted due to the resident’s diagnosis of complete
tetraplegia.

October 2024

Page GG-50

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
4. Sit to stand: Resident Z has amyotrophic lateral sclerosis with moderate weakness in their
lower and upper extremities. Resident Z has prominent foot drop in their left foot, requiring
the use of an ankle foot orthosis (AFO) for standing and walking. The certified nursing
assistant applies Resident Z’s AFO and places the platform walker in front of them;
Resident Z uses the walker to steady themself once standing. The certified nursing assistant
provides lifting assistance to get Resident Z to a standing position and must also provide
assistance to steady Resident Z’s balance to complete the activity.
Coding: GG0170D would be coded 02, Substantial/maximal assistance.
Rationale: The helper provided lifting assistance and more than half of the effort for

the resident to complete the activity of sit to stand.

5. Sit to stand: Resident R has severe rheumatoid arthritis and uses forearm crutches to
ambulate. The certified nursing assistant brings Resident R their crutches and helps them to
stand at the side of the bed. The certified nursing assistant provides some lifting assistance to
get Resident R to a standing position but provides less than half the effort to complete the
activity.
Coding: GG0170D would be coded 03, Partial/moderate assistance.
Rationale: The helper provided lifting assistance and less than half the effort for the

resident to complete the activity of sit to stand.

Coding Tips for GG0170E, Chair/bed-to-chair transfer
•

Depending on the resident’s abilities, the transfer may be a stand-pivot, squat-pivot, or a
slide board transfer.

•

For item GG0170E, Chair/bed-to-chair transfer:

o When assessing the resident moving from the chair/bed to the chair, the
assessment begins with the resident sitting at the edge of the bed (or alternative
sleeping surface) and ends with the resident sitting in a chair or wheelchair.

o When assessing the resident moving from the chair to the bed, the assessment
begins with the resident sitting in a chair or wheelchair and ends with the resident
returning to sitting at the edge of the bed (or alternative sleeping surface).

o The activities of GG0170B, Sit to lying, and GG0170C, Lying to sitting on side of
bed, are two separate activities that are not assessed as part of GG0170E.
•

If a mechanical lift is used to assist in transferring a resident for a chair/bed-to-chair
transfer and two helpers are needed to assist with the mechanical lift transfer, then code
as 01, Dependent, even if the resident assists with any part of the chair/bed-to-chair
transfer.

•

When possible, the transfer should be assessed in an environmental situation in which
taking more than a few steps would not be necessary to complete the transfer.

October 2024

Page GG-51

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Examples for GG0170E, Chair/bed-to-chair transfer
1. Chair/bed-to-chair transfer: Resident L had a stroke and currently is not able to walk. They
use a wheelchair for mobility. When Resident L gets out of bed, the certified nursing
assistant moves the wheelchair into the correct position and locks the brakes so that
Resident L can transfer into the wheelchair safely. Resident L had been observed several
other times to determine any safety concerns, and it was documented that they transfer safely
without the need for supervision. Resident L transfers into the wheelchair by themself (no
helper) after the certified nursing assistant leaves the room.
Coding: GG0170E would be coded 05, Setup or clean-up assistance.
Rationale: Resident L is not able to walk, so they transfer from their bed to a

wheelchair when getting out of bed. The helper provides setup assistance only.
Resident L transfers safely and does not need supervision or physical assistance during
the transfer.

2. Chair/bed-to-chair transfer: Resident C is sitting on the side of the bed. They stand and
pivot into the chair as the nurse provides contact guard (touching) assistance. The nurse
reports that one time Resident C only required verbal cues for safety, but usually Resident C
requires touching assistance.

Coding: GG0170E would be coded 04, Supervision or touching assistance.
Rationale: The helper provides touching assistance during the transfers.

3. Chair/bed-to-chair transfer: Resident F’s medical conditions include morbid obesity,
diabetes mellitus, and sepsis, and they recently underwent bilateral above-the-knee
amputations. Resident F requires full assistance with transfers from the bed to the wheelchair
using a lift device. Two certified nursing assistants are required for safety when using the
device to transfer Resident F from the bed to a wheelchair. Resident F is unable to assist in
the transfer from their bed to the wheelchair.

Coding: GG0170E would be coded 01, Dependent.
Rationale: The two helpers completed all the effort for the activity of chair/bed-to-chair

transfer. If two or more helpers are required to assist the resident to complete an activity,
code as 01, Dependent.

4. Chair/bed-to-chair transfer: Resident P has metastatic bone cancer, severely affecting their
ability to use their lower and upper extremities during daily activities. Resident P is
motivated to assist with their transfers from the side of their bed to the wheelchair.
Resident P pushes themself up from the bed to begin the transfer while the therapist provides
limited trunk support with weight-bearing assistance. Once standing, Resident P shuffles
their feet, turns, and slowly sits down into the wheelchair with the therapist providing trunk
support with weight-bearing assistance.
Coding: GG0170E would be coded 03, Partial/moderate assistance.
Rationale: The helper provided less than half of the effort for the resident to complete

the activity of chair/bed-to-chair transfer.

October 2024

Page GG-52

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
5. Chair/bed-to-chair transfer: Resident U had their left lower leg amputated due to gangrene
associated with their diabetes mellitus and they have reduced sensation and strength in their
right leg. They have not yet received their below-the-knee prosthesis. Resident U uses a
transfer board for chair/bed-to-chair transfers. The therapist places the transfer board under
their buttock. Resident U then attempts to scoot from the bed onto the transfer board.
Resident U has reduced sensation in their hands and limited upper body strength, but assists
with the transfer. The physical therapist assists them in side scooting by lifting their
buttocks/trunk in a rocking motion across the transfer board and into the wheelchair.
Coding: GG0170E would be coded 02, Substantial/maximal assistance.
Rationale: The helper provided more than half of the effort for the resident to complete

the activity of chair/bed-to-chair transfer.

Coding Tips for GG0170F, Toilet transfer
Toilet transfer includes the resident’s ability to get on and off a toilet (with or without a
raised toilet seat) or bedside commode.

•

Toileting hygiene, clothing management, and transferring on and off a bedpan are not
considered part of the Toilet transfer activity.

•

Code as 05, Setup or clean-up assistance, if the resident requires a helper to position/set
up the bedside commode before and/or after the resident’s bed-to-commode transfers
(place at an accessible angle/location next to the bed) and the resident does not require
helper assistance during Toilet transfers.

•

Examples for GG0170F, Toilet transfer

1. Toilet transfer: The certified nursing assistant moves the wheelchair footrests up so that
Resident T can transfer from the wheelchair onto the toilet by themself safely. The certified
nursing assistant is not present during the transfer, because supervision is not required. Once
Resident T completes the transfer from the toilet back to the wheelchair, they flip the
footrests back down themself.
Coding: GG0170F would be coded 05, Setup or clean-up assistance.
Rationale: The helper provides setup assistance (moving the footrest out of the way)

before Resident T can transfer safely onto the toilet.

October 2024

Page GG-53

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
2. Toilet transfer: The certified nursing assistant provides steadying (touching) assistance as
Resident Z lowers their underwear and then transfers onto the toilet. After voiding,
Resident Z cleanses themself. They then stand up as the helper steadies them and Resident Z
pulls up their underwear as the helper steadies them to ensure Resident Z does not lose their
balance.
Coding: GG0170F would be coded 04, Supervision or touching assistance.
Rationale: The helper provides steadying assistance as the resident transfers onto and

off the toilet. Assistance with managing clothing and cleansing is coded under item
GG0130C, Toileting hygiene and is not considered when rating the Toilet transfer item.
3. Toilet transfer: The therapist supports Resident M’s trunk with a gait belt by providing
weight-bearing as Resident M pivots and lowers themself onto the toilet.

Coding: GG0170F would be coded 03, Partial/moderate assistance.
Rationale: The helper provides less than half the effort to complete the activity. The

helper provided weight-bearing assistance as the resident transferred on and off the toilet.

4. Toilet transfer: Resident W has peripheral vascular disease and sepsis, resulting in lower
extremity pain and severe weakness. Resident W uses a bedside commode when having a
bowel movement. The certified nursing assistant raises the bed to a height that facilitates the
transfer activity. Resident W initiates lifting their buttocks from the bed and in addition
requires some of their weight to be lifted by the certified nursing assistant to stand upright.
Resident W then reaches and grabs onto the armrest of the bedside commode to steady
themself. The certified nursing assistant provides weight-bearing assistance as they slowly
rotate and lower Resident W onto the bedside commode.
Coding: GG0170F would be coded 02, Substantial/maximal assistance.
Rationale: The helper provided more than half of the effort for the resident to complete

the activity of toilet transfer.

5. Toilet transfer: Resident H has paraplegia incomplete, pneumonia, and a chronic respiratory
condition. Resident H prefers to use the bedside commode when moving their bowels. Due to
their severe weakness, history of falls, and dependent transfer status, two certified nursing
assistants assist during the toilet transfer.
Coding: GG0170F would be coded 01, Dependent.
Rationale: The activity required the assistance of two or more helpers for the resident

to complete the activity.

6. Toilet transfer: Resident S is on bedrest due to a medical complication. They use a bedpan
for bladder and bowel management.
Coding: GG0170F would be coded 88, Not attempted due to medical condition or safety

concerns.

Rationale: The resident does not transfer onto or off a toilet due to being on bedrest

because of a medical condition.

October 2024

Page GG-54

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Coding Tips for GG0170FF, Tub/shower transfer
•

Complete GG0170FF when A0310A = 01 – 06 or A0310F = 10 or 11.

•

Tub/shower transfers involve the ability to get into and out of the tub or shower. Do not
include washing, rinsing, drying, or any other bathing activities in this item.

Examples for GG0170FF, Tub/shower transfer
1. During the observation period, Resident M took one shower. They received physical help
from two staff members to get into and out of the shower.
Coding: GG0170FF would be coded 01. Dependent.
Rationale: Resident M required two staff members to assist with shower transfers

during the observation period. This represents their usual performance of this activity
during the observation period.

2. On Monday, Resident Q required trunk support from one certified nursing assistant to get
into and out of the tub. On Wednesday, day 3 of the assessment period, Resident Q required
trunk support from one certified nursing assistant to get into the tub and needed assistance
lifting their legs during the transfer out of the tub. No other tub or shower transfers occurred
during the observation period.
Coding: GG0170FF would be coded 03. Partial/moderate assistance.
Rationale: Resident Q participated in four tub transfers (two transfers into the tub and

two transfers out of the tub) during the observation period. They required trunk support
for three transfers and required the helper to lift their legs for one transfer. Because the
helper performed less than half the effort for three of the four transfers, Resident Q’s
usual performance is 03. Partial/moderate assistance.

ft
October 2024

Page GG-55

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Coding Tips for GG0170G, Car transfer
For item GG0170G, Car transfer, use of an indoor car can be used to simulate outdoor car
transfers.

•

The Car transfer does not include getting to or from the vehicle, opening/closing the car
door, or fastening/unfastening the seat belt.

•

If the resident remains in a wheelchair and does not transfer in and out of a car or van
seat, then the activity is not considered completed, and the appropriate “activity not
attempted” code would be used.

•

The setup and/or clean-up of an assistive device that is used for walking to and from the
car, but not used for the transfer in and out of the car seat, would not be considered when
coding the Car transfer activity.

•

In the event of inclement weather or if an indoor car simulator or outdoor car is not
available during the entire assessment period, then use code 10, Not attempted due to
environmental limitations.

•

If at the time of the assessment the resident is unable to attempt car transfers, and could
not perform the car transfers prior to the current illness, exacerbation or injury, code 09,
Not applicable.

•

Examples for GG0170G, Car transfer

1. Car transfer: Resident W uses a wheelchair and ambulates for only short distances. They
require lifting assistance from a physical therapist to get from a seated position in the
wheelchair to a standing position. The therapist provides trunk support when Resident W
takes several steps during the transfer turn. Resident W lowers themself into the car seat with
steadying assistance from the therapist. They lift their legs into the car with support from the
therapist.

Coding: GG0170G would be coded 02, Substantial/maximal assistance.
Rationale: Although Resident W also contributes effort to complete the activity, the

helper contributed more than half the effort needed to transfer Resident W into the car by
providing lifting assistance and trunk support.
2. Car transfer: During their rehabilitation stay Resident N works with an occupational
therapist on transfers in and out of the passenger side of a car. On the day before discharge,
when performing car transfers, Resident N requires verbal reminders for safety and light
touching assistance. The therapist instructs them on strategic hand placement while
Resident N transitions to sitting in the car’s passenger seat. The therapist opens and closes
the door.
Coding: GG0170G would be coded 04, Supervision or touching assistance.
Rationale: The helper provides touching assistance as the resident transfers into the

passenger seat of the car. Assistance with opening and closing the car door is not
included in the definition of this item and is not considered when coding this item.

October 2024

Page GG-56

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Coding Tips for GG0170I–GG0170L Walking Items
Assessment of the walking activities starts with the resident in a standing position.

•

A walking activity cannot be completed without some level of resident participation that
allows resident ambulation to occur for the entire stated distance. A helper cannot
complete a walking activity for a resident.

•

During a walking activity, a resident may take a brief standing rest break. If the resident
needs to sit to rest during a Section GG walking activity, consider the resident unable to
complete the walking activity and use the appropriate activity not attempted code.

•

Clinicians can use clinical judgment to determine how the actual resident assessment of
walking is conducted. If a clinician chooses to combine the assessment of multiple
walking activities, the clinician should use clinical judgment to determine the type and
amount of assistance needed for each individual activity.

•

Use clinical judgment when assessing activities that overlap or occur sequentially to
determine the type and amount of assistance needed for each individual activity.

•

Walking activities do not need to occur during one session. Allowing a resident to rest
between activities or completing activities at different times during the day or on
different days may facilitate completion of the activities.

•

When coding GG0170 walking items, do not consider the resident’s mobility
performance when using parallel bars. Parallel bars are not a portable assistive device. If
safe, assess and code walking using a portable walking device.

•

The turns included in item GG0170J, Walk 50 feet with two turns, are 90-degree turns.
The turns may be in the same direction (two 90-degree turns to the right or two 90-degree
turns to the left) or may be in different directions (one 90-degree turn to the left and one
90-degree turn to the right). The 90-degree turn should occur at the person’s ability level
and can include use of an assistive device (for example, cane).

•

When coding GG0170K, Walk 150 feet, if the resident’s environment does not
accommodate a walk of 150 feet without turns, but the resident demonstrates the ability
to walk, with or without assistance, 150 feet with turns without jeopardizing the
resident’s safety, code using the 6-point scale.

•

When coding GG0170L, Walking 10 feet on uneven surfaces, the activity can be assessed
inside or outside. Examples of uneven surfaces include uneven or sloping surfaces, turf,
and gravel. Use clinical judgment to determine whether a surface is uneven.

•

Examples for GG0170I, Walk 10 feet
1. Walk 10 feet: Resident C has resolving sepsis and has not walked in three weeks because of
their medical condition. A physical therapist determines that it is unsafe for Resident C to use
a walker, and the resident only walks using the parallel bars. On day 3 of the Admission
assessment period, Resident C walks 10 feet using the parallel bars while the therapist
provides substantial weight-bearing support throughout the activity.
October 2024

Page GG-57

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Coding: GG0170I would be coded 88, Not attempted due to medical condition or safety

concerns.

Rationale: When assessing a resident for GG0170 walking items, do not consider

walking in parallel bars, as parallel bars are not a portable assistive device. If the resident
is unable to walk without the use of parallel bars because of their medical condition or
safety concerns, use code 88, Activity not attempted due to medical condition or safety
concerns.
2. Walk 10 feet: Resident L had bilateral amputations three years ago, and prior to the current
admission they used a wheelchair and did not walk. Currently Resident L does not use
prosthetic devices and uses only a wheelchair for mobility. Resident L’s care plan includes
fitting and use of bilateral lower extremity prostheses.

Coding: GG0170I would be coded 09, Not applicable, not attempted and the resident did

not perform this activity prior to the current illness, exacerbation, or injury.

Rationale: When assessing a resident for GG0170I, Walk 10 feet, consider the

resident’s status prior to the current episode of care and current assessment status. Use
code 09, Not applicable, because Resident L did not walk prior to the current episode of
care and did not walk during the assessment period.

3. Walk 10 feet: Resident C has Parkinson’s disease and walks with a walker. A physical
therapist must advance the walker for Resident C with each step. The physical therapist
assists Resident C by physically initiating the stepping movement forward, advancing
Resident C’s foot, during the activity of walking 10 feet.
Coding: GG0170I would be coded 02, Substantial/maximal assistance.
Rationale: A helper provides more than half the effort as the resident completes the

activity.

4. Walk 10 feet: Resident O has bilateral upper extremity tremors, lower extremity weakness,
and Parkinson’s disease. A physical therapist assistant guides and steadies the shaking,
rolling walker forward while cueing Resident O to take larger steps. Resident O requires
steadying at the beginning of the walk and progressively requires some of their weight to be
supported for the last two feet of the 10-foot walk.
Coding: GG0170I would be coded 03, Partial/moderate assistance.
Rationale: The helper provides less than half the effort required for the resident to

complete the activity, Walk 10 feet. While the helper guided and steadied the walker
during the walk, Resident O supported their own body weight with their arms and legs and
propelled their legs forward for 8 of the 10 feet. The helper supported part of Resident O’s
weight only for 2 of the 10 feet; thus Resident O contributed more than half the effort.

October 2024

Page GG-58

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
5. Walk 10 feet: Resident U has an above-the-knee amputation and severe rheumatoid arthritis.
Once a nurse has donned their stump sock and prosthesis, Resident U is assisted to stand and
uses their rolling walker while walking. The nurse places their hand on Resident U’s back to
steady them toward the last half of their 10-foot walk.
Coding: GG0170I would be coded 04, Supervision or touching assistance.
Rationale: A helper provides touching assistance in order for the resident to complete

the activity of Walk 10 feet. Assistance in donning the stump stock, prosthesis, and
getting from a sitting to standing position is not coded as part of the Walk 10 feet item.

Examples for GG0170J, Walk 50 feet with two turns

1. Walk 50 feet with two turns: A therapist provides steadying assistance as Resident W gets
up from a sitting position to a standing position. After the therapist places Resident W’s
walker within reach, Resident W walks 60 feet down the hall with two turns without any
assistance from the therapist. No supervision is required while they walk.
Coding: GG0170J would be coded 05, Setup or clean-up assistance.
Rationale: Resident W walks more than 50 feet and makes two turns once the helper

places the walker within reach. Assistance with getting from a sitting to a standing
position is coded separately under the item GG0170D, Sit to stand (04, Supervision or
touching assistance).

2. Walk 50 feet with two turns: Resident P walks 70 feet with a quad cane, completing two
turns during the walk. The therapist provides steadying assistance only when Resident P
turns.
Coding: GG0170J would be coded 04, Supervision or touching assistance.
Rationale: The helper provides touching assistance as the resident walks more than 50

feet and makes two turns. The resident may use an assistive device.

3. Walk 50 feet with two turns: Resident L is unable to bear their full weight on their left leg.
As they walk 60 feet down the hall with their crutches and make two turns, the certified
nursing assistant supports their trunk providing weight-bearing assistance.
Coding: GG0170J would be coded 03, Partial/moderate assistance.
Rationale: The helper provides trunk support as the resident walks more than 50 feet

and makes two turns.

4. Walk 50 feet with two turns: Resident T walks 50 feet with the therapist providing trunk
support. They also require a second helper, the rehabilitation aide, who provides supervision
and follows closely behind with a wheelchair for safety. Resident T walks the 50 feet with
two turns with the assistance of two helpers.
Coding: GG0170J would be coded 01, Dependent.
Rationale: Resident T requires two helpers to complete the activity.

October 2024

Page GG-59

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
5. Walk 50 feet with two turns: Resident U has an above-the-knee amputation, severe
rheumatoid arthritis, and uses a prosthesis. Resident U is assisted to stand and, after walking
10 feet, requires progressively more help as they near the 50-foot mark. Resident U is
unsteady and typically loses their balance when turning, requiring significant support to
remain upright. The therapist provides significant trunk support for about 30 to 35 feet.
Coding: GG0170J would be coded 02, Substantial/maximal assistance.
Rationale: The helper provided more than half of the effort for the resident to complete

the activity of walk 50 feet with two turns.

Examples for GG0170K, Walk 150 feet

1. Walk 150 feet: Resident D walks down the hall using their walker and the certified nursing
assistant usually needs to provide touching assistance to Resident D, who intermittently loses
their balance while they use the walker.
Coding: GG0170K would be coded 04, Supervision or touching assistance.
Rationale: The helper provides touching assistance intermittently throughout the

activity.

2. Walk 150 feet: Resident R has endurance limitations due to heart failure and has only
walked about 30 feet during the assessment period. They have not walked 150 feet or more
during the assessment period, including with the physical therapist who has been working
with Resident R.
Coding: GG0170K would be coded 88, Not attempted due to medical condition or

safety concerns, and the resident’s ability to walk a shorter distance would be coded in
item GG0170I.
Rationale: The activity was not attempted. The resident did not complete the activity,
and a helper cannot complete the activity for the resident. A resident who walks less than
50 feet would be coded in item GG0170I, Walk 10 feet.

3. Walk 150 feet: Resident T has an unsteady gait due to balance impairment. Resident T walks
the length of the hallway using their quad cane in their right hand. The physical therapist
supports their trunk, helping them to maintain their balance while ambulating. The therapist
provides less than half of the effort to walk the 160-foot distance.
Coding: GG0170K would be coded 03, Partial/moderate assistance.
Rationale: The helper provides less than half of the effort for the resident to complete

the activity of walking at least 150 feet.

4. Walk 150 feet: Resident W, who has Parkinson’s disease, walks the length of the hallway
using their rolling walker. The physical therapist provides trunk support and advances
Resident W’s right leg in longer strides with each step. The therapist occasionally prevents
Resident W from falling as they lose their balance during the activity.

October 2024

Page GG-60

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Coding: GG0170K would be coded 02, Substantial/maximal assistance.
Rationale: The helper provides more than half the effort for the resident to complete

the activity of walk 150 feet.

Example for GG0170L, Walking 10 feet on uneven surfaces
1. Walking 10 feet on uneven surfaces: Resident N has severe joint degenerative disease and
is recovering from sepsis. Upon discharge Resident N will need to be able to walk on the
uneven and sloping surfaces of their driveway. During their SNF stay, a physical therapist
takes Resident N outside to walk on uneven surfaces. Resident N requires the therapist’s
weight-bearing assistance less than half the time during walking in order to prevent
Resident N from falling as they navigate walking 10 feet over uneven surfaces.

Coding: GG0170L would be coded 03, Partial/moderate assistance.
Rationale: Resident N requires a helper to provide weight-bearing assistance several

times to prevent them from falling as they walk 10 feet on uneven surfaces. The helper
contributes less than half the effort required for Resident N to walk 10 feet on uneven
surfaces.

Coding Tips for GG0170M, 1 step (curb); GG0170N, 4 steps; and
GG0170O, 12 steps
Completing the stair activities indicates that a resident goes up and down the stairs, by
any safe means, with or without any assistive devices (for example, railing or stair lift)
and with or without some level of assistance. Getting to and from the stairs is not
included when coding the curb or step activities.

•

Ascending and descending stairs does not have to occur sequentially or during one
session. If the assessment of going up the stairs and then down the stairs occurs
sequentially, the resident may take a standing or seated rest break between ascending and
descending the 4 steps or 12 steps.

•

If a resident requires a helper to provide total assist (for example, the resident requires
total assist from a helper to move up and down over a curb in their wheelchair), code as
01, Dependent.

•

A resident who uses a wheelchair may be assessed going up and down stairs (including
one step or curb) in a wheelchair. Code based on the type and amount of assistance
required from the helper.

•

If, at the time of the assessment, a resident is unable to complete the activity because of a
physician-prescribed restriction of no stair climbing, they may be able to complete the
stair activities safely by some other means (e.g., stair lift, bumping/scooting on their
buttocks). If so, code based on the type and amount of assistance required to complete the
activity. If, at the time of assessment, a resident is unable to complete the stair activities
because of a physician prescribed bedrest, code the stair activity using the appropriate
“activity not attempted” code.

•

October 2024

Page GG-61

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Assess the resident going up and down one step or up and down over a curb. If both are
assessed, and the resident’s performance going up and down over a curb is different from
their performance going up and down one step (e.g., because the step has a railing), code
GG0170M, 1 step (curb) based on the activity with which the resident requires the most
assistance.

•

If a resident’s environment does not have 12 steps, the combination of going up and
down 4 stairs three times consecutively in a safe manner is an acceptable alternative to
comply with the intention and meet the requirements of this activity.

•

While a resident may take a break between ascending or descending the 4 steps or 12
steps, once they start the activity, they must be able to ascend (or descend) all the steps,
by any safe means, without taking more than a brief rest break in order to consider the
stair activity completed.

•

Example for GG0170M, 1 step (curb)
1. 1 step (curb): Resident Z has had a stroke; they must be able to step up and down one step to
enter and exit their home. A physical therapist provides standby assistance as they use their
quad cane to support their balance in stepping up one step. The physical therapist provides
steadying assistance as Resident Z uses their cane for balance and steps down one step.

Coding: GG0170M would be coded 04, Supervision or touching assistance.
Rationale: A helper provides touching assistance as Resident Z completes the activity

of stepping up and down one step.

Example for GG0170N, 4 steps

1. 4 steps: Resident J has lower body weakness, and a physical therapist provides steadying
assistance when they ascend 4 steps. While descending 4 steps, the physical therapist
provides trunk support (more than touching assistance) as Resident J holds the stair railing.

Coding: GG0170N would be coded 03, Partial/moderate assistance.
Rationale: A helper provides touching assistance as Resident J ascends 4 steps. The

helper provides trunk support (more than touching assistance) when they descend the 4
steps.

Example for GG0170O, 12 steps

1. 12 steps: Resident Y is recovering from a stroke resulting in motor issues and poor
endurance. Resident Y’s home has 12 stairs, with a railing, and they need to use these stairs
to enter and exit their home. Their physical therapist uses a gait belt around their trunk and
supports less than half of the effort as Resident Y ascends and then descends 12 stairs.
Coding: GG0170O would be coded 03, Partial/moderate assistance.
Rationale: The helper provides less than half the required effort in providing the

necessary support for Resident Y as they ascend and descend 12 stairs.

October 2024

Page GG-62

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Coding Tips for GG0170P, Picking up object
The activity includes the resident bending or stooping from a standing position to pick up
a small object, such as a spoon, from the floor.

•

Picking up the object must be assessed while the resident is in a standing position. If the
resident is not able to stand, the activity did not occur, and the appropriate “not
attempted” code would be used.

•

If a standing resident is unable to pick up a small object from the floor, therefore
requiring the helper to assist in picking up the object, code as 01, 02, or 03, depending on
whether the helper is providing all the effort, more than half of the effort, or less than half
of the effort, respectively.

•

Assistive devices and adaptive equipment may be used, for example, a cane to support
standing balance and/or a reacher to pick up the object.

•

Examples for GG0170P, Picking up object

1. Picking up object: Resident P has a neurologic condition that has resulted in balance
problems. They want to be as independent as possible. Resident P lives with their spouse and
will soon be discharged from the SNF. They tend to drop objects and have been practicing
bending or stooping from a standing position to pick up small objects, such as a spoon, from
the floor. An occupational therapist needs to remind Resident P of safety strategies when
they bend to pick up objects from the floor, and the occupational therapist needs to steady
them to prevent them from falling.
Coding: GG0170P would be coded 04, Supervision or touching assistance.
Rationale: A helper is needed to provide verbal cues and touching or steadying

assistance when Resident P picks up an object because of their coordination issues.

2. Picking up object: Resident C has recently undergone a hip replacement. When they drop
items they use a long-handled reacher that they have been using at home prior to admission.
They are ready for discharge and can now ambulate with a walker without assistance. When
they drop objects from their walker basket they require a certified nursing assistant to locate
their long-handled reacher and bring it to them in order for them to use it. They do not need
assistance to pick up the object after the helper brings them the reacher.

Coding: GG0170P would be coded 05, Setup or clean-up assistance.
Rationale: The helper provides set-up assistance so that Resident C can use their long-

handled reacher.

October 2024

Page GG-63

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Coding Tips for GG0170Q, GG0170R, and GG0170S, Wheelchair Items
•

The intent of the wheelchair mobility items is to assess the ability of residents who are
learning how to self-mobilize using a wheelchair or who used a wheelchair for selfmobilization prior to admission. Use clinical judgment to determine whether a resident’s
use of a wheelchair is for self-mobilization as a result of the resident’s medical condition
or safety.

•

If the resident used a wheelchair for self-mobilization prior to admission to the facility,
indicate 1, Yes, to the gateway wheelchair items on the initial assessment in GG0170Q1.

The responses for gateway wheelchair items (GG0170Q1, GG0170Q3, and/or
GG0170Q5) do not have to be the same on subsequent assessments. For example, the
Admission assessment may indicate that the resident does not use a wheelchair but the
subsequent assessment may indicate that the resident uses a wheelchair.

•

If a wheelchair is used for transport purposes only, then GG0170Q1, GG0170Q3, and/or
GG0170Q5, Does the resident use a wheelchair or scooter? is coded as 0, No; then follow
the skip pattern to continue coding the assessment.

o Example of using a wheelchair for transport convenience: A resident is transported in
a wheelchair by staff between their room and the therapy gym or by family to the
facility cafeteria, but the resident is not expected to use a wheelchair after discharge.
The turns included in item GG0170R (wheeling 50 feet with two turns) are 90-degree
turns. The turns may be in the same direction (two 90-degree turns to the right or two 90degree turns to the left) or may be in different directions (one 90-degree turn to the left
and one 90-degree turn to the right). The 90-degree turn should occur at the person’s
ability level.

•

If a resident’s environment does not accommodate wheelchair or scooter use for 150 feet
without turns, but the resident demonstrates the ability to mobilize a wheelchair or
scooter with or without assistance for 150 feet with turns without jeopardizing the
resident’s safety, code GG0170S, Wheel 150 feet, using the 6-point scale.

•

For GG0170S, Wheel 150 feet, a helper can assist a resident in completing the required
distance in the wheelchair or in making turns if required. When a resident is unable to
wheel the entire distance themself, the activity can still be completed, and a performance
code can be determined based on the type and amount of assistance required from the
helper to complete the entire activity.

October 2024

•

Page GG-64

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
Example for GG0170Q1, Does the resident use a wheelchair/scooter?
1. Does the resident use a wheelchair/scooter? On admission, Resident T wheels themself
using a manual wheelchair, but with difficulty due to their severe osteoarthritis and COPD.
Coding: GG0170Q1 would be coded 1, Yes. The admission performance codes for

wheelchair items GG0170R and GG0170S are coded; in addition, the type of wheelchair
Resident T uses for GG0170RR1 is indicated as code 1, Manual.
Rationale: The resident currently uses a wheelchair. Coding the resident’s performance
and the type of wheelchair (manual) is indicated.

Examples for GG0170R, Wheel 50 feet with two turns, and GG0170RR,
Indicate the type of wheelchair/scooter used
1. Wheel 50 feet with two turns: Resident M is unable to bear any weight on their right leg
due to a recent fracture. The certified nursing assistant provides steadying assistance when
transferring Resident M from the bed into the wheelchair. Once in their wheelchair,
Resident M propels themself about 60 feet down the hall using their left leg and makes two
turns without any physical assistance or supervision.

Coding: GG0170R would be coded 06, Independent.
Rationale: The resident wheels themself more than 50 feet. Assistance provided with

the transfer is not considered when scoring Wheel 50 feet with two turns. There is a
separate item for scoring bed-to-chair transfers.

2. Indicate the type of wheelchair/scooter used: In the above example Resident M used a
manual wheelchair during the assessment period.
Coding: GG0170RR would be coded 1, Manual.
Rationale: Resident M used a manual wheelchair during the assessment period.

3. Wheel 50 feet with two turns: Resident R is very motivated to use their motorized
wheelchair with an adaptive throttle for speed and steering. Resident R has amyotrophic
lateral sclerosis, and moving their upper and lower extremities is very difficult. The physical
therapist assistant is required to walk next to Resident R for frequent readjustments of their
hand position to better control the steering and speed throttle. Resident R often drives too
close to corners, becoming stuck near doorways upon turning, preventing them from
continuing to mobilize/wheel themself. The physical therapist assistant backs up Resident
R’s wheelchair for them so that they may continue mobilizing/wheeling themself.
Coding: GG0170R would be coded 03, Partial/moderate assistance.
Rationale: The helper provided less than half of the effort for the resident to complete

the activity, Wheel 50 feet with two turns.

October 2024

Page GG-65

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
4. Indicate the type of wheelchair/scooter used: In the above example Resident R used a
motorized wheelchair during the assessment period.
Coding: GG0170RR would be coded 2, Motorized.
Rationale: Resident R used a motorized wheelchair during the assessment period.

5. Wheel 50 feet with two turns: Resident V had a spinal tumor resulting in paralysis of their
lower extremities. The physical therapist assistant provides verbal instruction for Resident V
to navigate their manual wheelchair in their room and into the hallway while making two
turns.
Coding: GG0170R would be coded 04, Supervision or touching assistance.
Rationale: The helper provided verbal cues for the resident to complete the activity,

Wheel 50 feet with two turns.

6. Indicate the type of wheelchair/scooter used: In the above example Resident V used a
manual wheelchair during the assessment period.
Coding: GG0170RR would be coded 1, Manual.
Rationale: Resident V used a manual wheelchair during the assessment period.

7. Wheel 50 feet with two turns: Once seated in the manual wheelchair, Resident R wheels
about 10 feet in the corridor, then asks the certified nursing assistant to push the wheelchair
an additional 40 feet turning into their room and then turning into their bathroom.
Coding: GG0170R would be coded 02, Substantial/maximal assistance.
Rationale: The helper provides more than half the effort to assist the resident to

complete the activity.

8. Indicate the type of wheelchair/scooter used: In the above example Resident R used a
manual wheelchair during the assessment period.

Coding: GG0170RR would be coded 1, Manual.
Rationale: Resident R used a manual wheelchair during the assessment period.

Examples for GG0170S, Wheel 150 feet and GG0170SS, Indicate the
type of wheelchair/scooter used

1. Wheel 150 feet: Resident G always uses a motorized scooter to mobilize themself down the
hallway and the certified nursing assistant provides cues due to safety issues (to avoid
running into the walls).
Coding: GG0170S would be coded 04, Supervision or touching assistance.
Rationale: The helper provides verbal cues to complete the activity.

2. Indicate the type of wheelchair/scooter used: In the example above, Resident G uses a
motorized scooter.
Coding: GG0170SS would be coded 2, Motorized.
Rationale: Resident G used a motorized scooter during the assessment period.
October 2024

Page GG-66

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
3. Wheel 150 feet: Resident N uses a below-the-knee prosthetic limb. Resident N has
peripheral neuropathy and limited vision due to complications of diabetes. Resident N’s prior
preference was to ambulate within the home and use a manual wheelchair when mobilizing
themself within the community. Resident N is assessed for the activity of 150 feet wheelchair
mobility. Resident N’s usual performance indicates a helper is needed to provide verbal cues
for safety due to vision deficits.
Coding: GG0170S would be coded 04, Supervision or touching assistance.
Rationale: Resident N requires the helper to provide verbal cues for their safety when

using a wheelchair for 150 feet.

4. Indicate the type of wheelchair/scooter used: In the above example Resident N used a
manual wheelchair during the assessment period.

Coding: GG0170SS would be coded 1, Manual.
Rationale: Resident N used a manual wheelchair during the assessment period.

5. Wheel 150 feet: Resident L has multiple sclerosis, resulting in extreme muscle weakness and
minimal vision impairment. Resident L uses a motorized wheelchair with an adaptive
joystick to control both the speed and steering of the motorized wheelchair. They
occasionally need reminders to slow down around the turns and require assistance from the
nurse for backing up the scooter when barriers are present.
Coding: GG0170S would be coded 03, Partial/moderate assistance.
Rationale: The helper provides less than half of the effort to complete the activity of

wheel 150 feet.

6. Indicate the type of wheelchair/scooter used: Resident L used a motorized wheelchair
during the assessment period.

Coding: GG0170SS would be coded 2, Motorized.
Rationale: Resident L used a motorized wheelchair during the assessment period.

7. Wheel 150 feet: Resident M has had a mild stroke, resulting in muscle weakness in their
right upper and lower extremities. Resident M uses a manual wheelchair. They usually can
self-propel themself about 60 to 70 feet but need assistance from a helper to complete the
distance of 150 feet.

Coding: GG0170S would be coded 02, Substantial/Maximal assistance.
Rationale: The helper provides more than half of the effort to complete the activity of

wheel 150 feet.

8. Indicate the type of wheelchair/scooter used: In the above example, Resident M used a
manual wheelchair during the assessment period.
Coding: GG0170SS would be coded 1, Manual.
Rationale: Resident M used a manual wheelchair during the assessment period.

October 2024

Page GG-67

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
9. Wheel 150 feet: Resident A has a cardiac condition with medical precautions that do not
allow them to propel their own wheelchair. Resident A is completely dependent on a helper
to wheel them 150 feet using a manual wheelchair.
Coding: GG0170S would be coded 01, Dependent.
Rationale: The helper provides all the effort and the resident does none of the effort to

complete the activity of wheel 150 feet.

10. Indicate the type of wheelchair/scooter used: In the above example, Resident A is wheeled
using a manual wheelchair during the assessment period.
Coding: GG0170SS would be coded 1, Manual.
Rationale: Resident A is assisted using a manual wheelchair during the assessment

period.

Examples of Probing Conversations with Staff
1. Sit to lying: Example of a probing conversation between a nurse determining a resident’s
score for sit to lying and a certified nursing assistant regarding the resident’s bed mobility:

Nurse: “Please describe how Resident H moves themself from sitting on the side of the
bed to lying flat on the bed. When they are sitting on the side of the bed, how do they
move to lying on their back?”
Certified nursing assistant: “They can lie down with some help.”

Nurse: “Please describe how much help they need and exactly how you help them.”
Certified nursing assistant: “I have to lift and position their right leg, but once I do that,
they can use their arms to position their upper body.”

In this example, the nurse inquired specifically about how Resident H moves from a sitting
position to a lying position. The nurse asked about physical assistance.
Coding: GG0170B would be coded 03, Partial/moderate assistance.
Rationale: The certified nursing assistant lifts Resident H’s right leg and helps them

position it as they move from a sitting position to a lying position. The helper does less
than half the effort.

October 2024

Page GG-68

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
2. Lying to sitting on side of bed: Example of a probing conversation between a nurse
determining a resident’s score for lying to sitting on side of bed and a certified nursing
assistant regarding the resident’s bed mobility:
Nurse: “Please describe how Resident L moves themself in bed. When they are in bed,
how do they move from lying on their back to sitting up on the side of the bed?”
Certified nursing assistant: “They can sit up by themself.”
Nurse: “They sit up without any instructions or physical help?”
Certified nursing assistant: “No, I have to remind them to check on the position of their
arm that has limited movement and sensation as they move in the bed, but once I remind
them to check their arm, they can do it themself.”

In this example, the nurse inquired specifically about how Resident L moves from a lying
position to a sitting position. The nurse asked about instructions and physical assistance.
Coding: GG0170C would be coded 04, Supervision or touching assistance.
Rationale: The certified nursing assistant provides verbal instructions as the resident

moves from a lying to sitting position.

3. Sit to stand: Example of a probing conversation between a nurse determining a resident’s sit
to stand score and a certified nursing assistant regarding the resident’s sit to stand ability:
Nurse: “Please describe how Resident L usually moves from sitting on the side of the
bed or chair to a standing position. Once they are sitting, how do they get to a standing
position?”
Certified nursing assistant: “They need help to get to sitting up and then standing.”
Nurse: “I’d like to know how much help they need for safely rising up from sitting in a
chair or sitting on the bed to get to a standing position.”

Certified nursing assistant: “They need two people to assist them to stand up from
sitting on the side of the bed or when they are sitting in a chair.”

In this example, the nurse inquired specifically about how Resident L moves from a sitting
position to a standing position and clarified that this did not include any other positioning to
be included in the answer. The nurse specifically asked about physical assistance.
Coding: GG0170D would be coded 01, Dependent.
Rationale: Resident L requires the assistance of two helpers to complete the activity.

October 2024

Page GG-69

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
4. Chair/bed-to-chair transfer: Example of a probing conversation between a nurse
determining a resident’s score for chair/bed-to-chair transfer and a certified nursing assistant
regarding the resident’s chair/bed-to-chair transfer ability:
Nurse: “Please describe how Resident C moves into the chair from the bed. When they
are sitting at the side of the bed, how much help do they need to move from the bed to the
chair?”
Certified nursing assistant: “They need me to help them move from the bed to the
chair.”
Nurse: “Do they help with these transfers when you give them any instructions, setup, or
physical help?”

Certified nursing assistant: “Yes, they will follow some of my instructions to get ready
to transfer, such as moving their feet from being spread out to placing them under their
knees. I have to place the chair close to the bed and then I lift them because they are very
weak. I then tell them to reach for the armrest of the chair. Resident C follows these
directions and that helps a little in transferring them from the bed to the chair. They do
help with the transfer.”

In this example, the nurse inquired specifically about how Resident C moves from sitting on
the side of the bed to sitting in a chair. The nurse asked about instructions, physical
assistance, and cueing instructions. If this nurse had not asked probing questions, they would
not have received enough information to make an accurate assessment of the actual
assistance Resident C received.
Coding: GG0170E would be coded 02, Substantial/maximal assistance.
Rationale: The helper provides more than half of the effort to complete the activity of

Chair/bed-to-chair transfer.

ft
October 2024

Page GG-70

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
5. Toilet transfer: Example of a probing conversation between a nurse determining the
resident’s score and a certified nursing assistant regarding a resident’s toilet transfer
assessment:
Nurse: “I understand that Resident M usually uses a wheelchair to get to their toilet.
Please describe how Resident M moves from their wheelchair to the toilet. How do they
move from sitting in a wheelchair to sitting on the toilet?”
Certified nursing assistant: “It is hard for them, but they do it with my help.”
Nurse: “Can you describe the amount of help in more detail?”

Certified nursing assistant: “I have to give them a bit of a lift using a gait belt to get
them to stand and then remind them to reach for the toilet grab bar while they pivot to the
toilet. Sometimes, I have to remind them to take a step while they pivot to or from the
toilet, but they do most of the effort themself.”

In this example, the nurse inquired specifically about how Resident M moves from sitting in
a wheelchair to sitting on the toilet. The nurse specifically asked about instructions and
physical assistance. If this nurse had not asked probing questions, they would not have
received enough information to make an accurate assessment of the actual assistance
Resident M received.
Coding: GG0170F would be coded 03, Partial/moderate assistance.
Rationale: The certified nursing assistant provides less than half the effort to complete

this activity.

6. Walk 50 feet with two turns: Example of a probing conversation between a nurse
determining a resident’s score for walking 50 feet with two turns and a certified nursing
assistant regarding the resident’s walking ability:
Nurse: “How much help does Resident T need to walk 50 feet and make two turns once
they are standing?”

Certified nursing assistant: “They need help to do that.”
Nurse: “How much help do they need?”

Certified nursing assistant: “They walk about 50 feet with one of us holding onto the
gait belt and another person following closely with a wheelchair in case they need to sit
down.”
In this example, the nurse inquired specifically about how Resident T walks 50 feet and
makes two turns. The nurse asked about physical assistance. If this nurse had not asked
probing questions, they would not have received enough information to make an accurate
assessment of the actual assistance Resident T received.
Coding: GG0170J would be coded 01, Dependent.
Rationale: Resident T requires two helpers to complete this activity.

October 2024

Page GG-71

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
7. Walk 150 feet: Example of a probing conversation between a nurse determining a resident’s
score for walking 150 feet and a certified nursing assistant regarding the resident’s walking
ability:
Nurse: “Please describe how Resident D walks 150 feet in the corridor once they are
standing.”
Certified nursing assistant: “They use a walker and some help.”
Nurse: “They use a walker and how much instructions or physical help do they need?”
Certified nursing assistant: “I have to support them by holding onto the gait belt that is
around their waist so that they don’t fall. They do push the walker forward most of the
time.”

Nurse: “Do you help with more than or less than half the effort?”

Certified nursing assistant: “I have to hold onto their belt firmly when they walk
because they frequently lose their balance when taking steps. Their balance gets worse
the further they walk, but they are very motivated to keep walking. I would say I help
them with more than half the effort.”

In this example, the nurse inquired specifically about how Resident D walks 150 feet. The
nurse asked about instructions and physical assistance. If this nurse had not asked probing
questions, they would not have received enough information to make an accurate assessment
of the actual assistance Resident D received.
Coding: GG0170K would be coded 02, Substantial/maximal assistance.
Rationale: The certified nursing assistant provides trunk support that is more than half

the effort as Resident D walks 150 feet.

ft
October 2024

Page GG-72

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [GG]

GG0170: Mobility (cont.)
8. Wheel 50 feet with two turns: Example of a probing conversation between a nurse
determining a resident’s score for wheel 50 feet with two turns and a certified nursing
assistant regarding the resident’s mobility:
Nurse: “I understand that Resident R uses a manual wheelchair. Describe to me how
Resident R wheels themself 50 feet and makes two turns once they are seated in the
wheelchair.”
Certified nursing assistant: “They wheel themself.”
Nurse: “They wheel themself without any instructions or physical help?”
Certified nursing assistant: “Well yes, they need help to get around turns, so I have to
help them and set them on a straight path, but once I do, they wheel themself.”

In this example, the nurse inquired specifically about how Resident R wheels 50 feet with
two turns. The nurse asked about instructions and physical assistance. If this nurse had not
asked probing questions, they would not have received enough information to make an
accurate assessment of the actual assistance Resident R received.
Coding: GG0170R would be coded 03, Partial/Moderate assistance.
Rationale: The certified nursing assistant must physically push the wheelchair at some

points of the activity; however, the helper does less than half of the activity for the
resident.

9. Wheel 150 feet: Example of a probing conversation between a nurse determining a
resident’s score for wheel 150 feet and a certified nursing assistant regarding the resident’s
mobility:
Nurse: “I understand that Resident G usually uses an electric scooter for longer
distances. Once they are seated in the scooter, do they need any help to mobilize themself
at least 150 feet?”

Certified nursing assistant: “They drive the scooter themself … they are very slow.”
Nurse: “They use the scooter themself without any instructions or physical help?”
Certified nursing assistant: “That is correct.”

In this example, the nurse inquired specifically about how Resident G uses an electric scooter
to mobilize themself 150 feet. If this nurse had not asked probing questions, they would not
have received enough information to make an accurate assessment of the actual assistance
Resident G received.
Coding: GG0170S would be coded 06, Independent.
Rationale: The resident navigates in the corridor for at least 150 feet without

assistance.

October 2024

Page GG-73

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

SECTION H: BLADDER AND BOWEL
Intent: The intent of the items in this section is to gather information on the use of bowel and
bladder appliances, the use of and response to urinary toileting programs, urinary and bowel
continence, bowel training programs, and bowel patterns. Each resident who is incontinent or at
risk of developing incontinence should be identified, assessed, and provided with individualized
treatment (medications, non-medicinal treatments and/or devices) and services to achieve or
maintain as normal elimination function as possible.

H0100: Appliances

D
Item Rationale
•

It is important to know what appliances are in use and
the history and rationale for such use.

•

External catheters should fit well and be comfortable,
minimize leakage, maintain skin integrity, and promote
resident dignity.

Indwelling catheters should not be used unless there is
valid medical justification. Assessment should include
consideration of the risk and benefits of an indwelling
catheter, the anticipated duration of use, and
consideration of complications resulting from the use of
an indwelling catheter. Complications can include an
increased risk of urinary tract infection, blockage of the
catheter with associated bypassing of urine, expulsion of
the catheter, pain, discomfort, and bleeding.

•

Ostomies (and peristomal skin) should be free of
redness, tenderness, excoriation, and breakdown.
Appliances should fit well, be comfortable, and
promote resident dignity.

SUPRAPUBIC
CATHETER
An indwelling catheter that is
placed by a urologist directly
into the bladder through the
abdomen. This type of
catheter is frequently used
when there is an obstruction
of urine flow through the
urethra.

•

Planning for Care
•

INDWELLING
CATHETER
A catheter that is maintained
within the bladder for the
purpose of continuous
drainage of urine.

Health-related Quality of Life

DEFINITIONS

Care planning should include interventions that are
consistent with the resident’s goals and minimize
complications associated with appliance use.

October 2024

NEPHROSTOMY TUBE
A catheter inserted through
the skin into the kidney in
individuals with an
abnormality of the ureter (the
fibromuscular tube that
carries urine from the kidney
to the bladder) or the
bladder.

Page H-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0100: Appliances (cont.)
•

DEFINITIONS

Care planning should be based on an assessment and
evaluation of the resident’s history, physical
examination, physician orders, progress notes, nurses’
notes and flow sheets, pharmacy and lab reports, voiding
history, resident’s overall condition, risk factors and
information about the resident’s continence status,
catheter status, environmental factors related to
continence programs, and the resident’s response to
catheter/continence services.

Steps for Assessment

1. Examine the resident to note the presence of any urinary or
bowel appliances.
2. Review the medical record, including bladder and bowel
records, for documentation of current or past use of urinary
or bowel appliances.

Coding Instructions

•

H0100A, indwelling catheter (including suprapubic

•

catheter and nephrostomy tube)
H0100B, external catheter

•

H0100C, ostomy (including urostomy, ileostomy, and

•

H0100Z, none of the above

Coding Tips and Special Populations

•
•
•

UROSTOMY
A stoma for the urinary
system used in cases where
long-term drainage of urine
through the bladder and
urethra is not possible, e.g.,
after extensive surgery or in
case of obstruction.
ILEOSTOMY
A stoma that has been
constructed by bringing the
end or loop of small intestine
(the ileum) out onto the
surface of the skin.
COLOSTOMY
A stoma that has been
constructed by connecting a
part of the colon onto the
anterior abdominal wall.

•

colostomy)
H0100D, intermittent catheterization

•

OSTOMY
Any type of surgically created
opening of the
gastrointestinal or
genitourinary tract for
discharge of body waste.

Check next to each appliance that was used at any time in the
past 7 days. Select none of the above if none of the appliances
A-D were used in the past 7 days.

EXTERNAL CATHETER
Device attached to the shaft
of the penis like a condom or
a receptacle pouch that fits
around the labia majora and
connected to a drainage bag.

INTERMITTENT
CATHETERIZATION
Insertion and removal of a
catheter through the urethra
for bladder drainage.

Suprapubic catheters and nephrostomy tubes should be
coded as an indwelling catheter (H0100A) only and not
as an ostomy (H0100C).
Condom catheters and external urinary pouches are
often used intermittently or at night only; these should be coded as external catheters.
Do not code gastrostomies or other feeding ostomies in this section. Only appliances used
for elimination are coded here.
Do not include one-time catheterizations for urine specimen collection or other diagnostic
exams (e.g., to measure post-void residual) during look-back period as intermittent
catheterization.

October 2024

Page H-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0100: Appliances (cont.)
•

Self-catheterizations that are performed by the resident in the facility should be coded as
intermittent catheterization (H0100D). This includes self-catheterizations using clean
technique.

H0200: Urinary Toileting Program

D
•
•
•

•
•
•

An individualized, resident-centered toileting program may decrease or prevent urinary
incontinence, minimizing or avoiding the negative consequences of incontinence.
Determining the type of urinary incontinence can allow staff to provide more
individualized programming or interventions to enhance the resident’s quality of life and
functional status.
Many incontinent residents (including those with dementia) respond to a toileting
program, especially during the day.

Planning for Care

•

Item Rationale
Health-related Quality of Life

The steps toward ensuring that the resident receives appropriate treatment and services to
restore as much bladder function as possible are
— determining if the resident is currently experiencing some level of incontinence or is
at risk of developing urinary incontinence;
— completing an accurate, thorough assessment of factors that may predispose the
resident to having urinary incontinence; and
— implementing appropriate, individualized interventions and modifying them as
appropriate.
If the toileting program or bladder retraining leads to a decrease or resolution of
incontinence, the program should be maintained.
Research has shown that one quarter to one third of residents will have a decrease or
resolution of incontinence in response to a toileting program.
If incontinence is not decreased or resolved with a toileting trial, consider whether other
reversible or treatable causes are present.

October 2024

Page H-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0200: Urinary Toileting Program (cont.)
•
•

Residents may need to be referred to practitioners who specialize in diagnosing and
treating conditions that affect bladder function.
Residents who do not respond to a toileting trial and for whom other reversible or
treatable causes are not found should receive supportive management (such as checking
the resident for incontinence and changing their brief if needed and providing good skin
care).

Steps for Assessment: H0200A, Trial of a
Toileting Program

The look-back period for this item is since the most recent
admission/entry or reentry or since urinary incontinence was
first noted within the facility.

BLADDER
REHABILITATION/
BLADDER RETRAINING
A behavioral technique that
requires the resident to resist
or inhibit the sensation of
urgency (the strong desire to
urinate), to postpone or delay
voiding, and to urinate
according to a timetable
rather than to the urge to
void.

1. Review the medical record for evidence of a trial of an
individualized, resident-centered toileting program. A
toileting trial should include observations of at least 3 days
of toileting patterns with prompting to toilet and of
recording results in a bladder record or voiding diary.
Toileting programs may have different names, e.g., habit
training/scheduled voiding, bladder rehabilitation/bladder
retraining.
2. Review records of voiding patterns (such as frequency,
volume, duration, nighttime or daytime, quality of stream)
over several days for those who are experiencing
incontinence.
3. Voiding records help detect urinary patterns or intervals
between incontinence episodes and facilitate providing care
to avoid or reduce the frequency of episodes.
4. Simply tracking continence status using a bladder record or
voiding diary should not be considered a trial of an
individualized, resident-centered toileting program.
5. Residents should be reevaluated whenever there is a change
in cognition, physical ability, or urinary tract function.
Nursing home staff must use clinical judgment to determine
when it is appropriate to reevaluate a resident’s ability to
participate in a toileting trial or, if the toileting trial was
unsuccessful, the need for a trial of a different toileting
program.

DEFINITIONS

PROMPTED VOIDING
Prompted voiding includes
(1) regular monitoring with
encouragement to report
continence status, (2) using a
schedule and prompting the
resident to toilet, and (3)
praise and positive feedback
when the resident is
continent and attempts to
toilet.
HABIT TRAINING/
SCHEDULED VOIDING
A behavior technique that
calls for scheduled toileting at
regular intervals on a
planned basis to match the
resident’s voiding habits or
needs.
CHECK AND CHANGE
Involves checking the
resident’s dry/wet status at
regular intervals and using
incontinence devices and
products.

October 2024

Page H-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0200: Urinary Toileting Program (cont.)
Steps for Assessment: H0200B, Response to Trial Toileting Program
1. Review the resident’s responses as recorded during the toileting trial, noting any change in
the number of incontinence episodes or degree of wetness the resident experiences.

Steps for Assessment: H0200C, Current Toileting Program or Trial

1. Review the medical record for evidence of a toileting program being used to manage
incontinence during the 7-day look-back period. Note the number of days during the lookback period that the toileting program was implemented or carried out.
2. Look for documentation in the medical record showing that the following three requirements
have been met:
• implementation of an individualized, resident-specific toileting program that was based
on an assessment of the resident’s unique voiding pattern;
• evidence that the individualized program was communicated to staff and the resident (as
appropriate) verbally and through a care plan, flow records, and a written report; and
• notations of the resident’s response to the toileting program and subsequent evaluations,
as needed.
3. Guidance for developing a toileting program may be obtained from sources found in
Appendix C.

Coding Instructions H0200A, Toileting Program Trial
•

•

Code 0, no: if for any reason the resident did not undergo a toileting trial. This includes
residents who are continent of urine with or without toileting assistance, or who use a
permanent catheter or ostomy, as well as residents who prefer not to participate in a trial.
Skip to Urinary Continence item (H0300).
Code 1, yes: for residents who underwent a trial of an individualized, resident-centered
toileting program at least once since the most recent admission/entry or reentry or since
urinary incontinence was first noted within the facility.
Code 9, unable to determine: if records cannot be obtained to determine if a trial
toileting program has been attempted. If code 9, skip H0200B and go to H0200C,
Current Toileting Program or Trial.

Coding Instructions H0200B, Toileting Program Trial Response
•

Code 0, no improvement: if the frequency of resident’s urinary incontinence did not

•

Code 1, decreased wetness: if the resident’s urinary incontinence frequency

decrease during the toileting trial.

decreased, but the resident remained incontinent. There is no quantitative definition of
improvement. However, the improvement should be clinically meaningful—for example,
having at least one less incontinent void per day than before the toileting program was
implemented.

October 2024

Page H-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0200: Urinary Toileting Program (cont.)
•

•

Code 2, completely dry (continent): if the resident becomes completely continent
of urine, with no episodes of urinary incontinence during the toileting trial. (For residents

who have undergone more than one toileting program trial during their stay, use the most
recent trial to complete this item.)
Code 9, unable to determine or trial in progress: if the response to the toileting
trial cannot be determined because information cannot be found or because the trial is still
in progress.

Coding Instructions H0200C, Current Toileting Program
•

voiding, scheduled toileting, or bladder training) is used less than 4 days of the 7-day
look-back period to manage the resident’s urinary continence.
Code 1, yes: for residents who are being managed, during 4 or more days of the 7-day
look-back period, with some type of systematic toileting program (i.e., bladder
rehabilitation/bladder retraining, prompted voiding, habit training/scheduled voiding).
Some residents prefer to not be awakened to toilet. If that resident, however, is on a
toileting program during the day, code “yes.”

•

Code 0, no: if an individualized resident-centered toileting program (i.e., prompted

•

Coding Tips for H0200A-C

Toileting (or trial toileting) programs refer to a specific approach that is organized,
planned, documented, monitored, and evaluated that is consistent with the nursing home’s
policies and procedures and current standards of practice. A toileting program does not
refer to
— simply tracking continence status,
— changing pads or wet garments, and
— random assistance with toileting or hygiene.
For a resident currently undergoing a trial of a toileting program,
— H0200A would be coded 1, yes,
— H0200B would be coded 9, unable to determine or trial in progress, and
— H0200C would be coded 1, yes.

October 2024

Page H-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0200: Urinary Toileting Program (cont.)
Examples
1. Resident H has a diagnosis of advanced Alzheimer’s disease. They are dependent on the staff
for their ADLs, do not have the cognitive ability to void in the toilet or other appropriate
receptacle, and are totally incontinent. Their voiding assessment/diary indicates no pattern to
their incontinence. Their care plan states that due to their total incontinence, staff should
follow the facility standard policy for incontinence, which is to check and change every 2
hours while awake and apply a superabsorbent brief at bedtime so as not to disturb their
sleep.
Coding: H0200A would be coded as 0, no. H0200B and H0200C would be skipped.
Rationale: Based on this resident’s voiding assessment/diary, there was no pattern to

their incontinence. Therefore, H0200A would be coded as 0, no. Due to total
incontinence a toileting program is not appropriate for this resident. Since H0200A is
coded 0, no, skip to H0300, Urinary Continence.
2. Resident M., who has a diagnosis of congestive heart failure (CHF) and a history of left-sided
hemiplegia from a previous stroke, has had an increase in urinary incontinence. The team has
assessed them for a reversible cause of the incontinence and has evaluated their voiding
pattern using a voiding assessment/diary. After completing the assessment, it was determined
that incontinence episodes could be reduced. A plan was developed and implemented that
called for toileting every hour for 4 hours after receiving their 8 a.m. diuretic, then every 3
hours until bedtime at 9 p.m. The team has communicated this approach to the resident and
the care team and has placed these interventions in the care plan. The team will reevaluate the
resident’s response to the plan after 1 month and adjust as needed.
Coding: H0200A would be coded as 1, yes.
H0200B would be coded as 9, unable to determine or trial in

progress.

H0200C would be coded as 1, current toileting program or trial.

Rationale: Based on this resident’s voiding assessment/diary, it was determined that
this resident could benefit from a toileting program. Therefore H0200A is coded as 1,
yes. Based on the assessment it was determined that incontinence episodes could be
reduced, therefore H0200B is coded as 9, unable to determine or trial in progress. An
individualized plan has been developed, implemented, and communicated to the resident
and staff, therefore H0200C is coded as 1, current toileting program or trial.

October 2024

Page H-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0300: Urinary Continence

Item Rationale
Health-related Quality of Life
•

Incontinence can
— interfere with participation in activities,
— be socially embarrassing and lead to increased
feelings of dependency,
— increase risk of long-term institutionalization,
— increase risk of skin rashes and breakdown,

DEFINITIONS
URINARY
INCONTINENCE
The involuntary loss of urine.
CONTINENCE
Any void that occurs
voluntarily, or as the result of
prompted toileting, assisted
toileting, or scheduled
toileting.

— increase risk of repeated urinary tract infections, and
— increase the risk of falls and injuries resulting from attempts to reach a toilet
unassisted.

Planning for Care
•

•

For many residents, incontinence can be resolved or minimized by
— identifying and treating underlying potentially reversible causes, including
medication side effects, urinary tract infection, constipation and fecal impaction,
and immobility (especially among those with the new or recent onset of
incontinence);
— eliminating environmental physical barriers to accessing commodes, bedpans, and
urinals; and
— bladder retraining, prompted voiding, or scheduled toileting.
For residents whose incontinence does not have a reversible cause and who do not
respond to retraining, prompted voiding, or scheduled toileting, the interdisciplinary team
should establish a plan to maintain skin dryness and minimize exposure to urine.

Steps for Assessment
1. Review the medical record for bladder or incontinence records or flow sheets, nursing
assessments and progress notes, physician history, and physical examination.
2. Interview the resident if they are capable of reliably reporting their continence. Speak with
family members or significant others if the resident is not able to report on continence.
3. Ask direct care staff who routinely work with the resident on all shifts about incontinence
episodes.

October 2024

Page H-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0300: Urinary Continence (cont.)
Coding Instructions
•

Code 0, always continent: if throughout the 7-day look-back period the resident has

•

Code 1, occasionally incontinent: if during the 7-day look-back period the

•

Code 2, frequently incontinent: if during the 7-day look-back period, the resident

•

Code 3, always incontinent: if during the 7-day look-back period, the resident had

•

Code 9, not rated: if during the 7-day look-back period the resident had an indwelling

been continent of urine, without any episodes of incontinence.

resident was incontinent less than 7 episodes. This includes incontinence of any amount
of urine sufficient to dampen undergarments, briefs, or pads during daytime or nighttime.
was incontinent of urine during seven or more episodes but had at least one continent
void. This includes incontinence of any amount of urine, daytime and nighttime.

no continent voids.

bladder catheter, condom catheter, ostomy, or no urine output (e.g., is on chronic dialysis
with no urine output) for the entire 7 days.

Coding Tips and Special Populations
If intermittent catheterization is used to drain the bladder, code continence level based on
continence between catheterizations.

Examples

•

DEFINITION

STRESS
INCONTINENCE
Episodes of a small amount
of urine leakage only
associated with physical
movement or activity such as
coughing, sneezing,
laughing, lifting heavy
objects, or exercise.

1. An 86-year-old resident has had longstanding stress-type
incontinence for many years. When they have an upper
respiratory infection and are coughing, they involuntarily
lose urine. However, during the current 7-day look-back
period, the resident has been free of respiratory symptoms
and has not had an episode of incontinence.
Coding: H0300 would be coded 0, always
continent.
Rationale: Even though the resident has known

intermittent stress incontinence, they were continent
during the current 7-day look-back period.
2. A resident with multi-infarct dementia is incontinent of urine on three occasions on day one
of observation, continent of urine in response to toileting on days two and three, and has one
urinary incontinence episode during each of the nights of days four, five, six, and seven of
the look-back period.

Coding: H0300 would be coded as 2, frequently incontinent.
Rationale: The resident had seven documented episodes of urinary incontinence during

the look-back period. The criterion for “frequent” incontinence has been set at seven or
more episodes over the 7-day look-back period with at least one continent void.

October 2024

Page H-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0300: Urinary Continence (cont.)
3. A resident with Parkinson’s disease is severely immobile and cannot be transferred to a toilet.
They are unable to use a urinal, and the incontinence is managed by the resident using adult
briefs and bed pads that are regularly changed. They did not have a continent void during the
7-day look-back period.
Coding: H0300 would be coded as 3, always incontinent.
Rationale: The resident has no urinary continent episodes and cannot be toileted due to

severe disability or discomfort. Incontinence is managed by a “check and change”
protocol.
4. A resident had one continent urinary void during the 7-day look-back period, after the nursing
assistant assisted them to the toilet and helped with clothing. All other voids were
incontinent.

Coding: H0300 would be coded as 2, frequently incontinent.
Rationale: The resident had at least one continent void during the look-back period. The

reason for the continence does not enter into the coding decision.

H0400: Bowel Continence

Item Rationale

Health-related Quality of Life
•

Planning for Care
•

Incontinence can
— interfere with participation in activities,
— be socially embarrassing and lead to increased feelings of dependency,
— increase risk of long-term institutionalization,
— increase risk of skin rashes and breakdown, and
— increase the risk of falls and injuries resulting from attempts to reach a toilet
unassisted.

For many residents, incontinence can be resolved or minimized by
— identifying and managing underlying potentially reversible causes, including
medication side effects, constipation and fecal impaction, and immobility (especially
among those with the new or recent onset of incontinence); and
— eliminating environmental physical barriers to accessing commodes, bedpans, and
urinals.

October 2024

Page H-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0400: Bowel Continence (cont.)
•

For residents whose incontinence does not have a reversible cause and who do not
respond to retraining programs, the interdisciplinary team should establish a plan to
maintain skin dryness and minimize exposure to stool.

Steps for Assessment
1. Review the medical record for bowel records and incontinence flow sheets, nursing
assessments and progress notes, physician history and physical examination.
2. Interview the resident if they are capable of reliably reporting their bowel habits. Speak with
family members or significant other if the resident is unable to report on continence.
3. Ask direct care staff who routinely work with the resident on all shifts about incontinence
episodes.

Coding Instructions
•

•

•
•

been continent of bowel on all occasions of bowel movements, without any episodes of
incontinence.
Code 1, occasionally incontinent: if during the 7-day look-back period the resident
was incontinent of stool once. This includes incontinence of any amount of stool day or
night.
Code 2, frequently incontinent: if during the 7-day look-back period, the resident
was incontinent of bowel more than once, but had at least one continent bowel
movement. This includes incontinence of any amount of stool day or night.
Code 3, always incontinent: if during the 7-day look-back period, the resident was
incontinent of bowel for all bowel movements and had no continent bowel movements.
Code 9, not rated: if during the 7-day look-back period the resident had an ostomy or
did not have a bowel movement for the entire 7 days. (Note that these residents should be
checked for fecal impaction and evaluated for constipation.)

•

Code 0, always continent: if during the 7-day look-back period the resident has

Coding Tips and Special Populations
•

Bowel incontinence precipitated by loose stools or diarrhea from any cause (including
laxatives) would count as incontinence.

October 2024

Page H-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0500: Bowel Toileting Program

Item Rationale
Health-related Quality of Life
•

A systematically implemented bowel toileting program may decrease or prevent bowel
incontinence, minimizing or avoiding the negative consequences associated with
incontinence.

•

Many incontinent residents respond to a bowel toileting program, especially during the
day.

D
Planning for Care

If the bowel toileting program leads to a decrease or resolution of incontinence, the
program should be maintained.

•

If bowel incontinence is not decreased or resolved with a bowel toileting trial, consider
whether other reversible or treatable causes are present.

•

Residents who do not respond to a bowel toileting trial and for whom other reversible or
treatable causes are not found should receive supportive management (such as a regular
check and change program with good skin care).

•

Residents with a colostomy or colectomy may need their diet monitored to promote
healthy bowel elimination and careful monitoring of skin to prevent skin irritation and
breakdown.

•

When developing a toileting program the provider may want to consider assessing the
resident for adequate fluid intake, adequate fiber in the diet, exercise, and scheduled times
to attempt bowel movement (Newman, 2009).

Steps for Assessment

•

1. Review the medical record for evidence of a bowel toileting program being used to manage
bowel incontinence during the 7-day look-back period.
2. Look for documentation in the medical record showing that the following three requirements
have been met:
• implementation of an individualized, resident-specific bowel toileting program based on
an assessment of the resident’s unique bowel pattern;
•

evidence that the individualized program was communicated to staff and the resident (as
appropriate) verbally and through a care plan, flow records, verbal and a written report;
and

•

notations of the resident’s response to the toileting program and subsequent evaluations,
as needed.

October 2024

Page H-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0500: Bowel Toileting Program (cont.)
Coding Instructions
•

Code 0, no: if the resident is not currently on a toileting program targeted specifically
at managing bowel continence.

•

Code 1, yes: if the resident is currently on a toileting program targeted specifically at

managing bowel continence.

H0600: Bowel Patterns

D
Item Rationale

Health-related Quality of Life
Severe constipation can cause abdominal pain,
anorexia, vomiting, bowel incontinence, and delirium.

•

If unaddressed, constipation can lead to fecal impaction.

CONSTIPATION
If the resident has two or
fewer bowel movements
during the 7-day look-back
period or if for most bowel
movements their stool is hard
and difficult for them to pass
(no matter what the
frequency of bowel
movements).

•

DEFINITION

Planning for Care
•

This item identifies residents who may need further
evaluation of and intervention on bowel habits.

•

Constipation may be a manifestation of serious
conditions such as

— dehydration due to a medical condition or inadequate access to and intake of fluid, and

Steps for Assessment

— side effects of medications.

1. Review the medical record for bowel records or flow
sheets, nursing assessments and progress notes, physician
history and physical examination to determine if the
resident has had problems with constipation during the 7day look-back period.
2. Residents who are capable of reliably reporting their
continence and bowel habits should be interviewed. Speak
with family members or significant others if the resident is
unable to report on bowel habits.
3. Ask direct care staff who routinely work with the resident
on all shifts about problems with constipation.

October 2024

DEFINITION

FECAL IMPACTION
A large mass of dry, hard
stool that can develop in the
rectum due to chronic
constipation. This mass may
be so hard that the resident is
unable to move it from the
rectum. Watery stool from
higher in the bowel or
irritation from the impaction
may move around the mass
and leak out, causing soiling,
often a sign of a fecal
impaction.

Page H-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [H]

H0600: Bowel Patterns (cont.)
Coding Instructions
•

Code 0, no: if the resident shows no signs of constipation during the look-back period.

•

Code 1, yes: if the resident shows signs of constipation during the look-back period.

Coding Tips and Special Populations
•

Fecal impaction is caused by chronic constipation. Fecal impaction is not synonymous
with constipation.

D
October 2024

Page H-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

SECTION I: ACTIVE DIAGNOSES

Intent: The items in this section are intended to code diseases that have a direct relationship to
the resident’s current functional status, cognitive status, mood or behavior status, medical
treatments, nursing monitoring, or risk of death. One of the important functions of the MDS
assessment is to generate an updated, accurate picture of the resident’s current health status.

I0020: Indicate the resident’s primary medical condition category

D
Item Rationale

Health-related Quality of Life
•

Disease processes can have a significant adverse effect on residents’ functional
improvement.

Planning for Care
•

Steps for Assessment

Indicate the resident’s primary medical condition category that best describes the primary
reason for the Medicare Part A stay.

1. Indicate the resident’s primary medical condition category that best describes the primary
reason for the Medicare Part A stay. Medical record sources for physician diagnoses include
the most recent history and physical, transfer documents, discharge summaries, progress
notes, and other resources as available.

October 2024

Page I-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I0020: Indicate the resident’s primary medical condition category
(cont.)
Coding Instructions
Complete only if A0310B = 01 or 08
Indicate the resident’s primary medical condition category that best describes the primary
reason for the Medicare Part A stay; then proceed to I0020B and enter the International
Classification of Diseases (ICD) code for that condition, including the decimal.

•

When an acute condition represents the primary reason for the resident's SNF stay, it can be
coded in I0020B. However, it is more common that a resident presents to the SNF for care
related to an aftereffect of a disease, condition, or injury. Therefore, subsequent encounter or
sequelae codes should be used.

•

Include the primary medical condition coded in this item in Section I: Active Diagnoses in
the last 7 days.

•

— Code 01, Stroke, if the resident’s primary medical condition category is due to
stroke. Examples include ischemic stroke, subarachnoid hemorrhage, cerebral vascular
accident (CVA), and other cerebrovascular disease.
— Code 02, Non-Traumatic Brain Dysfunction, if the resident’s primary medical
condition category is non-traumatic brain dysfunction. Examples include Alzheimer’s
disease, dementia with or without behavioral disturbance, malignant neoplasm of brain,
and anoxic brain damage.
— Code 03, Traumatic Brain Dysfunction, if the resident’s primary medical
condition category is traumatic brain dysfunction. Examples include traumatic brain
injury, severe concussion, and cerebral laceration and contusion.
— Code 04, Non-Traumatic Spinal Cord Dysfunction, if the resident’s primary
medical condition category is non-traumatic spinal cord injury. Examples include
spondylosis with myelopathy, transverse myelitis, spinal cord lesion due to spinal
stenosis, and spinal cord lesion due to dissection of aorta.
— Code 05, Traumatic Spinal Cord Dysfunction, if the resident’s primary medical
condition category is due to traumatic spinal cord dysfunction. Examples include
paraplegia and quadriplegia following trauma.
— Code 06, Progressive Neurological Conditions, if the resident’s primary
medical condition category is a progressive neurological condition. Examples include
multiple sclerosis and Parkinson’s disease.
— Code 07, Other Neurological Conditions, if the resident’s primary medical
condition category is other neurological condition. Examples include cerebral palsy,
polyneuropathy, and myasthenia gravis.
— Code 08, Amputation, if the resident’s primary medical condition category is an
amputation. An example is acquired absence of limb.

October 2024

Page I-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I0020: Indicate the resident’s primary medical condition category
(cont.)

— Code 09, Hip and Knee Replacement, if the resident’s primary medical
condition category is due to a hip or knee replacement. An example is total knee
replacement. If hip replacement is secondary to hip fracture, code as fracture.
— Code 10, Fractures and Other Multiple Trauma, if the resident’s primary
medical condition category is fractures and other multiple trauma. Examples include hip
fracture, pelvic fracture, and fracture of tibia and fibula.
— Code 11, Other Orthopedic Conditions, if the resident’s primary medical
condition category is other orthopedic condition. An example is unspecified disorders of
joint.
— Code 12, Debility, Cardiorespiratory Conditions, if the resident’s primary
medical condition category is debility or a cardiorespiratory condition. Examples include
chronic obstructive pulmonary disease (COPD), asthma, and other malaise and fatigue.
— Code 13, Medically Complex Conditions, if the resident’s primary medical
condition category is a medically complex condition. Examples include diabetes,
pneumonia, chronic kidney disease, open wounds, pressure ulcer/injury, infection, and
disorders of fluid, electrolyte, and acid-base balance.

Examples of Primary Medical Condition

1. Resident K is a 67-year-old individual with a history of Alzheimer’s dementia and
diabetes who is admitted after a stroke. The diagnosis of stroke, as well as the history of
Alzheimer’s dementia and diabetes, is documented in Resident K’s history and physical
by the admitting physician.
Coding: I0020 would be coded 01, Stroke. I0020B would be coded as I69.051
(Hemiplegia and hemiparesis following non-traumatic subarachnoid hemorrhage).
Rationale: The physician’s history and physical documents the diagnosis stroke as
the reason for Resident K’s admission. The ICD-10 code provided in I0020B above is
only an example of an appropriate code for this condition category.

October 2024

Page I-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I0020: Indicate the resident’s primary medical condition category
(cont.)

2. Resident E is an 82-year-old individual who was hospitalized for a hip fracture with
subsequent total hip replacement and is admitted for rehabilitation. The admitting
physician documents Resident E’s primary medical condition as total hip replacement
(THR) in their medical record. The hip fracture resulting in the total hip replacement is
also documented in the medical record in the discharge summary from the acute care
hospital.
Coding: I0020 would be coded 10, Fractures and Other Multiple Trauma.
I0020B would be coded as S72.062D (Displaced articular fracture of the head of the
left femur).
Rationale: Medical record documentation demonstrates that Resident E had a total
hip replacement due to a hip fracture and required rehabilitation. Because they were
admitted for rehabilitation as a result of the hip fracture and total hip replacement,
Resident E’s primary medical condition category is 10, Fractures and Other
Multiple Trauma. The ICD-10 code provided in I0020B above is only an example
of an appropriate code for this condition category.

3. Resident H is a 78-year-old individual with a history of hypertension and a hip
replacement 2 years ago. There were admitted to an extended hospitalization for
idiopathic pancreatitis. They had a central line placed during the hospitalization so they
could receive TPN (total parenteral nutrition). They also received regular blood glucose
monitoring and treatment with insulin when they became hyperglycemic. During their
SNF stay, they are being transitioned from being NPO (nothing by mouth) and receiving
their nutrition parenterally to being able to tolerate oral nutrition. The hospital discharge
diagnoses of idiopathic pancreatitis, hypertension, and malnutrition were incorporated
into Resident H’s SNF medical record.
Coding: I0020 would be coded 13, Medically Complex Conditions. I0020B
would be coded as K85.00 (Idiopathic acute pancreatitis without necrosis or infection).
Rationale: Resident H had hospital care for pancreatitis immediately prior to their
SNF stay. Their principal diagnosis of pancreatitis was included in the summary from
the hospital. The surgical placement of their central line does not change their care to a
surgical category because it is not considered to be a major surgery. The ICD-10 code
provided in I0020B above is only an example of an appropriate code for this condition
category.

October 2024

Page I-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days

D
October 2024

Page I-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)

D
October 2024

Page I-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)
Item Rationale
Health-related Quality of Life
•

Disease processes can have a significant adverse effect
on an individual’s health status and quality of life.

Planning for Care
•

This section identifies active diseases and infections
that drive the current plan of care.

Steps for Assessment

There are two look-back periods for this section:
• Diagnosis identification (Step 1) is a 60-day look-back
period.
•

Diagnosis status: Active or Inactive (Step 2) is a 7-day
look-back period (except for Item I2300 UTI, which
does not use the active 7-day look-back period).

ACTIVE DIAGNOSES
Physician-documented
diagnoses in the last 60 days
that have a direct relationship
to the resident’s current
functional status, cognitive
status, mood or behavior,
medical treatments, nursing
monitoring, or risk of death
during the 7-day look-back
period.
FUNCTIONAL
LIMITATIONS
Loss of range of motion,
contractures, muscle
weakness, fatigue,
decreased ability to perform
ADLs, paresis, or paralysis.

1. Identify diagnoses: The disease conditions in this section
require a physician-documented diagnosis (or by a nurse
practitioner, physician assistant, or clinical nurse specialist
if allowable under state licensure laws) in the last 60 days.

DEFINITIONS

NURSING MONITORING
Nursing Monitoring includes
clinical monitoring by a
licensed nurse (e.g., serial
blood pressure evaluations,
medication management,
etc.).

Medical record sources for physician diagnoses include
progress notes, the most recent history and physical,
transfer documents, discharge summaries, diagnosis/
problem list, and other resources as available. If a
diagnosis/problem list is used, only diagnoses confirmed by the physician should be entered.
Although open communication regarding diagnostic information between the physician
and other members of the interdisciplinary team is important, it is also essential that
diagnoses communicated verbally be documented in the medical record by the physician
to ensure follow-up.

•

Diagnostic information, including past history obtained from family members and close
contacts, must also be documented in the medical record by the physician to ensure
validity and follow-up.

•

2. Determine whether diagnoses are active: Once a diagnosis is identified, it must be
determined if the diagnosis is active. Active diagnoses are diagnoses that have a direct
relationship to the resident’s current functional, cognitive, or mood or behavior status,
medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.
Do not include conditions that have been resolved, do not affect the resident’s current status,
or do not drive the resident’s plan of care during the 7-day look-back period, as these would
be considered inactive diagnoses.

October 2024

Page I-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)
•

Item I2300 UTI, has specific coding criteria and does not use the active 7-day look-back.
Please refer to Page I-12 for specific coding instructions for Item I2300 UTI.

•

Check the following information sources in the medical record for the last 7 days to
identify “active” diagnoses: transfer documents, physician progress notes, recent history
and physical, recent discharge summaries, nursing assessments, nursing care plans,
medication sheets, doctor’s orders, consults and official diagnostic reports, and other
sources as available.

Coding Instructions

Code diseases that have a documented diagnosis in the last 60 days and have a direct
relationship to the resident’s current functional status, cognitive status, mood or behavior status,
medical treatments, nursing monitoring, or risk of death during the 7-day look-back period
(except Item I2300 UTI, which does not use the active diagnosis 7-day look-back. Please refer to
Item I2300 UTI, Page I-12 for specific coding instructions).
•

Document active diagnoses on the MDS as follows:
— Diagnoses are listed by major disease category: Cancer; Heart/Circulation;
Gastrointestinal; Genitourinary; Infections; Metabolic; Musculoskeletal;
Neurological; Nutritional; Psychiatric/Mood Disorder; Pulmonary; and Vision.

— Examples of diseases are included for some disease categories. Diseases to be coded
in these categories are not meant to be limited to only those listed in the examples.
For example, I0200, Anemia, includes anemia of any etiology, including those listed
(e.g., aplastic, iron deficiency, pernicious, sickle cell).
Check off each active disease. Check all that apply.

•

If a disease or condition is not specifically listed, enter the diagnosis and ICD code in
item I8000, Additional active diagnosis.

•

Computer specifications are written such that the ICD code should be automatically
justified. The important element is to ensure that the ICD code’s decimal point is in its
own box and should be right justified (aligned with the right margin so that any unused
boxes end on the left.)

•

If an individual is receiving aftercare following a hospitalization, a Z code may be
assigned. Z codes cover situations where a patient requires continued care for healing,
recovery, or long-term consequences of a disease when initial treatment for that disease
has already been performed. When Z codes are used, another diagnosis for the related
primary medical condition should be checked in items I0100–I7900 or entered in I8000.
ICD-10-CM coding guidance with links to appendices can be found here:
https://www.cms.gov/Medicare/Coding/ICD10/index.html.

•

Cancer
•

I0100, cancer (with or without metastasis)

October 2024

Page I-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)
Heart/Circulation
•

I0200, anemia (e.g., aplastic, iron deficiency, pernicious, sickle cell)

•

I0300, atrial fibrillation or other dysrhythmias (e.g., bradycardias, tachycardias)

•

I0400, coronary artery disease (CAD) (e.g., angina, myocardial infarction,

•

I0500, deep venous thrombosis (DVT), pulmonary embolus (PE), or pulmonary

•

I0600, heart failure (e.g., congestive heart failure [CHF], pulmonary edema)

•

I0700, hypertension

•

I0800, orthostatic hypotension

•

I0900, peripheral vascular disease or peripheral arterial disease

atherosclerotic heart disease [ASHD])
thrombo-embolism (PTE)

D
Gastrointestinal

I1100, cirrhosis

•

I1200, gastroesophageal reflux disease (GERD) or ulcer (e.g., esophageal, gastric, and

•

peptic ulcers)

I1300, ulcerative colitis or Crohn’s disease or inflammatory bowel disease

Genitourinary

I1400, benign prostatic hyperplasia (BPH)

•

I1500, renal insufficiency, renal failure, or end-stage renal disease (ESRD)

•

I1550, neurogenic bladder

•

I1650, obstructive uropathy

Infections

•

I1700, multidrug resistant organism (MDRO)

•

I2000, pneumonia

•

I2100, septicemia

•

I2200, tuberculosis

•

I2300, urinary tract infection (UTI) (last 30 days)

•

I2400, viral hepatitis (e.g., hepatitis A, B, C, D, and E)

•

I2500, wound infection (other than foot)

Metabolic
•

I2900, diabetes mellitus (DM) (e.g., diabetic retinopathy, nephropathy, neuropathy)

October 2024

Page I-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)
•

I3100, hyponatremia

•

I3200, hyperkalemia

•

I3300, hyperlipidemia (e.g., hypercholesterolemia)

•

I3400, thyroid disorder (e.g., hypothyroidism, hyperthyroidism, Hashimoto’s

thyroiditis)

Musculoskeletal
I3700, arthritis (e.g., degenerative joint disease [DJD], osteoarthritis, rheumatoid
arthritis [RA])

•

I3800, osteoporosis

•

I3900, hip fracture (any hip fracture that has a relationship to current status, treatments,

•

I4000, other fracture

•

monitoring (e.g., subcapital fractures and fractures of the trochanter and femoral neck)

Neurological

I4200, Alzheimer’s disease

•

I4300, aphasia

•

I4400, cerebral palsy

•

I4500, cerebrovascular accident (CVA), transient ischemic attack (TIA), or stroke

•

I4800, dementia (e.g., Lewy-Body dementia; vascular or multi-infarct dementia; mixed
dementia; frontotemporal dementia, such as Pick’s disease; and dementia related to
stroke, Parkinson’s disease or Creutzfeldt-Jakob diseases)

•

I4900, hemiplegia or hemiparesis

•

I5000, paraplegia

•

I5100, quadriplegia

•

I5200, multiple sclerosis (MS)

•

I5250, Huntington’s disease

•

I5300, Parkinson’s disease

•

I5350, Tourette’s syndrome

•

I5400, seizure disorder or epilepsy

•

I5500, traumatic brain injury (TBI)

•

Nutritional
•

I5600, malnutrition (protein or calorie) or at risk for malnutrition

Psychiatric/Mood Disorder
•

I5700, anxiety disorder

October 2024

Page I-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)
•

I5800, depression (other than bipolar)

•

I5900, bipolar disorder

•

I5950, psychotic disorder (other than schizophrenia)

•

I6000, schizophrenia (e.g., schizoaffective and schizophreniform disorders)

•

I6100, post-traumatic stress disorder (PTSD)

Pulmonary
•

I6200, asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease

•

I6300, respiratory failure

(e.g., chronic bronchitis and restrictive lung diseases, such as asbestosis)

Vision
•

I6500, cataracts, glaucoma, or macular degeneration

None of Above
•

I7900, none of the above active diagnoses within the past 7 days

Other

I8000, additional active diagnoses

•

Coding Tips

The following indicators may assist assessors in determining whether a diagnosis should be
coded as active in the MDS.
•

There may be specific documentation in the medical record by a physician, nurse
practitioner, physician assistant, or clinical nurse specialist of active diagnosis.

— The physician may specifically indicate that a condition is active. Specific
documentation may be found in progress notes, most recent history and physical,
transfer notes, hospital discharge summary, etc.

— For example, the physician documents that the resident has inadequately controlled
hypertension and will modify medications. This would be sufficient documentation of
active disease and would require no additional confirmation.
•

In the absence of specific documentation that a disease is active, the following
indicators may be used to confirm active disease:

— Recent onset or acute exacerbation of the disease or condition indicated by a positive
study, test or procedure, hospitalization for acute symptoms and/or recent change in
therapy in the last 7 days. Examples of a recent onset or acute exacerbation include
the following: new diagnosis of pneumonia indicated by chest X-ray; hospitalization
for fractured hip; or a blood transfusion for a hematocrit of 24. Sources may include
radiological reports, hospital discharge summaries, doctor’s orders, etc.

October 2024

Page I-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)
— Symptoms and abnormal signs indicating ongoing or decompensated disease in the
last 7 days. For example, intermittent claudication (lower extremity pain on exertion)
in conjunction with a diagnosis of peripheral vascular disease would indicate active
disease. Sometimes signs and symptoms can be nonspecific and could be caused by
several disease processes. Therefore, a symptom must be specifically attributed to the
disease. For example, a productive cough would confirm a diagnosis of pneumonia if
specifically noted as such by a physician. Sources may include radiological reports,
nursing assessments and care plans, progress notes, etc.

— Listing a disease/diagnosis (e.g., arthritis) on the resident’s medical record problem
list is not sufficient for determining active or inactive status. To determine if arthritis,
for example, is an “active” diagnosis, the reviewer would check progress notes
(including the history and physical) during the 7-day look-back period for notation of
treatment of symptoms of arthritis, doctor’s orders for medications for arthritis, and
documentation of physical or other therapy for functional limitations caused by
arthritis.

— Ongoing therapy with medications or other interventions to manage a condition that
requires monitoring for therapeutic efficacy or to monitor potentially severe side
effects in the last 7 days. A medication indicates active disease if that medication is
prescribed to manage an ongoing condition that requires monitoring or is prescribed
to decrease active symptoms associated with a condition. This includes medications
used to limit disease progression and complications. If a medication is prescribed for
a condition that requires regular staff monitoring of the drug’s effect on that condition
(therapeutic efficacy), then the prescription of the medication would indicate active
disease.
It is expected that nurses monitor all medications for adverse effects as part of usual
nursing practice. For coding purposes, this monitoring relates to management of
pharmacotherapy and not to management or monitoring of the underlying disease.

•

In situations where practitioners have potentially misdiagnosed residents with a condition
for which there is a lack of appropriate diagnostic information in the medical record, such
as for a mental disorder, the corresponding diagnosis in Section I should not be coded,
and a referral by the facility and/or the survey team to the State Medical Boards or
Boards of Nursing may be necessary.

•

Item I2300 Urinary tract infection (UTI):

•

— The UTI has a look-back period of 30 days for active disease instead of 7 days.
— Code only if both of the following are met in the last 30 days:

1. It was determined that the resident had a UTI using evidence-based criteria
such as McGeer, NHSN, or Loeb in the last 30 days,
AND
2. A physician documented UTI diagnosis (or by a nurse practitioner, physician
assistant, or clinical nurse specialist if allowable under state licensure laws) in
the last 30 days.
October 2024

Page I-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)
— In accordance with requirements at §483.80(a) Infection Prevention and Control
Program, the facility must establish routine, ongoing and systematic collection,
analysis, interpretation, and dissemination of surveillance data to identify infections.
The facility’s surveillance system must include a data collection tool and the use of
nationally recognized surveillance criteria. Facilities are expected to use the same
nationally recognized criteria chosen for use in their Infection Prevention and Control
Program to determine the presence of a UTI in a resident.
— Example: if a facility chooses to use the Surveillance Definitions of Infections
(updated McGeer criteria) as part of the facility’s Infection Prevention and Control
Program, then the facility should also use the same criteria to determine whether or
not a resident has a UTI.

— If the diagnosis of UTI was made prior to the resident’s admission, entry, or reentry
into the facility, it is not necessary to obtain or evaluate the evidence-based criteria
used to make the diagnosis in the prior setting. A documented physician diagnosis of
UTI prior to admission is acceptable. This information may be included in the
hospital transfer summary or other paperwork.

— When the resident is transferred, but not admitted, to a hospital (e.g., emergency room
visit, observation stay) the facility must use evidence-based criteria to evaluate the
resident and determine if the criteria for UTI are met AND verify that there is a
physician-documented UTI diagnosis when completing I2300 Urinary Tract Infection
(UTI).
— Resources for evidence-based UTI criteria:
•

•

Surveillance Definitions of Infections in LTC (updated McGeer criteria):
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3538836/

•

Loeb criteria:
https://www.researchgate.net/publication/12098745_Development_of_Minimum_
Criteria_for_the_Initiation_of_Antibiotics_in_Residents_of_Long-TermCare_Facilities_Results_of_a_Consensus_Conference

National Healthcare Safety Network (NHSN):
https://www.cdc.gov/nhsn/ltc/uti/index.html

In response to questions regarding the resident with colonized MRSA, we consulted with
the Centers for Disease Control (CDC) who provided the following information:

A physician often prescribes empiric antimicrobial therapy for a suspected infection after
a culture is obtained, but prior to receiving the culture results. The confirmed
diagnosis of UTI will depend on the culture results and other clinical assessment to
determine appropriateness and continuation of antimicrobial therapy. This should not be
any different, even if the resident is known to be colonized with an antibiotic resistant
organism. An appropriate culture will help to ensure the diagnosis of infection is correct,
and the appropriate antimicrobial is prescribed to treat the infection. The CDC does not

October 2024

Page I-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)
recommend routine antimicrobial treatment for the purposes of attempting to eradicate
colonization of MRSA or any other antimicrobial resistant organism.
The CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) has
released infection prevention and control guidelines that contain recommendations that
should be applied in all healthcare settings. At this site you will find information related
to UTIs and many other issues related to infections in LTC.
http://www.cdc.gov/hai/
•

Item I5100 Quadriplegia:
— Quadriplegia primarily refers to the paralysis of all four limbs, arms and legs, caused
by spinal cord injury.

— Coding I5100 Quadriplegia is limited to spinal cord injuries and must be a primary
diagnosis and not the result of another condition.

— Functional quadriplegia refers to complete immobility due to severe physical
disability or frailty. Conditions such as cerebral palsy, stroke, contractures, brain
disease, advanced dementia, etc. can also cause functional paralysis that may extend
to all limbs hence, the diagnosis functional quadriplegia. For individuals with these
types of severe physical disabilities, where there is minimal ability for purposeful
movement, their primary physician-documented diagnosis should be coded on the
MDS and not the resulting paralysis or paresis from that condition. For example, an
individual with cerebral palsy with spastic quadriplegia should be coded in I4400
Cerebral Palsy, and not in I5100, Quadriplegia.

Examples of Active Disease

1. A resident is prescribed hydrochlorothiazide for hypertension. The resident requires regular
blood pressure monitoring to determine whether blood pressure goals are achieved by the
current regimen. Physician progress note documents hypertension.

Coding: Hypertension item (I0700), would be checked.
Rationale: This would be considered an active diagnosis because of the need for

ongoing monitoring to ensure treatment efficacy.

2. Warfarin is prescribed for a resident with atrial fibrillation to decrease the risk of embolic
stroke. The resident requires monitoring for change in heart rhythm, for bleeding, and for
anticoagulation.
Coding: Atrial fibrillation item (I0300), would be checked.
Rationale: This would be considered an active diagnosis because of the need for

ongoing monitoring to ensure treatment efficacy as well as to monitor for side effects
related to the medication.

October 2024

Page I-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)
3. A resident with a past history of healed peptic ulcer is prescribed a non-steroidal antiinflammatory (NSAID) medication for arthritis. The physician also prescribes a proton-pump
inhibitor to decrease the risk of peptic ulcer disease (PUD) from NSAID treatment.
Coding: Arthritis item (I3700), would be checked.
Rationale: Arthritis would be considered an active diagnosis because of the need for

medical therapy. Given that the resident has a history of a healed peptic ulcer without
current symptoms, the proton-pump inhibitor prescribed is preventive and therefore PUD
would not be coded as an active disease.

4. The resident had a stroke 4 months ago and continues to have left-sided weakness, visual
problems, and inappropriate behavior. The resident is on aspirin and has physical therapy and
occupational therapy three times a week. The physician’s note 25 days ago lists stroke.

Coding: Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or
Stroke item (I4500), would be checked.
Rationale: The physician note within the last 30 days indicates stroke, and the resident

is receiving medication and therapies to manage continued symptoms from stroke.

Examples of Inactive Diagnoses (do not code)

1. The admission history states that the resident had pneumonia 2 months prior to this
admission. The resident has recovered completely, with no residual effects and no continued
treatment during the 7-day look back period.
Coding: Pneumonia item (I2000), would not be checked.
Rationale: The pneumonia diagnosis would not be considered active because of the

resident’s complete recovery and the discontinuation of any treatment during the lookback period.

2. The problem list includes a diagnosis of coronary artery disease (CAD). The resident had an
angioplasty 3 years ago, is not symptomatic, and is not taking any medication for CAD.

Coding: CAD item (I0400), would not be checked.
Rationale: The resident has had no symptoms and no treatment during the 7-day look-

back period; thus, the CAD would be considered inactive.

3. Resident J fell and fractured their hip 2 years ago. At the time of the injury, the fracture was
surgically repaired. Following the surgery, the resident received several weeks of physical
therapy in an attempt to restore them to their previous ambulation status, which had been
independent without any devices. Although they received therapy services at that time, they
now require assistance to stand from the chair and uses a walker. They also need help with
lower body dressing because of difficulties standing and leaning over.
Coding: Hip Fracture item (I3900), would not be checked.
Rationale: Although the resident has mobility and self-care limitations in ambulation

and ADLs due to the hip fracture, they have not received therapy services during the 7day look-back period; thus, Hip Fracture would be considered inactive.

October 2024

Page I-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [I]

I: Active Diagnoses in the Last 7 Days (cont.)
4. The resident was admitted without a diagnosis of schizophrenia. After admission, the resident
is prescribed an antipsychotic medication for schizophrenia by the primary care physician.
However, the resident’s medical record includes no documentation of a detailed evaluation
by an appropriate practitioner of the resident’s mental, physical, psychosocial, and functional
status (§483.45(e)) and persistent behaviors for six months prior to the start of the
antipsychotic medication in accordance with professional standards.
Coding: Schizophrenia item (I6000), would not be checked.
Rationale: Although the resident has a physician diagnosis of schizophrenia and is

receiving antipsychotic medications, coding the schizophrenia diagnosis would not be
appropriate because of the lack of documentation of a detailed evaluation, in accordance
with professional standards (§483.21(b)(3)(i)), of the resident’s mental, physical,
psychosocial, and functional status (§483.45(e)) and persistent behaviors for the time
period required.

October 2024

Page I-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

SECTION J: HEALTH CONDITIONS
Intent: The intent of the items in this section is to document a number of health conditions that
impact the resident’s functional status and quality of life. The items include an assessment of
pain which uses an interview with the resident or staff if the resident is unable to participate. The
pain items assess the management of pain, the presence of pain, pain frequency, effect of pain on
sleep, and pain interference with therapy and day-to-day activities. Other items in the section
assess dyspnea, tobacco use, prognosis, problem conditions, falls, prior surgery, and surgery
requiring active SNF care.

J0100: Pain Management

D
•
•
•

Item Rationale

Health-related Quality of Life

DEFINITION

Pain can cause suffering and is associated with
inactivity, social withdrawal, depression, and functional
decline.
Pain can interfere with participation in rehabilitation.
Effective pain management interventions can help to
avoid these adverse outcomes.

PAIN MEDICATION
REGIMEN

•
•

•

Planning for Care

Pharmacological agent(s)
prescribed to relieve or
prevent the recurrence of
pain. Include all medications
used for pain management
by any route and any
frequency during the lookback period. Include oral,
transcutaneous,
subcutaneous, intramuscular,
rectal, intravenous injections
or intraspinal delivery. This
item does not include
medications that primarily
target treatment of the
underlying condition, such as
chemotherapy or steroids,
although such treatments
may lead to pain reduction.

Goals for pain management for most residents should
be to achieve a consistent level of comfort while
maintaining as much function as possible.
Identification of pain management interventions
facilitates review of the effectiveness of pain
management and revision of the plan if goals are not
met.
Residents may have more than one source of pain and
will need a comprehensive, individualized management
regimen.
Most residents with moderate to severe pain will require
regularly dosed pain medication, and some will require
additional PRN (as-needed) pain medications for
breakthrough pain.
Some residents with intermittent or mild pain may have orders for PRN dosing only.

October 2024

Page J-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0100: Pain Management (cont.)
•

Non-medication pain (non-pharmacologic)
interventions for pain can be important adjuncts to pain
treatment regimens.

•

Interventions must be included as part of a care plan
that aims to prevent or relieve pain and includes
monitoring for effectiveness and revision of care plan if
stated goals are not met. There must be documentation
that the intervention was received and its effectiveness
was assessed. It does not have to have been successful
to be counted.

Steps for Assessment

1. Review medical record to determine if a pain regimen
exists.
2. Review the medical record and interview staff and direct
caregivers to determine what, if any, pain management
interventions the resident received any time during the last
5 days. Include information from all disciplines.

SCHEDULED PAIN
MEDICATION REGIMEN
Pain medication order that
defines dose and specific
time interval for pain
medication administration.
For example, “once a day,”
“every 12 hours.”
PRN PAIN
MEDICATIONS
Pain medication order that
specifies dose and indicates
that pain medication may be
given on an as needed basis,
including a time interval,
such as “every 4 hours as
needed for pain” or “every 6
hours as needed for pain.”
NON-MEDICATION PAIN
INTERVENTION
Scheduled and implemented
nonpharmacological
interventions include, but are
not limited to, biofeedback,
application of heat/cold,
massage, physical therapy,
nerve block, stretching and
strengthening exercises,
chiropractic, electrical
stimulation, radiotherapy,
ultrasound and acupuncture.
Herbal or alternative
medicine products are not
included in this category.

Coding Instructions for J0100A-C

DEFINITIONS

Determine all interventions for pain provided to the resident
any time in the last 5 days. Answer these items even if the
resident currently denies pain.

Coding Instructions for J0100A, Been on a
Scheduled Pain Medication Regimen
•

Code 0, no: if the medical record does not contain

•

Code 1, yes: if the medical record contains

documentation that a scheduled pain medication was
received.
documentation that a scheduled pain medication was
received.

Coding Instructions for J0100B, Received PRN Pain Medication
•

Code 0, no: if the medical record does not contain documentation that a PRN

•

Code 1, yes: if the medical record contains documentation that a PRN medication was

medication was received or offered.

either received OR was offered but declined.

October 2024

Page J-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0100: Pain Management (cont.)
Coding Instructions for J0100C, Received Non-medication
Intervention for Pain
•
•

Code 0, no: if the medical record does not contain documentation that a non-

medication pain intervention was received.
Code 1, yes: if the medical record contains documentation that a non-medication pain
intervention was scheduled as part of the care plan and it is documented that the
intervention was actually received and assessed for efficacy.

Coding Tips
•

•

Code only pain medication regimens without PRN pain medications in J0100A. Code
receipt of PRN pain medications in J0100B.
For J0100B code only residents with PRN pain medication regimens here. If the resident
has a scheduled pain medication J0100A should be coded.

Examples

1. The resident’s medical record documents that they received the following pain management
in the last 5 days:
• Hydrocodone/acetaminophen 5/500 1 tab PO every 6 hours. Discontinued on day 1 of the
look-back period.
• Acetaminophen 500mg PO every 4 hours. Started on day 2 of the look-back period.
• Cold pack to left shoulder applied by PT BID. PT notes that resident reports significant
pain improvement after cold pack applied.
Coding: J0100A would be coded 1, yes.
Rationale: Medical record indicated that resident received a scheduled pain
medication in the last 5 days.
Coding: J0100B would be coded 0, no.
Rationale: No documentation was found in the medical record that resident
received or was offered and declined any PRN medications in the last 5 days.
Coding: J0100C would be coded 1, yes.
Rationale: The medical record indicates that the resident received scheduled nonmedication pain intervention (cold pack to the left shoulder) in the last 5 days.
2. The resident’s medical record includes the following pain management documentation:
• Morphine sulfate controlled-release 15 mg PO Q 12 hours: Resident refused every dose
of medication in the last 5 days. No other pain management interventions were
documented.

October 2024

Page J-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0100: Pain Management (cont.)
Coding: J0100A would be coded 0, no.
Rationale: The medical record documented that the resident did not receive

scheduled pain medication in the last 5 days. Residents may refuse scheduled
medications; however, medications are not considered “received” if the resident
refuses the dose.
Coding: J0100B would be coded 0, no.
Rationale: The medical record contained no documentation that the resident
received or was offered and declined any PRN medications in the last 5 days.
Coding: J0100C would be coded 0, no.
Rationale: The medical record contains no documentation that the resident
received non-medication pain intervention in the last 5 days.

J0200: Should Pain Assessment Interview Be Conducted?

Item Rationale

Health-related Quality of Life
•
•

Most residents who are capable of communicating can answer questions about how they
feel.
Obtaining information about pain directly from the resident, sometimes called “hearing
the resident’s voice,” is more reliable and accurate than observation alone for identifying
pain.

•
•

Planning for Care

Interview allows the resident’s voice to be reflected in the care plan.
Information about pain that comes directly from the resident provides symptom-specific
information for individualized care planning.

October 2024

Page J-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0200: Should Pain Assessment Interview Be Conducted? (cont.)
Steps for Assessment
1. Interact with the resident using their preferred language. Be sure they can hear you and/or
have access to their preferred method for communication. If the resident appears unable to
communicate, offer alternatives such as writing, pointing, sign language, or cue cards.
2. Determine whether or not the resident is rarely/never understood verbally, in writing, or using
another method. If the resident is rarely/never understood, skip to item J0800, Indicators of
Pain or Possible Pain.
3. Review Language item (A1110) to determine whether or not the resident needs or wants an
interpreter.
• If the resident needs or wants an interpreter, complete the interview with an interpreter.

Coding Instructions

Attempt to complete the interview with all residents.
•

•

Code 0, no: if the resident is rarely/never understood or an interpreter is required but

not available. Skip to Indicators of Pain or Possible Pain item (J0800).
Code 1, yes: if the resident is at least sometimes understood and an interpreter is
present or not required. Continue to Pain Presence.

Coding Tips and Special Populations

•

If the resident interview should have been conducted, but was not done within the lookback period of the ARD (except when an interpreter is needed/requested and
unavailable), item J0200 must be coded 1, Yes, and the standard “no information” code
(a dash “—”) entered in the Pain Assessment Interview items (J0300–J0600). Item J0700,
Should the Staff Assessment for Pain be Conducted?, is coded 0, No.

•

Do not complete the Staff Assessment for Pain items (J0800–J0850) if the Pain
Assessment Interview should have been conducted but was not done.

•

If it is not possible for an interpreter to be present during the look-back period, code
J0200 = 0 to indicate the Pain Assessment Interview was not attempted, skip the Pain
Assessment Interview items (J0300–J0600), and complete the Staff Assessment of Pain
item (J0800).

October 2024

•

Page J-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0300–J0600: Pain Assessment Interview

D
October 2024

Page J-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0300–J0600: Pain Assessment Interview (cont.)
Item Rationale
Health-related Quality of Life
•
•
•

The effects of unrelieved pain impact the individual in terms of functional decline,
complications of immobility, skin breakdown and infections.
Pain significantly adversely affects a person’s quality of life and is tightly linked to
depression, diminished self-confidence and self-esteem, as well as an increase in
behavior problems, particularly for cognitively impaired residents.
Some older adults limit their activities in order to avoid having pain. Their report of
lower pain frequency may reflect their avoidance of activity more than it reflects
adequate pain management.

Planning for Care

•

•
•
•

•

October 2024

•
•
•

•
•

Directly asking the resident about pain rather than relying on the resident to volunteer the
information or relying on clinical observation significantly improves the detection of
pain.
Resident self-report is the most reliable means for assessing pain.
Pain assessment provides a basis for evaluation, treatment need, and response to
treatment.
Assessing whether pain interferes with sleep or activities provides additional
understanding of the functional impact of pain and potential care planning implications.
Assessment of pain provides insight into the need to adjust the timing of pain
interventions to better cover sleep or preferred activities.
The assessment of pain is not associated with any particular approach to pain
management. Since the use of opioids is associated with serious complications, an array
of successful nonpharmacologic and nonopioid approaches to pain management may be
considered. There are a range of pain management strategies that can be used, including
but not limited to non-opioid analgesic medications, transcutaneous electrical nerve
stimulation (TENS) therapy, supportive devices, acupuncture, biofeedback, application of
heat/cold, massage, physical therapy, nerve block, stretching and strengthening exercises,
chiropractic, electrical stimulation, radiotherapy, and ultrasound.
Pain assessment prompts discussion about factors that aggravate and alleviate pain.
Similar pain stimuli can have varying impact on different individuals.
Consistent use of a standardized pain intensity scale improves the validity and reliability
of pain assessment. Using the same scale in different settings may improve continuity of
care.
Pain intensity scales allow providers to evaluate whether pain is responding to pain
medication regimen(s) and/or nonpharmacological intervention(s).

Page J-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0300–J0600: Pain Assessment Interview (cont.)
Steps for Assessment: Basic Interview Instructions for Pain
Assessment Interview (J0300-J0600)

1. Interview any resident not screened out by the Should Pain Assessment Interview be
Conducted? item (J0200).
2. The Pain Assessment Interview for residents consists of seven items: the primary question
Pain Presence item (J0300) and six follow-up questions. If the resident is unable to answer
the primary question on Pain Presence item J0300, skip to the Staff Assessment for Pain
beginning with Indicators of Pain or Possible Pain item (J0800).
3. Conduct the interview in a private setting.
4. Be sure the resident can hear you.
• Residents with hearing impairment should be tested using their usual communication
devices/techniques, as applicable.
• Try an external assistive device (headphones or hearing amplifier) if you have any doubt
about hearing ability.
• Minimize background noise.
5. Sit so that the resident can see your face. Minimize glare by directing light sources away
from the resident’s face.
6. Give an introduction before starting the interview. Suggested language: “I’d like to ask you
some questions about pain. The reason I am asking these questions is to understand how
often you have pain, how severe it is, and how pain affects your daily activities. This will
help us to develop the best plan of care to help manage your pain.”
7. Directly ask the resident each item in the Pain Assessment
DEFINITION
Interview in the order provided.
PAIN
• Use other terms for pain or follow-up discussion if the
resident seems unsure or hesitant. Some residents avoid Any type of physical pain or
discomfort in any part of the
use of the term “pain” but may report that they “hurt.”
body. It may be localized to
Residents may use other terms such as “aching” or
one area or may be more
“burning” to describe pain.
generalized. It may be acute
or chronic, continuous or
8. If the resident chooses not to answer a particular item,
intermittent, or occur at rest
accept their refusal, code 9, and move on to the next item.
9. If the resident is unsure about whether pain or the effects or or with movement. Pain is
very subjective; pain is
interference of pain occurred in the last 5 days, prompt the
whatever the experiencing
resident to think about the most recent episode of pain and
person says it is and exists
try to determine whether it occurred in the last 5 days.
whenever they say it does.

October 2024

Page J-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0300: Pain Presence

Steps for Assessment
1. Ask the resident: “Have you had pain or hurting at any time
in the last 5 days?”

Coding Instructions for J0300, Pain Presence

Code for the presence or absence of pain regardless of pain
management efforts in the last 5 days.
•

Code 0, no: if the resident responds “no” to having
any pain or hurting in the last 5 days. Code 0, no:

DEFINITION
NONSENSICAL
RESPONSE
Any unrelated,
incomprehensible, or
incoherent response that is
not informative with respect
to the item being coded.

even if the reason for no pain is that the resident received pain management interventions.
If coded 0, the pain interview is complete. Skip to Shortness of Breath item (J1100).

•

Code 1, yes: if the resident responds “yes” to having any pain or hurting in the last 5

•

Code 9, unable to answer: if the resident is unable to answer, does not respond, or

days. If coded 1, proceed to the Pain Assessment Interview.

gives a nonsensical response. If coded 9, skip to the Staff Assessment for Pain.

Coding Tips
•

Rates of self-reported pain are higher than observed rates. Although some observers have
expressed concern that residents may not complain and may deny pain, the regular and
objective use of self-report pain scales enhances residents’ willingness to report.

Examples

1. When asked about pain, Resident S responds, “No. I have been taking the pain medication
regularly, so fortunately I have had no pain.”
Coding: J0300 would be coded 0, no.

Rationale: Resident S reports having no pain during the look-back period. Even though

they received pain management interventions during the look-back period, the item is
coded “No,” because there was no pain.
2. When asked about pain, Resident T responds, “No pain, but I have had a terrible burning
sensation all down my leg.”
Coding: J0300 would be coded 1, yes.

Rationale: Although Resident T’s initial response is “no,” the comments indicate that

they have experienced pain (burning sensation) during the look-back period.

October 2024

Page J-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0300: Pain Presence (cont.)
3. When asked about pain, Resident G responds, “I was on a train in 1905.”
Coding: J0300 would be coded 9, unable to respond.
Rationale: Resident G has provided a nonsensical answer to the question. The assessor

will complete the Staff Assessment for Pain.

J0410: Pain Frequency

D
Steps for Assessment

1. Ask the resident: “How much of the time have you experienced pain or hurting over the last
5 days?” Staff may present response options on a written sheet or cue card. This can help the
resident respond to the items.
2. If the resident provides a related response but does not use the provided response scale, help
clarify the best response by echoing (repeating) the resident’s own comment and providing
related response options. This interview approach frequently helps the resident clarify which
response option they prefer.
3. If the resident, despite clarifying statement and repeating response options, continues to have
difficulty selecting between two of the provided responses, then select the more frequent of
the two.

Coding Instructions

Code for pain frequency over the last 5 days.
•

Code 1, Rarely or not at all: if the resident responds “rarely” to the question.

•

Code 2, Occasionally: if the resident responds “occasionally” to the question.

•

Code 3, Frequently: if the resident responds “frequently” to the question.

•

Code 4, Almost constantly: if the resident responds “almost constantly” to the

•

Code 9, Unable to answer: if the resident is unable to respond, does not respond, or

question.

gives a nonsensical response.

October 2024

Page J-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0410: Pain Frequency (cont.)
Coding Tips
•

No predetermined definitions are offered to the resident related to frequency of pain.
— The response should be based on the resident’s interpretation of the frequency
options.
— Facility policy should provide standardized tools to use throughout the facility in
assessing pain to ensure consistency in interpretation and documentation of the
resident’s pain.

Examples

1. When asked about pain, Resident C responds, “All the time. It has been a terrible week. I
have not been able to get comfortable for more than 10 minutes at a time since I started
physical therapy four days ago.”
Coding: J0410 would be coded 4, Almost constantly.
Rationale: Resident C describes pain that has occurred “all the time.”

2. When asked about pain, Resident J responds, “I don’t know if it is frequent or occasional.
My knee starts throbbing every time they move me from the bed or the wheelchair.”
The interviewer says: “Your knee throbs every time they move you. If you had to choose
an answer, would you say that you have pain frequently or occasionally?”
Resident J is still unable to choose between frequently and occasionally.
Coding: J0410 would be coded 3, Frequently.
Rationale: The interviewer appropriately echoed Resident J’s comment and provided

related response options to help them clarify which response they preferred. Resident J.
remained unable to decide between frequently and occasionally. The interviewer
therefore coded for the higher frequency of pain.
3. When asked about pain, Resident K responds: “I can’t remember. I think I had a headache a
few times in the past couple of days, but they gave me acetaminophen and the headaches
went away.”
The interviewer clarifies by echoing what Resident K said: “You’ve had a headache a
few times in the past couple of days and the headaches went away when you were given
acetaminophen. If you had to choose from the answers, would you say you had pain
occasionally or rarely?”
Resident K replies “Occasionally.”
Coding: J0410 would be coded 2, Occasionally.
Rationale: After the interviewer clarified the resident’s choice using echoing, the

resident selected a response option.

October 2024

Page J-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0410: Pain Frequency (cont.)
4. When asked about pain, Resident M responds, “I would say rarely. Since I started using the
patch, I don’t have much pain at all, but four days ago the pain came back. I think they were
a bit overdue in putting on the new patch, so I had some pain for a little while that day.”
Coding: J0410 would be coded 1, Rarely or not at all.
Rationale: Resident M selected the “Rarely or not at all” response option.

J0510: Pain Effect on Sleep

D
Steps for Assessment

Coding Instructions

1. Read the question and response choices exactly as they are written.
2. No predetermined definitions are offered to the resident. The resident’s response should be
based on their interpretation of frequency response options.
3. If the resident’s response does not lead to a clear answer, repeat the resident’s response and
then try to narrow the focus of the response. For example, if the resident responded to the
question, “Over the past 5 days, how much of the time has pain made it hard for you to sleep
at night?” by saying, “I always have trouble sleeping,” then the assessor
might reply, “You always have trouble sleeping. Is it your pain that makes it hard for you to
sleep?” The assessor can then narrow down responses with additional follow-up questions
about the frequency.
Code for pain effect on sleep over the last 5 days.
•
•
•
•
•

Code 1, Rarely or not at all: if the resident responds that pain has rarely or not at all

made it hard to sleep over the past 5 days.
Code 2, Occasionally: if the resident responds that pain has occasionally made it
hard to sleep over the past 5 days.
Code 3, Frequently: if the resident responds that pain has frequently made it hard to
sleep over the past 5 days.
Code 4, Almost constantly: if the resident responds that pain has almost constantly
made it hard to sleep over the past 5 days.
Code 8, Unable to answer: if the resident is unable to answer the question, does not
respond or gives a nonsensical response.

October 2024

Page J-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0510: Pain Effect on Sleep (cont.)
Coding Tips
•
•

This item should be coded based on the resident’s interpretation of the provided response
options for frequency. If the resident is unable to decide between two options, then the
assessor should code for the option with the higher frequency.
If the resident reports they had pain over the past 5 days and the pain does not interfere
with their sleep (e.g., because the resident is using pain management strategies
successfully), code 1, Rarely or not at all.

Examples

1. When asked, “Over the past 5 days, how much of the time has pain made it hard for you to
sleep at night?” the resident replied, “I’ve had a little back pain from being in the wheelchair
all day, but it felt so much better when I went to bed. The pain hasn’t kept me from sleeping
at all.”
Coding: J0510 would be coded 1, Rarely or not at all.
Rationale: The resident reports pain has been present over the past 5 days but that they

have had no sleep problems related to pain.
2. When asked, “Over the past 5 days, how much of the time has pain made it hard for you to
sleep at night?” the resident responded, “All the time. It’s been hard for me to sleep all the
time. I have to ask for extra pain medicine, and I still wake up several times during the night
because my back hurts so much.”

Coding: J0510 would be coded 4, Almost constantly.
Rationale: The resident reports pain-related sleep problems “all the time” over the past

5 days, so the most applicable response is “Almost constantly.”

ft
October 2024

Page J-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0520: Pain Interference with Therapy Activities

Steps for Assessment
1. Read the question and response choices as written.

Coding Instructions

Code for pain interference with therapy activities over the last 5 days.
•

•

Coding Tips
•

•

that they did not participate in rehabilitation therapy for DEFINITION
reasons unrelated to pain (e.g., therapy not needed,
REHABILITATION
unable to schedule) over the past 5 days.
THERAPY
Code 1, Rarely or not at all: if the resident
Special healthcare services
or programs that help a
responds that pain has rarely or not at all limited their
participation in rehabilitation therapy sessions over the person regain physical,
mental, and/or cognitive
past 5 days.
(thinking and learning)
Code 2, Occasionally: if the resident responds that
abilities that have been lost
pain has occasionally limited their participation in
or impaired as a result of
rehabilitation therapy sessions over the past 5 days.
disease, injury, or treatment.
Can include, for example,
Code 3, Frequently: if the resident responds that
physical therapy,
pain has frequently limited their participation in
occupational therapy, speech
rehabilitation therapy sessions over the past 5 days.
therapy, and cardiac and
Code 4, Almost constantly: if the resident
pulmonary therapies.
responds that pain has almost constantly limited their
participation in rehabilitation therapy sessions over the past 5 days.
Code 8, Unable to answer: if the resident is unable to answer the question, does not
respond, or gives a nonsensical response.

•

Code 0, Does not apply: if the resident responds

October 2024

Page J-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0520: Pain Interference with Therapy Activities (cont.)
•
•

Rehabilitation therapies may include treatment supervised in person by a therapist or
nurse or other staff or the resident carrying out a prescribed therapy program without staff
members present.
Rehabilitation therapies do not include restorative nursing programs.

Example
1. When asked, “Over the past 5 days, how often have you limited your participation in
rehabilitation therapy sessions due to pain?” the resident responded, “Since the surgery a
week ago, the pain has made it hard to even get out of bed. I try to push myself, but the pain
frequently limits how much I can do with my therapist.”

Coding: J0520 would be coded 3, Frequently.
Rationale: The resident reports that pain frequently limited participation in therapies
over the past 5 days.

J0530: Pain Interference with Day-to-Day Activities

Steps for Assessment

1. Read the question and response choices as written.

Coding Instructions

Code for pain interference with day-to-day activities over the last 5 days.
•
•
•
•

Code 1, Rarely or not at all: if the resident responds that pain has rarely or not at all

limited their day-to-day activities (excluding rehabilitation therapy sessions) over the past
5 days.
Code 2, Occasionally: if the resident responds that pain has occasionally limited
their day-to-day activities (excluding rehabilitation therapy sessions) over the past 5
days.
Code 3, Frequently: if the resident responds that pain has frequently limited their
day-to-day activities (excluding rehabilitation therapy sessions) over the past 5 days.
Code 4, Almost constantly: if the resident responds that pain has almost constantly
limited their day-to-day activities (excluding rehabilitation therapy sessions) over the
past 5 days.

October 2024

Page J-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0530: Pain Interference with Day-to-Day Activities (cont.)
•

Code 8, Unable to answer: if the resident is unable to answer the question, does not

respond, or gives a nonsensical response.

Coding Tips
•

Examples

1. When asked, “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?” the resident responded,
“Although I have some pain in my back, I’m still able to read, eat my meals, and take walks
like I usually do.”
Coding: J0530 would be coded 1, Rarely or not at all.
Rationale: The resident reports that pain has not limited their participation in day-to-

day activities over the past 5 days.

2. When asked, “Over the past 5 days, how often have you limited your day-to-day activities
(excluding rehabilitation therapy sessions) because of pain?” the resident responded, “The
pain has made it hard to do pretty much anything. Even getting out of bed to brush my teeth
has been hard. I haven’t been able to talk to my family because the pain is so bad. It’s just
constant. I’d say it constantly limits what I do.”
Coding: J0530 would be coded 4, Almost constantly.
Rationale: The resident reports that pain has constantly limited their participation in

other activities over the past 5 days.

ft
October 2024

Page J-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0600: Pain Intensity

Steps for Assessment

1. You may use either the Numeric Rating Scale item (J0600A) or the Verbal Descriptor
Scale item (J0600B) to interview the resident about pain intensity.
• For each resident, try to use the same scale used on prior assessments.
2. If the resident is unable to answer using one scale, the other scale should be attempted.
3. Record either the Numeric Rating Scale item or the Verbal Descriptor Scale item. Leave
the response for the unused scale blank.
4. Read the question and item choices slowly. While reading, you may show the resident the
response options (the Numeric Rating Scale or Verbal Descriptor Scale) clearly printed on
a piece of paper, such as a cue card. Use large, clear print.
• For the Numeric Rating Scale, say, “Please rate your worst pain over the last 5 days
with zero being no pain, and ten as the worst pain you can imagine.”
• For Verbal Descriptor Scale, say, “Please rate the intensity of your worst pain over the
last 5 days.”
5. The resident may provide a verbal response, point to the written response, or both.

Coding Instructions for J0600A. Numeric Rating Scale (00-10)

Enter the two digit number (00-10) indicated by the resident as corresponding to the intensity of
their worst pain over the last 5 days, where zero is no pain, and 10 is the worst pain imaginable.
•
•

Enter 99 if unable to answer.
If the Numeric Rating Scale is not used, leave the response box blank.

Coding Instructions for J0600B. Verbal Descriptor Scale
•

Code 1, mild: if resident indicates that their pain is “mild.”

•

Code 2, moderate: if resident indicates that their pain is “moderate.”

•

Code 3, severe: if resident indicates that their pain is “severe.”

•

Code 4, very severe, horrible: if resident indicates that their pain is “very severe or

horrible.”

October 2024

Page J-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0600: Pain Intensity (cont.)
•
•

Code 9, unable to answer: if resident is unable to answer, chooses not to respond,

does not respond or gives a nonsensical response.
If the Verbal Descriptor Scale is not used, leave the response box blank.

Examples for J0600A. Numeric Rating Scale (00-10)
1. The nurse asks Resident T to rate their pain on a scale of 0 to 10. Resident T states that they
are not sure, because they have shoulder pain and knee pain, and sometimes it is really bad,
and sometimes it is OK. The nurse reminds Resident T to think about all the pain they had
over the last 5 days and select the number that describes their worst pain. They report that
their pain is a “6.”

Coding: J0600A would be coded 06.
Rationale: The resident said their pain was 6 on the 0 to 10 scale. Because a 2-digit

number is required, it is entered as 06.

2. The nurse asks Resident S to rate their pain, reviews use of the scale, and provides the 0 to 10
visual aid. Resident S says, “My pain doesn’t have any numbers.” The nurse explains that the
numbers help the staff understand how severe their pain is and repeats that the “0” end is no
pain and the “10” end is the worst pain imaginable. Resident S replies, “I don’t know where
it would fall.”
Coding: Item J0600A would be coded 99, unable to answer. The interviewer

would go on to ask about pain intensity using the Verbal Descriptor Scale item
(J0600B).
Rationale: The resident was unable to select a number or point to a location on the 0-10
scale that represented their level of pain intensity.

Examples for J0600B. Verbal Descriptor Scale

1. The nurse asks Resident R to rate their pain using the verbal descriptor scale. They look at
the response options presented using a cue card and say their pain is “severe” sometimes, but
most of the time it is “mild.”
Coding: J0600B would be coded 3, severe.
Rationale: The resident said their worst pain was “Severe.”

2. The nurse asks Resident U to rate their pain, reviews use of the verbal descriptor scale, and
provides a cue card as a visual aid. Resident U says, “I’m not sure whether it’s mild or
moderate.” The nurse reminds Resident U to think about their worst pain over the last 5 days.
Resident U says, “At its worst, it was moderate.”
Coding: Item J0600B would be coded 2, moderate.
Rationale: The resident indicated that their worst pain was “Moderate.”

October 2024

Page J-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0700: Should the Staff Assessment for Pain be Conducted?

Item Rationale
Item J0700 closes the pain interview and determines if the resident interview was complete or
incomplete and based on this determination, whether a staff assessment should be completed.

Health-related Quality of Life
•

Resident interview for pain is preferred because it
improves the detection of pain. However, a small
percentage of residents are unable or unwilling to
complete the pain interview.

•

Persons unable to complete the pain interview may still
have pain.

Planning for Care

DEFINITION
COMPLETED PAIN
ASSESSMENT
INTERVIEW
The Pain Assessment
Interview is successfully
completed if the resident
reported no pain (J0300 =
0. No), or if the resident
reported pain (J0300 =
1. Yes) and the follow-up
question J0410 is answered.

Resident self-report is the most reliable means of
assessing pain. However, when a resident is unable to
provide the information, staff assessment is necessary.

•

Even though the resident was unable to complete the interview, important insights may
be gained from the responses that were obtained, observing behaviors and observing the
resident’s affect during the interview.

•

Steps for Assessment

1. The Staff Assessment for Pain should only be completed if the Pain Assessment Interview
(J0300–J0600) was not completed.

Coding Instructions for J0700. Should the Staff Assessment for Pain
be Conducted?
•
•

Code 0, no: if the resident completed the Pain Assessment Interview item (J0410 =
1, 2, 3, or 4). Skip to Shortness of Breath (dyspnea) item (J1100).
Code 1, yes: if the resident was unable to complete the Pain Assessment Interview
(J0410 = 9). Continue to Indicators of Pain or Possible Pain item (J0800).

October 2024

Page J-19

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0800: Indicators of Pain

Item Rationale
Health-related Quality of Life

Residents who cannot verbally communicate about their pain are at particularly high risk
for under-detection and undertreatment of pain.

•

Severe cognitive impairment may affect the ability of residents to verbally communicate,
thus limiting the availability of self-reported information about pain. In this population,
fewer complaints may not mean less pain.

•

Individuals who are unable to verbally communicate may be more likely to use
alternative methods of expression to communicate their pain.

•

Even in this population some verbal complaints of pain may be made and should be taken
seriously.

•

Planning for Care

Consistent approach to observation improves the accuracy of pain assessment for
residents who are unable to verbally communicate their pain.

•

Particular attention should be paid to using the indicators of pain during activities when
pain is most likely to be demonstrated (e.g., bathing, transferring, dressing, walking and
potentially during eating).

•

Staff must carefully monitor, track, and document any possible signs and symptoms of
pain.

•

Identification of these pain indicators can:

•

— provide a basis for more comprehensive pain assessment,

— provide a basis for determining appropriate treatment, and

— provide a basis for ongoing monitoring of pain presence and treatment response.
•

If pain indicators are present, assessment should identify aggravating/alleviating factors
related to pain.

October 2024

Page J-20

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0800: Indicators of Pain (cont.)
Steps for Assessment

•

DEFINITIONS
NON VERBAL SOUNDS
e.g., crying, whining,
gasping, moaning, groaning
or other audible indications
associated with pain.
VOCAL COMPLAINTS
OF PAIN
e.g., “That hurts,” “ouch,”
“stop,” etc.
FACIAL EXPRESSIONS
THAT MAY BE
INDICATORS OF PAIN
e.g., grimaces, winces,
wrinkled forehead, furrowed
brow, clenched teeth or jaw,
etc.

1. Review the medical record for documentation of
each indicator of pain listed in J0800 that occurred in the
last 5 days. If the record documents the presence of any of
the signs and symptoms listed, confirm your record review
with the direct care staff on all shifts who work most
closely with the resident during activities of daily living
(ADL).
2. Interview staff because the medical record may fail to
note all observable pain behaviors. For any indicators that
were not noted as present in medical record review,
interview direct care staff on all shifts who work with the
resident during ADL. Ask directly about the presence of
each indicator that was not noted as being present in the
record.
3. Observe resident during care activities. If you observe
additional indicators of pain in the last 5 days code the
corresponding items.
Observations for pain indicators may be more sensitive
if the resident is observed during ADL, or wound care.

Coding Instructions

Check all that apply in the last 5 days based on staff
observation of pain indicators.

PROTECTIVE BODY
MOVEMENTS OR
POSTURES
e.g., bracing, guarding,
rubbing or massaging a body
part/area, clutching or
holding a body part during
movement, etc.

If the medical record review and the interview with
direct care providers and observation on all shifts
provide no evidence of pain indicators, Check J0800Z, None of these signs observed or
documented, and proceed to the Shortness of Breath item (J1100).

•

Check J0800A, nonverbal sounds: included but not limited to if crying, whining,
gasping, moaning, or groaning were observed or reported in the last 5 days.

•

Check J0800B, vocal complaints of pain: included but not limited to if the

•

Check J0800C, facial expressions: included but not limited to if grimaces,

•

Check J0800D, protective body movements or postures: included but not

•

resident was observed to or reported to have made vocal complaints of pain (e.g. “that
hurts,” “ouch,” or “stop”) in the last 5 days.
winces, wrinkled forehead, furrowed brow, clenched teeth or jaw were observed or
reported in the last 5 days.
limited to if bracing, guarding, rubbing or massaging a body part/area, or clutching or
holding a body part during movement were observed or reported in the last 5 days.

October 2024

Page J-21

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0800: Indicators of Pain (cont.)
•

Check J0800Z, none of these signs observed or documented: if none of

these signs were observed or reported in the last 5 days.

Coding Tips
•

Behavior change, depressed mood, rejection of care and decreased activity participation
may be related to pain. These behaviors and symptoms are identified in other sections and
not reported here as pain screening items. However, the contribution of pain should be
considered when following up on those symptoms and behaviors.

Examples

1. Resident P has advanced dementia and is unable to verbally communicate. A note in their
medical record documents that they have been awake during the last night crying and rubbing
their elbow. When you go to their room to interview the certified nurse aide (CNA) caring
for them, you observe Resident P grimacing and clenching their teeth. The CNA reports that
they have been moaning and said “ouch” when the CNA tried to move their arm.
Coding: Nonverbal Sounds item (J0800A); Vocal Complaints of Pain item (J0800B);
Facial Expressions item (J0800C); and Protective Body Movements or Postures item
(J0800D), would be checked.

Rationale: Resident P has demonstrated vocal complaints of pain (ouch), nonverbal

sounds (crying and moaning), facial expression of pain (grimacing and clenched teeth),
and protective body movements (rubbing their elbow).
2. Resident M has end-stage Parkinson’s disease and is unable to verbally communicate. There is
no documentation of pain in their medical record in the last 5 days. The CNAs caring for them
report that on some mornings they moan and wince when their arms and legs are moved
during morning care. During direct observation, you note that Resident M cries and attempts
to pull their hand away when the CNA tries to open the contracted hand to wash it.
Coding: Nonverbal Sounds items (J0800A); Facial Expressions item (J0800C); and
Protective Body Movements or Postures item (J0800D), would be checked.
Rationale: Resident M has demonstrated nonverbal sounds (crying, moaning); facial
expression of pain (wince), and protective body movements (attempt to withdraw).
3. Resident E has been unable to verbally communicate following a massive cerebrovascular
accident (CVA) several months ago and has a Stage 3 pressure ulcer. There is no
documentation of pain in their medical record. The CNA who cares for them reports that they
do not seem to have any pain. You observe the resident during their pressure ulcer dressing
change. During the treatment, you observe groaning, facial grimaces, and a wrinkled
forehead.
Coding: Nonverbal Sounds item (J0800A), and Facial Expressions item (J0800C),
would be checked.
Rationale: The resident has demonstrated nonverbal sounds (groaning) and facial

expression of pain (wrinkled forehead and grimacing).

October 2024

Page J-22

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0800: Indicators of Pain (cont.)
Examples (cont.)
4. Resident S is in a persistent vegetative state following a traumatic brain injury. They are
unable to verbally communicate. There is no documentation of pain in their medical
record in the last 5 days. The CNA reports that they appear comfortable whenever the
CNA cares for them. You observe the CNA providing morning care and transferring them
from bed to chair. No pain indicators are observed at any time.
Coding: None of These Signs Observed or Documented item (J0800Z), would be
checked.
Rationale: All steps for the assessment have been followed and no pain indicators have

been documented, reported or directly observed.

J0850: Frequency of Indicator of Pain or Possible Pain

Item Rationale

Health-related Quality of Life
•

Unrelieved pain adversely affects function and mobility contributing to dependence, skin
breakdown, contractures, and weight loss.

•

Pain significantly adversely affects a person’s quality of life and is tightly linked to
depression, diminished self-confidence and self-esteem, as well as to an increase in
behavior problems, particularly for cognitively impaired residents.

•

Planning for Care

Assessment of pain frequency provides:

— A basis for evaluating treatment need and response to treatment.
— Information to aide in identifying optimum timing of treatment.

Steps for Assessment

1. Review medical record and interview staff and direct caregivers to determine the number of
days the resident either complained of pain or showed evidence of pain as described in J0800
in the last 5 days.

October 2024

Page J-23

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J0850: Frequency of Indicator of Pain or Possible Pain (cont.)
Coding Instructions
Code for pain frequency in the last 5 days.
•
•
•

Code 1: if based on staff observation, the resident complained or showed evidence of

pain 1 to 2 days.
Code 2: if based on staff observation, the resident complained or showed evidence of
pain 3 to 4 days.
Code 3: if based on staff observation, the resident complained or showed evidence of
pain on a daily basis.

Examples

1. Resident M is an 80-year-old individual with advanced dementia. During the last 5 days,
Resident M was noted to be grimacing and verbalizing “ouch” over the past 2 days when
their right shoulder was moved.
Coding: Item J0850 would be coded 1, indicators of pain observed 1 to 2
days.
Rationale: They have demonstrated vocal complaints of pain (“ouch”), facial

expression of pain (grimacing) on 2 of the last 5 days.
2. Resident C is a 78-year-old individual with a history of CVA with expressive aphasia and
dementia. In the last 5 days, the resident was noted on a daily basis to be rubbing their
right knee and grimacing.
Coding: Item J0850 would be coded 3, indicators of pain observed daily.
Rationale: The resident was observed with a facial expression of pain (grimacing) and

protective body movements (rubbing their knee) every day in the last 5 days.

J1100: Shortness of Breath (dyspnea)

Item Rationale

Health-related Quality of Life
•

Shortness of breath can be an extremely distressing symptom to residents and lead to
decreased interaction and quality of life.

•

Some residents compensate for shortness of breath by limiting activity. They sometimes
compensate for shortness of breath when lying flat by elevating the head of the bed and
do not alert caregivers to the problem.

October 2024

Page J-24

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1100: Shortness of Breath (dyspnea) (cont.)
Planning for Care
•
•

Shortness of breath can be an indication of a change in condition requiring further
assessment and should be explored.
The care plan should address underlying illnesses that may exacerbate symptoms of
shortness of breath as well as symptomatic treatment for shortness of breath when it is
not quickly reversible.

Steps for Assessment
Interview the resident about shortness of breath. Many residents, including those with mild to
moderate dementia, may be able to provide feedback about their own symptoms.

1. If the resident is not experiencing shortness of breath or trouble breathing during the
interview, ask the resident if shortness of breath occurs when they engage in certain
activities.
2. Review the medical record for staff documentation of the presence of shortness of breath or
trouble breathing. Interview staff on all shifts, and family/significant other regarding resident
history of shortness of breath, allergies or other environmental triggers of shortness of breath.
3. Observe the resident for shortness of breath or trouble breathing. Signs of shortness of breath
include: increased respiratory rate, pursed lip breathing, a prolonged expiratory phase,
audible respirations and gasping for air at rest, interrupted speech pattern (only able to say a
few words before taking a breath) and use of shoulder and other accessory muscles to
breathe.
4. If shortness of breath or trouble breathing is observed, note whether it occurs with certain
positions or activities.

Coding Instructions

Check all that apply during the 7-day look-back period.

•

•
•
•

Any evidence of the presence of a symptom of shortness of breath should be captured in this item.
A resident may have any combination of these symptoms.
Check J1100A: if shortness of breath or trouble breathing is present when the resident

is engaging in activity. Shortness of breath could be present during activity as limited as
turning or moving in bed during daily care or with more strenuous activity such as
transferring, walking, or bathing. If the resident avoids activity or is unable to engage in
activity because of shortness of breath, then code this as present.
Check J1100B: if shortness of breath or trouble breathing is present when the resident
is sitting at rest.
Check J1100C: if shortness of breath or trouble breathing is present when the resident
attempts to lie flat. Also code this as present if the resident avoids lying flat because of
shortness of breath.
Check J1100Z: if the resident reports no shortness of breath or trouble breathing and
the medical record and staff interviews indicate that shortness of breath appears to be
absent or well controlled with current medication.

October 2024

Page J-25

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1100: Shortness of Breath (dyspnea) (cont.)
Examples
1. Resident W has diagnoses of chronic obstructive pulmonary disease (COPD) and heart
failure. They are on 2 liters of oxygen and daily respiratory treatments. With oxygen they
are able to ambulate and participate in most group activities. They report feeling “winded”
when going on outings that require walking one or more blocks and have been observed
having to stop to rest several times under such circumstances. Recently, they describe
feeling “out of breath” when they try to lie down.
Coding: J1100A and J1100C would be checked.
Rationale: Resident W reported being short of breath when lying down as well as

during outings that required ambulating longer distances.
2. Resident T has used an inhaler for years. They are not typically noted to be short of breath.
Three days ago, during a respiratory illness, they had mild trouble with their breathing,
even when sitting in bed. Their shortness of breath also caused them to limit group
activities.
Coding: J1100A and J1100B would be checked.
Rationale: Resident T was short of breath at rest and was noted to avoid activities

because of shortness of breath.

J1300: Current Tobacco Use

Item Rationale

Health-related Quality of Life

The negative effects of smoking can shorten life expectancy and create health problems
that interfere with daily activities and adversely affect quality of life.

Planning for Care

•

This item opens the door to negotiation of a plan of care with the resident that includes
support for smoking cessation.

•

If cessation is declined, a care plan that allows safe and environmental accommodation of
resident preferences is needed.

Steps for Assessment
1. Ask the resident if they used tobacco in any form during the
7-day look-back period.
2. If the resident states that they used tobacco in some form
during the 7-day look-back period, code 1, yes.

October 2024

DEFINITION
TOBACCO USE
Includes tobacco used in any
form.

Page J-26

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1300: Current Tobacco Use (cont.)
3. If the resident is unable to answer or indicates that they did not use tobacco of any kind
during the look-back period, review the medical record and interview staff for any indication
of tobacco use by the resident during the look-back period.

Coding Instructions
•

Code 0, no: if there are no indications that the resident used any form of tobacco.

•

Code 1, yes: if the resident or any other source indicates that the resident used tobacco

in some form during the look-back period.

J1400: Prognosis

D
Item Rationale
•

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
•

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.

Steps for Assessment

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.

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.

October 2024

DEFINITION

Health-related Quality of Life

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.

Page J-27

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1400: Prognosis (cont.)

DEFINITIONS

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.

HOSPICE SERVICES
A program for terminally ill
persons where an array of
services is provided for the
palliation and management
of terminal illness and related
conditions. The hospice must
be licensed by the state as a
hospice provider and/or
certified under the Medicare
program as a hospice
provider. Under the hospice
program benefit regulations,
a physician is required to
document in the medical
record a life expectancy of
less than 6 months, so if a
resident is on hospice the
expectation is that the
documentation is in the
medical record.

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.

TERMINALLY ILL
“Terminally ill” means that
the individual has a medical
prognosis that their life
expectancy is 6 months or
less if the illness runs its
normal course.

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.

J1550: Problem Conditions

October 2024

Page J-28

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1550: Problem Conditions (cont.)
Intent: This item provides an opportunity for screening in the areas of fever, vomiting, fluid
deficits, and internal bleeding. Clinical screenings provide indications for further evaluation,
diagnosis and clinical care planning.

Item Rationale
Health-related Quality of Life
•

Timely assessment is needed to identify underlying causes and risk for complications.

Planning for Care
•

Implementation of care plans to treat underlying causes and avoid complications is
critical.

Steps for Assessment

1. Review the medical record, interview staff on all shifts and observe the resident for any
indication that the resident had vomiting, fever, potential signs of dehydration, or internal
bleeding during the 7-day look-back period.

Coding Instructions

Check all that apply (blue box)
•

J1550A, fever

•

J1550B, vomiting

•

J1550C, dehydrated

•

J1550D, internal bleeding

•

J1550Z, none of the above

Coding Tips
•

Fever: Fever is defined as a temperature 2.4 degrees F higher than baseline. The

•

Fever assessment prior to establishing base line temperature: A

•

Vomiting: Regurgitation of stomach contents; may be caused by many factors (e.g.,

resident’s baseline temperature should be established prior to the Assessment Reference
Date.
temperature of 100.4 degrees F (38 degrees C) on admission (i.e., prior to the
establishment of the baseline temperature) would be considered a fever.

drug toxicity, infection, psychogenic).

October 2024

Page J-29

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1550: Problem Conditions (cont.)
•

Dehydrated: Check this item if the resident presents with two or more of the following

potential indicators for dehydration:

1. Resident takes in less than the recommended 1,500 ml of fluids daily (water or
liquids in beverages and water in foods with high fluid content, such as gelatin and
soups). Note: The recommended intake level has been changed from 2,500 ml to
1,500 ml to reflect current practice standards.
2. Resident has one or more potential clinical signs (indicators) of dehydration,
including but not limited to dry mucous membranes, poor skin turgor, cracked
lips, thirst, sunken eyes, dark urine, new onset or increased confusion, fever, or
abnormal laboratory values (e.g., elevated hemoglobin and hematocrit, potassium
chloride, sodium, albumin, blood urea nitrogen, or urine specific gravity).
3. Resident’s fluid loss exceeds the amount of fluids they take in (e.g., loss from
vomiting, fever, diarrhea that exceeds fluid replacement).

•

Internal Bleeding: Bleeding may be frank (such as bright red blood) or occult (such

as guaiac positive stools). Clinical indicators include black, tarry stools, vomiting “coffee
grounds,” hematuria (blood in urine), hemoptysis (coughing up blood), and severe
epistaxis (nosebleed) that requires packing. However, nose bleeds that are easily
controlled, menses, or a urinalysis that shows a small amount of red blood cells should
not be coded as internal bleeding.

J1700: Fall History on Admission/Entry or Reentry

Item Rationale

Health-related Quality of Life
•

Falls are a leading cause of injury, morbidity, and mortality in older adults.

•

A previous fall, especially a recent fall, recurrent falls, and falls with significant injury
are the most important predictors of risk for future falls and injurious falls.

•

Persons with a history of falling may limit activities because of a fear of falling and
should be evaluated for reversible causes of falling.

October 2024

Page J-30

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1700: Fall History on Admission/Entry or
Reentry (cont.)
Planning for Care
•

Determine the potential need for further assessment and
intervention, including evaluation of the resident’s need
for rehabilitation or assistive devices.

•

Evaluate the physical environment as well as staffing
needs for residents who are at risk for falls.

Steps for Assessment

The period of review is 180 days (6 months) prior to admission,
looking back from the resident’s entry date (A1600).

FALL
Unintentional change in
position coming to rest on the
ground, floor or onto the next
lower surface (e.g., onto a
bed, chair, or bedside mat).
The fall may be witnessed,
reported by the resident or an
observer or identified when a
resident is found on the floor
or ground. Falls include any
fall, no matter whether it
occurred at home, while out
in the community, in an acute
hospital or a nursing home.
Falls are not a result of an
overwhelming external force
(e.g., a resident pushes
another resident).
An intercepted fall occurs
when the resident would
have fallen if they had not
caught themself or had not
been intercepted by another
person – this is still
considered a fall.

1. Ask the resident and family or significant other about a
history of falls in the month prior to admission and in the 6
months prior to admission. This would include any fall, no
matter where it occurred.
2. Review inter-facility transfer information (if the resident is
being admitted from another facility) for evidence of falls.
3. Review all relevant medical records received from facilities
where the resident resided during the previous 6 months;
also review any other medical records received for evidence
of one or more falls.

DEFINITION

Coding Instructions for J1700A, Did the
Resident Have a Fall Any Time in the
Last Month Prior to Admission/Entry or
Reentry?

CMS understands that
challenging a resident’s
balance and training them to
recover from a loss of
balance is an intentional
therapeutic intervention and
does not consider anticipated
losses of balance that occur
during supervised
therapeutic interventions as
intercepted falls.

Code 0, no: if resident and family report no falls and

•

Code 1, yes: if resident or family report or transfer

•

Code 9, unable to determine: if the resident is unable to provide the information or

•

transfer records and medical records do not document a
fall in the month preceding the resident’s entry date
item (A1600).

records or medical records document a fall in the month
preceding the resident’s entry date item (A1600).

if the resident and family are not available or do not have the information and medical
record information is inadequate to determine whether a fall occurred.

October 2024

Page J-31

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1700: Fall History on Admission/Entry or Reentry (cont.)
Coding Instructions for J1700B, Did the Resident Have a Fall Any
Time in the Last 2-6 Months prior to Admission/Entry or
Reentry?
•

Code 0, no: if resident and family report no falls and transfer records and medical

•

Code 1, yes: if resident or family report or transfer records or medical records

•

records do not document a fall in the 2-6 months prior to the resident’s entry date item
(A1600).

document a fall in the 2-6 months prior to the resident’s entry date item (A1600).
Code 9, unable to determine: if the resident is unable to provide the information,

or if the resident and family are not available or do not have the information, and medical
record information is inadequate to determine whether a fall occurred.

Coding Instructions for J1700C. Did the
Resident Have Any Fracture Related to a DEFINITION
Fall in the 6 Months prior to
FRACTURE RELATED
Admission/Entry or Reentry?
TO A FALL

•

Any documented bone
fracture (in a problem list
from a medical record, an xray report, or by history of the
resident or caregiver) that
occurred as a direct result of
a fall or was recognized and
later attributed to the fall. Do
not include fractures caused
by trauma related to car
crashes or pedestrian versus
car accidents or impact of
another person or object
against the resident.

related to falls and transfer records and medical records
do not document a fracture related to fall in the 6
months (0-180 days) preceding the resident’s entry date
item (A1600).
Code 1, yes: if resident or family report or transfer

records or medical records document a fracture related
to fall in the 6 months (0-180 days) preceding the
resident’s entry date item (A1600).
Code 9, unable to determine: if the resident is

•

Code 0, no: if resident and family report no fractures

•

unable to provide the information, or if the resident and
family are not available or do not have the information,
and medical record information is inadequate to determine whether a fall occurred.

Examples

1. On admission interview, Resident J is asked about falls and says they have "not really
fallen." However, they go on to say that when they went shopping with their child about 2
weeks ago, their walker got tangled with the shopping cart and they slipped down to the
floor.
Coding: J1700A would be coded 1, yes.
Rationale: Falls caused by slipping meet the definition of falls.

October 2024

Page J-32

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1700: Fall History on Admission/Entry or Reentry (cont.)

2. On admission interview a resident denies a history of falling. However, their child says that
they found their parent on the floor near their toilet twice about 3–4 months ago.
Coding: J1700B would be coded 1, yes.
Rationale: If the individual is found on the floor, a fall is assumed to have occurred.
3. On admission interview, Resident M and their family deny any history of falling. However,
nursing notes in the transferring hospital record document that Resident M repeatedly tried to
get out of bed unassisted at night to go to the bathroom and was found on a mat placed at
their bedside to prevent injury the week prior to nursing home transfer.
Coding: J1700A would be coded 1, yes.
Rationale: Medical records from an outside facility document that Resident M was
found on a mat on the floor. This is defined as a fall.
4. Medical records note that Resident K had hip surgery 5 months prior to admission to the
nursing home. Resident K’s child says the surgery was needed to fix a broken hip due to a
fall.
Coding: Both J1700B and J1700C would be coded 1, yes.
Rationale: Resident K had a fall related fracture 1–6 months prior to nursing home
entry.
5. Resident O’s hospital transfer record includes a history of osteoporosis and vertebral
compression fractures. The record does not mention falls, and Resident O denies any history
of falling.
Coding: J1700C would be coded 0, no.
Rationale: The fractures were not related to a fall.
6. Resident P has a history of a “Colles’ fracture” of their left wrist about 3 weeks before
nursing home admission. Their child recalls that the fracture occurred when Resident P
tripped on a rug and fell forward on their outstretched hands.
Coding: Both J1700A and J1700C would be coded 1, yes.
Rationale: Resident P had a fall-related fracture less than 1 month prior to entry.

October 2024

Page J-33

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1800: Any Falls Since Admission/Entry or Reentry or Prior
Assessment (OBRA or Scheduled PPS), whichever is more
recent

Item Rationale

DEFINITION

Health-related Quality of Life
•

Falls are a leading cause of morbidity and mortality
among nursing home residents.
Falls result in serious injury, especially hip fractures.
Fear of falling can limit an individual’s activity and negatively impact quality of life.

D
•
•

PRIOR ASSESSMENT
Most recent MDS
assessment that reported on
falls.

Planning for Care

•

•
•

Steps for Assessment

•

Identification of residents who are at high risk of falling is a top priority for care
planning. A previous fall is the most important predictor of risk for future falls.
Falls may be an indicator of functional decline and development of other serious
conditions such as delirium, adverse drug reactions, dehydration, and infections.
External risk factors include medication side effects, use of appliances and restraints, and
environmental conditions.
A fall should stimulate evaluation of the resident’s need for rehabilitation, ambulation
aids, modification of the physical environment, or additional monitoring (e.g., toileting,
to avoid incontinence).

1. If this is the first assessment/entry or reentry (A0310E = 1), review the medical record for the
time period from the admission date to the ARD.
2. If this is not the first assessment/entry or reentry (A0310E = 0), the review period is from the
day after the ARD of the last MDS assessment to the ARD of the current assessment.
3. Review all available sources for any fall since the last assessment, no matter whether it
occurred while out in the community, in an acute hospital, or in the nursing home. Include
medical records generated in any health care setting since last assessment.
4. Review nursing home incident reports, fall logs and the medical record (physician, nursing,
therapy, and nursing assistant notes).
5. Ask the resident and family about falls during the look-back period. Resident and family
reports of falls should be captured here whether or not these incidents are documented in the
medical record.

October 2024

Page J-34

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1800: Any Falls Since Admission/Entry or Reentry or Prior
Assessment (OBRA or Scheduled PPS), whichever is more
recent (cont.)
Coding Instructions
•

•

Code 0, no: if the resident has not had any fall since the last assessment. Skip to

Swallowing Disorder item (K0100) if the assessment being completed is an OBRA
assessment. If the assessment being completed is a Scheduled PPS assessment, skip to
Prior Surgery item (J2000).
Code 1, yes: if the resident has fallen since the last assessment. Continue to Number
of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or
Scheduled PPS) item (J1900), whichever is more recent.

Example

1. An incident report describes an event in which Resident S was walking down the hall and
appeared to slip on a wet spot on the floor. They lost their balance and bumped into the wall,
but were able to grab onto the hand rail and steady themself.
Coding: J1800 would be coded 1, yes.
Rationale: An intercepted fall is considered a fall.

ra
October 2024

Page J-35

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1900: Number of Falls Since Admission/Entry or Reentry or Prior
Assessment (OBRA or Scheduled PPS), whichever is more
recent

D
Item Rationale

Health-related Quality of Life

•

INJURY RELATED TO A
FALL
Any documented injury that
occurred as a result of, or
was recognized within a
short period of time (e.g.,
hours to a few days) after the
fall and attributed to the fall.

•
•

Falls are a leading cause of morbidity and mortality
among nursing home residents.
Falls result in serious injury, especially hip fractures.
Previous falls, especially recurrent falls and falls with
injury, are the most important predictor of future falls
and injurious falls.

DEFINITION

Planning for Care
•

•
•

•

October 2024

•

Identification of residents who are at high risk of falling DEFINITIONS
is a top priority for care planning.
INJURY (EXCEPT
Falls indicate functional decline and other serious
MAJOR)
conditions such as delirium, adverse drug reactions,
Includes skin tears,
dehydration, and infections.
abrasions, lacerations,
External risk factors include medication side effects,
superficial bruises,
use of appliances and restraints, and environmental
hematomas, and sprains; or
conditions.
any fall-related injury that
A fall should stimulate evaluation of the resident’s need causes the resident to
for rehabilitation or ambulation aids and of the need for complain of pain.
monitoring or modification of the physical
MAJOR INJURY
environment.
Includes bone fractures, joint
dislocations, closed head
It is important to ensure the accuracy of the level of
injuries with altered
injury resulting from a fall. Since injuries can present
consciousness, subdural
themselves later than the time of the fall, the assessor
hematoma.
may need to look beyond the ARD to obtain the
accurate information for the complete picture of the fall that occurs in the look back of
the MDS.

Page J-36

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1900: Number of Falls Since Admission/Entry or Reentry or Prior
Assessment (OBRA or Scheduled PPS), whichever is more
recent (cont.)
Steps for Assessment

1. If this is the first assessment (A0310E = 1), review the medical record for the time period
from the admission date to the ARD.
2. If this is not the first assessment (A0310E = 0), the review period is from the day after the
ARD of the last MDS assessment to the ARD of the current assessment.
3. Review all available sources for any fall since the last assessment, no matter whether it
occurred while out in the community, in an acute hospital, or in the nursing home. Include
medical records generated in any health care setting since last assessment. All relevant
records received from acute and post-acute facilities where the resident was admitted during
the look-back period should be reviewed for evidence of one or more falls.
4. Review nursing home incident reports and medical record (physician, nursing, therapy, and
nursing assistant notes) for falls and level of injury.
5. Ask the resident, staff, and family about falls during the look-back period. Resident and
family reports of falls should be captured here, whether or not these incidents are
documented in the medical record.
6. Review any follow-up medical information received pertaining to the fall, even if this
information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results),
and ensure that this information is used to code the assessment.

Coding Instructions for J1900

Determine the number of falls that occurred since admission/entry or reentry or prior
assessment (OBRA or Scheduled PPS) and code the level of fall-related injury for each. Code
each fall only once. If the resident has multiple injuries in a single fall, code the fall for the
highest level of injury.
•
•
•

Coding Instructions for J1900A, No Injury

Code 0, none: if the resident had no injurious fall since the admission/entry or reentry

or prior assessment (OBRA or Scheduled PPS).
Code 1, one: if the resident had one non-injurious fall since admission/entry or reentry
or prior assessment (OBRA or Scheduled PPS).
Code 2, two or more: if the resident had two or more non-injurious falls since
admission/entry or reentry or prior assessment (OBRA or Scheduled PPS).

Coding Instructions for J1900B, Injury (Except Major)
•
•

Code 0, none: if the resident had no injurious fall (except major) since admission/entry

or reentry or prior assessment (OBRA or Scheduled PPS).
Code 1, one: if the resident had one injurious fall (except major) since admission/entry
or reentry or prior assessment (OBRA or Scheduled PPS).

October 2024

Page J-37

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1900: Number of Falls Since Admission/Entry or Reentry or Prior
Assessment (OBRA or Scheduled PPS), whichever is more
recent (cont.)
•

Code 2, two or more: if the resident had two or more injurious falls (except major)

since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS).

Coding Instructions for J1900C, Major Injury
•
•

reentry or prior assessment (OBRA or Scheduled PPS).
Code 1, one: if the resident had one major injurious fall since admission/entry or
reentry or prior assessment (OBRA or Scheduled PPS).
Code 2, two or more: if the resident had two or more major injurious falls since
admission/entry or reentry or prior assessment (OBRA or Scheduled PPS).

•

Code 0, none: if the resident had no major injurious fall since admission/entry or

Coding Tip
•

Examples

If the level of injury directly related to a fall that occurred during the look-back period is
identified after the ARD and is at a different injury level than what was originally coded
on an assessment that was submitted to the Internet Quality Improvement and Evaluation
System (iQIES), the assessment must be modified to update the level of injury that
occurred with that fall.

1. A nursing note states that Resident K slipped out of their wheelchair onto the floor while at
the dining room table. Before being assisted back into their chair, a range of motion
assessment was completed that indicated no injury. A skin assessment conducted shortly
after the fall also revealed no injury.

Coding: J1900A would be coded 1, one.
Rationale: Slipping to the floor is a fall. No injury was noted.

2. Nurse’s notes describe a situation in which Resident Z went out with their family for dinner.
When they returned, their child stated that while at the restaurant, Resident Z fell in the
bathroom. No injury was noted when they returned from dinner.
Coding: J1900A would be coded 1, one.
Rationale: Falls during the nursing home stay, even if on outings, are captured here.

3. A nurse’s note describes a resident who, while being treated for pneumonia, climbed over
their bedrails and fell to the floor. They had a cut over their left eye and some swelling on
their arm. They were sent to the emergency room, where X-rays revealed no injury and
neurological checks revealed no changes in mental status.
Coding: J1900B would be coded 1, one.
Rationale: Lacerations and swelling without fracture are classified as injury (except

major).

October 2024

Page J-38

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J1900: Number of Falls Since Admission/Entry or Reentry or Prior
Assessment (OBRA or Scheduled PPS), whichever is more
recent (cont.)
4. A resident fell, lacerated their head, and head CT scan indicated a subdural hematoma.
Coding: J1900C would be coded 1, one.
Rationale: Subdural hematoma is a major injury. The injury occurred as a result of a

fall.

5. Resident R fell on their right hip in the facility on the ARD of their Quarterly MDS and
complained of mild right hip pain. The initial x-ray of the hip did not show any injury. The
nurse completed Resident R’s Quarterly assessment and coded the assessment to reflect this
information. The assessment was submitted to iQIES. Three days later, Resident R
complained of increasing pain and had difficulty ambulating, so a follow-up x-ray was done.
The follow-up x-ray showed a hairline fracture of the right hip. This injury is noted by the
physician to be attributed to the recent fall that occurred during the look-back period of the
Quarterly assessment.

pain.

Original Coding: J1900B, Injury (except major) is coded 1, one and J1900C,
Major Injury is coded 0, none.
Rationale: Resident R had a fall-related injury that caused them to complain of
Modification of Quarterly assessment: J1900B, Injury (except major) is
coded 0, none and J1900C, Major Injury, is coded 1, one.
Rationale: The extent of the injury did not present itself right after the fall;

however, it was directly related to the fall that occurred during the look-back period
of the Quarterly assessment. Since the assessment had been submitted to iQIES and
the level of injury documented on the submitted Quarterly was now found to be
different based on a repeat x-ray of the resident’s hip, the Quarterly assessment
needed to be modified to accurately reflect the injury sustained during that fall.

J2000: Prior Surgery

Item Rationale
Health-related Quality of Life
•

A recent history of major surgery during the 100 days prior to admission can affect a
resident’s recovery.

October 2024

Page J-39

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J2000: Prior Surgery (cont.)
Planning for Care
•

This item identifies whether the resident has had major
surgery during the 100 days prior to the start of the
Medicare Part A stay. A recent history of major surgery
can affect a resident’s recovery.

Steps for Assessment

1. Ask the resident and their family or significant other about
any surgical procedures in the 100 days prior to admission.
2. Review the resident’s medical record to determine whether
the resident had major surgery during the 100 days prior to
admission.
Medical record sources include medical records received
from facilities where the resident received health care
during the previous 100 days, the most recent history and
physical, transfer documents, discharge summaries,
progress notes, and other resources as available.

DEFINITION
MAJOR SURGERY
Refers to a procedure that
meets the following criteria:
1. The resident was an
inpatient in an acute care
hospital for at least 1 day
in the 100 days prior to
admission to the skilled
nursing facility (SNF), and
2. The surgery carried some
degree of risk to the
resident’s life or the
potential for severe
disability.

•

Coding Instructions

Code 0, No: if the resident did not have major surgery during the 100 days prior to

admission.

•

Code 1, Yes: if the resident had major surgery during the 100 days prior to admission.

•

Code 8, Unknown: if it is unknown or cannot be determined whether the resident had

major surgery during the 100 days prior to admission.

Examples

1. Resident T reports that they required surgical removal of a skin tag from their neck a month
and a half ago. They had the procedure as an outpatient. Resident T report no other surgeries
in the last 100 days.
Coding: J2000 would be coded 0, No.
Rationale: Resident T’s skin tag removal surgery did not require an acute care

inpatient stay; therefore, the skin tag removal does not meet the required criteria to be
coded as major surgery. Resident T did not have any other surgeries in the last 100 days.

October 2024

Page J-40

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J2000: Prior Surgery (cont.)
2. Resident A’s spouse informs their nurse that six months ago Resident A was admitted to the
hospital for five days following a bowel resection (partial colectomy) for diverticulitis.
Resident A’s spouse reports Resident A has had no other surgeries since the time of their
bowel resection.
Coding: J2000 would be coded 0, No.
Rationale: Bowel resection is a major surgery that has some degree of risk for death or

severe disability, and Resident A required a five-day hospitalization. However, the bowel
resection did not occur in the last 100 days; it happened six months ago, and Resident A
has not undergone any surgery since that time.

3. Resident G was admitted to the facility for wound care related to dehiscence of a surgical
wound subsequent to a complicated cholecystectomy. The attending physician also noted
diagnoses of anxiety, diabetes, and morbid obesity in their medical record. They were
transferred to the facility immediately following a four-day acute care hospital stay.
Coding: J2000 would be coded 1, Yes.
Rationale: In the last 100 days, Resident G underwent a complicated cholecystectomy,

which required a four-day hospitalization. They additionally had comorbid diagnoses of
diabetes, morbid obesity, and anxiety contributing some additional degree of risk for
death or severe disability.

J2100: Recent Surgery Requiring Active SNF Care

Item Rationale

Health-related Quality of Life
•

A recent history of major surgery during the inpatient stay that preceded the resident’s
Part A admission can affect a resident’s recovery.

Planning for Care
•

This item identifies whether the resident had major surgery during the inpatient stay that
immediately preceded the resident’s Part A admission. A recent history of major surgery
can affect a resident’s recovery.

October 2024

Page J-41

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J2100: Recent Surgery Requiring Active SNF Care (cont.)
Steps for Assessment
1. Ask the resident and their family or significant other about any surgical procedures that
occurred during the inpatient hospital stay that immediately preceded the resident’s Part A
admission.
2. Review the resident’s medical record to determine whether the resident had major surgery
during the inpatient hospital stay that immediately preceded the resident’s Part A admission.
Medical record sources include medical records received from facilities where the resident
received health care during the inpatient hospital stay that immediately preceded the
resident’s Part A admission, the most recent history and physical, transfer documents,
discharge summaries, progress notes, and other resources as available.

Coding Instructions
•

•

Code 0, No: if the resident did not have major surgery during the inpatient hospital stay

that immediately preceded the resident’s Part A admission.
Code 1, Yes: if the resident had major surgery during the inpatient hospital stay that
immediately preceded the resident’s Part A admission.
Code 8, Unknown: if it is unknown or cannot be determined whether the resident had
major surgery during the inpatient hospital stay that immediately preceded the resident’s
Part A admission.

Coding Tips
•

Generally, major surgery for item J2100 refers to a procedure that meets the following
criteria:
1. the resident was an inpatient in an acute care hospital for at least one day in the 30
days prior to admission to the skilled nursing facility (SNF), and
2. the surgery carried some degree of risk to the resident’s life or the potential for severe
disability.

October 2024

Page J-42

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J2300–J5000: Recent Surgeries Requiring Active SNF Care

D
Item Rationale

Health-related Quality of Life
•

A recent history of major surgery during the inpatient stay that preceded the resident’s
Part A admission can affect a resident’s recovery.

Planning for Care
•

October 2024

Page J-43

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J2300–J5000: Recent Surgeries Requiring Active SNF Care
(cont.)
Steps for Assessment
1. Identify recent surgeries: The surgeries in this section must have been documented by a
physician (nurse practitioner, physician assistant, or clinical nurse specialist if allowable
under state licensure laws) in the last 30 days and must have occurred during the inpatient
stay that immediately preceded the resident’s Part A admission.
Medical record sources for recent surgeries include progress notes, the most recent
history and physical, transfer documents, discharge summaries, diagnosis/problem list,
and other resources as available.

•

Although open communication regarding resident information between the physician and
other members of the interdisciplinary team is important, it is also essential that resident
information communicated verbally be documented in the medical record by the
physician to ensure follow-up.

•

Surgery information, including past history obtained from family members and close
contacts, must also be documented in the medical record by the physician to ensure
validity and follow-up.

2. Determine whether the surgeries require active care during the SNF stay: Once a recent
surgery is identified, it must be determined if the surgery requires active care during the SNF
stay. Surgeries requiring active care during the SNF stay are surgeries that have a direct
relationship to the resident’s primary SNF diagnosis, as coded in I0020B.
Do not include conditions that have been resolved, do not affect the resident’s current
status, or do not drive the resident’s plan of care during the 7-day look-back period, as
these would be considered surgeries that do not require active care during the SNF stay.

•

Check the following information sources in the medical record for the last 30 days to
identify “active” surgeries: transfer documents, physician progress notes, recent history
and physical, recent discharge summaries, nursing assessments, nursing care plans,
medication sheets, doctor’s orders, consults and official diagnostic reports, and other
sources as available.

Coding Instructions

•

Code surgeries that are documented to have occurred in the last 30 days, and during the
inpatient stay that immediately preceded the resident’s Part A admission, that have a direct
relationship to the resident’s primary SNF diagnosis, as coded in I0020B.
•

Check off each surgery requiring active SNF care as defined above, as follows:
— Surgeries are listed by major surgical category: Major Joint Replacement, Spinal
Surgery, Orthopedic Surgery, Neurologic Surgery, Cardiopulmonary Surgery,
Genitourinary Surgery, Other Major Surgery.

October 2024

Page J-44

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J2300–J5000: Recent Surgeries Requiring Active SNF Care
(cont.)
— Examples of surgeries are included for each surgical category. For example, J2810,
Genitourinary surgery - the kidneys, ureter, adrenals, and bladder—open,
laparoscopic, includes open or laparoscopic surgeries on the kidneys, ureter,
adrenals, and bladder, but not other components of the genitourinary system.
•

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, Spinal surgery - spinal cord or major spinal nerves

•

J2410, Spinal surgery - fusion of spinal bones

•

J2420, Spinal surgery - lamina, discs, or facets

•

J2499, Spinal surgery - other

•

Orthopedic Surgery

J2500, Ortho surgery - repair fractures of shoulder or arm

•

J2510, Ortho surgery - repair fractures of pelvis, hip, leg, knee, or ankle

•

J2520, Ortho surgery - repair but not replace joints

•

J2530, Ortho surgery - repair other bones

•

J2599, Ortho surgery - other

Neurologic Surgery

•

J2600, Neuro surgery - brain, surrounding tissue or blood vessels

•

J2610, Neuro surgery - peripheral and autonomic nervous system - open and
percutaneous

•

J2620, Neuro surgery - insertion or removal of spinal and brain neurostimulators,
electrodes, catheters, and CSF drainage devices

•

J2699, Neuro surgery - other

October 2024

Page J-45

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J2300–J5000: Recent Surgeries Requiring Active SNF Care
(cont.)
Cardiopulmonary Surgery
•

J2700, Cardiopulmonary surgery - heart or major blood vessels - open and
percutaneous procedures

•

J2710, Cardiopulmonary surgery - respiratory system, including lungs, bronchi,
trachea, larynx, or vocal cords - open and endoscopic

•

J2799, Cardiopulmonary surgery - other

Genitourinary Surgery
J2800, Genitourinary surgery - male or female organs

•

J2810, Genitourinary surgery - the kidneys, ureter, adrenals, and bladder - open,
laparoscopic

•

J2899, Genitourinary surgery - other

•

Other Major Surgery

J2900, Major surgery - tendons, ligament, or muscles

•

J2910, Major surgery - the GI tract and abdominal contents from the esophagus to the
anus, the biliary tree, gall bladder, liver, pancreas, spleen - open or laparoscopic

•

J2920, Major surgery - endocrine organs (such as thyroid, parathyroid), neck, lymph
nodes, and thymus - open

•

J2930, Major surgery - the breast

•

J2940, Major surgery - repair of deep ulcers, internal brachytherapy, bone marrow, or
stem cell harvest or transplant

•

J5000, Major surgery - not listed above

Coding Tips

•

The following information may assist assessors in determining whether a surgery should be
coded as requiring active care during the SNF stay.
•

There may be specific documentation in the medical record by a physician, nurse
practitioner, physician assistant, or clinical nurse specialist.
— The physician (nurse practitioner, physician assistant, or clinical nurse specialist if
allowable under state licensure laws) may specifically indicate that the SNF stay is
for treatment related to the surgical intervention. Specific documentation may be
found in progress notes, most recent history and physical, transfer notes, hospital
discharge summary, etc.

October 2024

Page J-46

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J2300–J5000: Recent Surgeries Requiring Active SNF Care
(cont.)
•

In the rare circumstance of the absence of specific documentation that a surgery
requires active SNF care, the following indicators may be used to confirm that the
surgery requires active SNF care:
The inherent complexity of the services prescribed for a resident is such that they can be
performed safely and/or effectively only by or under the general supervision of skilled
nursing. For example:
— The management of a surgical wound that requires skilled care (e.g., managing
potential infection or drainage).
— Daily skilled therapy to restore functional loss after surgical procedures.

— Administration of medication and monitoring that requires skilled nursing.

Examples of surgeries requiring active SNF care and related to the
primary SNF diagnosis

1. Resident V was hospitalized for gram-negative pneumonia. Since this was their second
episode of pneumonia in the past six months, a diagnostic bronchoscopy was performed
while in the hospital. They also have Parkinson’s disease and rheumatoid arthritis. They were
discharged to a SNF for continued antibiotic treatment for their pneumonia and require daily
skilled care.
Coding: I0020 is coded as 13, Medically Complex Conditions, and the I0020B SNF
ICD-10 code is J15.6, Pneumonia due to other aerobic Gram-negative bacteria. There is
no documentation that the resident had major surgery; therefore, J2100 is coded 0, No.
Rationale: Resident V did not receive any major surgery during the prior inpatient stay,
and they were admitted to the SNF for continued care due to pneumonia.

2. Resident O, a diabetic, was hospitalized for sepsis from an infection due to Methicillin
susceptible Staphylococcus aureus that developed after outpatient bunion surgery. A central
line was placed to administer antibiotics. They were discharged to a SNF for continued
antibiotic treatment and monitoring.
Coding: I0020 is coded as 13, Medically Complex Conditions. The I0020B SNF ICD-

10 code is A41.01 (Sepsis due to Methicillin susceptible Staphylococcus aureus). There is
no documentation that the resident had major surgery; therefore, J2100 is coded 0, No.
Rationale: Neither the placement of a central line nor the outpatient bunion surgery is
considered to be a major surgery, but the resident was admitted to the SNF for continued
antibiotic treatment and monitoring.

October 2024

Page J-47

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J2300–J5000: Recent Surgeries Requiring Active SNF Care
(cont.)
3. Resident H was hospitalized for severe back pain from a compression fracture of a lumbar
vertebral body, which was caused by their age-related osteoporosis. They were treated with a
kyphoplasty that relieved their pain. They were transferred to a SNF after discharge because
of their mild dementia and need to regulate their anticoagulant treatment for atrial fibrillation.
Coding: I0020 is coded 10, Fractures and Other Multiple Trauma. The I0020B SNF

ICD-10 code is M80.08XD (Age-related osteoporosis with current pathological fracture,
vertebra(e), subsequent encounter for fracture with routine healing). There was no
documentation that the resident had major surgery; therefore, J2100 is coded 0, No.
Rationale: Resident H was treated with a kyphoplasty during the inpatient stay prior to
SNF admission. Although kyphoplasty is a minor surgery and does not require SNF care
in and of itself, the resident has other conditions requiring skilled care that are unrelated
to the kyphoplasty surgery.

4. Resident J had a craniotomy to drain a subdural hematoma after suffering a fall at home.
They have COPD and use oxygen at night. In addition, they have moderate congestive heart
failure, are moderately overweight, and have hypothyroidism. After a six-day hospital stay,
they were discharged to a SNF for continuing care. The hospital discharge summary
indicated that the patient had a loss of consciousness of 45 minutes.
Coding: I0020 is coded 07, Other Neurological Conditions. The I0020B SNF ICD-10

code is S06.5X2D (Traumatic subdural hemorrhage with loss of consciousness of 31
minutes to 59 minutes, subsequent encounter). J2100 would be coded 1, Yes. J2600,
Neuro surgery - brain, surrounding tissue or blood vessels, would be checked.
Rationale: The craniotomy surgery during the inpatient stay immediately preceding the
SNF stay requires continued skilled care and skilled monitoring for wound care, as well
as therapies to address any deficits that led to their fall or any functional deficits resulting
from their fall.

5. Resident D was admitted to an acute care hospital for cytoreductive surgery for metastatic
renal cell carcinoma. They were admitted to the SNF for further treatment of the metastatic
renal cell carcinoma and post-surgical care.

Coding: I0020 is coded as 13, Medically Complex Conditions. The I0020B SNF ICD-

10 code is C79.01 (Secondary malignant neoplasm of the right kidney and renal pelvis).
J2100 would be coded 1, Yes. J2810, Genitourinary surgery – the kidneys, ureter,
adrenals, and bladder – open, laparoscopic, would be checked.
Rationale: Resident D was treated with a surgical procedure, genitourinary surgery of
the kidney, and admitted to the SNF for further treatment of the metastatic kidney cancer
and post-surgical care.

October 2024

Page J-48

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [J]

J2300–J5000: Recent Surgeries Requiring Active SNF Care
(cont.)
6. Resident G was admitted to an acute care hospital for severe abdominal pain. They were
found to have diverticulitis of the small intestine with perforation and abscess without
bleeding. They had surgery to repair the perforation. They were admitted to the SNF for
continued antibiotics and post-surgical care.
Coding: I0020 is coded 13, Medically Complex Conditions. The I0020B SNF ICD-10

code is K57.00 (Diverticulitis of small intestine with perforation and abscess without
bleeding), and J2100 would be coded 1, Yes. J2910, Major surgery – the GI tract and
abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver,
pancreas, spleen – open or laparoscopic, would be checked.
Rationale: Resident G was treated with a surgical procedure, repair of the small
intestine perforation, which is a major surgical procedure. They were admitted to the SNF
for continued antibiotics and post-surgical care.

7. Resident W underwent surgical repair for a left fractured hip (i.e., subtrochanteric fracture)
during an inpatient hospitalization. They were admitted to the SNF for post-surgical care.
Coding: I0020 is coded as Code 10, Fractures and Other Multiple Trauma. The I0020B

SNF ICD-10 code is S72.22XD (Displaced subtrochanteric fracture of left femur,
subsequent encounter for closed fracture with routine healing) and J2100 is coded as 1,
Yes. J2510, Ortho surgery – repair fractures of pelvis, hip, leg, knee, or ankle, would be
checked.
Rationale: This is major surgery requiring skilled nursing care to provide wound care
and to monitor for early signs of infection or blood clots, for which Resident W was
admitted to the SNF.

October 2024

Page J-49

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

SECTION K: SWALLOWING/NUTRITIONAL STATUS
Intent: The items in this section are intended to assess the many conditions that could affect
the resident’s ability to maintain adequate nutrition and hydration. This section covers
swallowing disorders, height and weight, weight loss, and nutritional approaches. The assessor
should collaborate with the dietitian and dietary staff to ensure that items in this section have
been assessed and calculated accurately.

K0100: Swallowing Disorder

Item Rationale
Health-related Quality of Life
•

•
•

•

Planning for Care

Care planning should include provisions for monitoring the resident during mealtimes
and during functions/activities that include the consumption of food and liquids.
When necessary, the resident should be evaluated by the physician, speech language
pathologist and/or occupational therapist to assess for any need for swallowing therapy
and/or to provide recommendations regarding the consistency of food and liquids.
Assess for signs and symptoms that suggest a swallowing disorder that has not been
successfully treated or managed with diet modifications or other interventions (e.g., tube
feeding, double swallow, turning head to swallow, etc.) and therefore represents a
functional problem for the resident.
Care plan should be developed to assist resident to maintain safe and effective swallow
using compensatory techniques, alteration in diet consistency, and positioning during and
following meals.

•

The ability to swallow safely can be affected by many disease processes and functional
decline.
Alterations in the ability to swallow can result in choking and aspiration, which can
increase the resident’s risk for malnutrition, dehydration, and aspiration pneumonia.

Steps for Assessment

1. Ask the resident if they have had any difficulty swallowing during the 7-day look-back
period. Ask about each of the symptoms in K0100A through K0100D.
Observe the resident during meals or at other times when they are eating, drinking, or
swallowing to determine whether any of the listed symptoms of possible swallowing disorder
are exhibited.

October 2024

Page K-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0100: Swallowing/Nutritional Status (cont.)
2. Interview staff members on all shifts who work with the resident and ask if any of the four
listed symptoms were evident during the 7-day look-back period.
3. Review the medical record, including nursing, physician, dietician, and speech language
pathologist notes, and any available information on dental history or problems. Dental
problems may include poor fitting dentures, dental caries, edentulous, mouth sores, tumors
and/or pain with food consumption.

Coding Instructions
Check all that apply.
•

K0100A, loss of liquids/solids from mouth when eating or drinking. When

the resident has food or liquid in their mouth, the food or liquid dribbles down chin or
falls out of the mouth.

•

K0100B, holding food in mouth/cheeks or residual food in mouth after
meals. Holding food in mouth or cheeks for prolonged periods of time (sometimes

labeled pocketing) or food left in mouth because resident failed to empty mouth
completely.

•
•

K0100C, coughing or choking during meals or when swallowing
medications. The resident may cough or gag, turn red, have more labored breathing,

•

or have difficulty speaking when eating, drinking, or taking medications. The resident
may frequently complain of food or medications “going down the wrong way.”
K0100D, complaints of difficulty or pain with swallowing. Resident may
refuse food because it is painful or difficult to swallow.
K0100Z, none of the above: if none of the K0100A through K0100D signs or
symptoms were present during the look-back period.

•
•

Coding Tips

Do not code a swallowing problem when interventions have been successful in treating
the problem and therefore the signs/symptoms of the problem (K0100A through
K0100D) did not occur during the 7-day look-back period.
Code even if the symptom occurred only once in the 7-day look-back period.

K0200: Height and Weight

October 2024

Page K-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0200: Height and Weight (cont.)
Item Rationale
Health-related Quality of Life
•

Diminished nutritional and hydration status can lead to debility that can adversely affect
health and safety as well as quality of life.

Planning for Care
•

Height and weight measurements assist staff with assessing the resident’s nutrition and
hydration status by providing a mechanism for monitoring stability of weight over a
period of time. The measurement of weight is one guide for determining nutritional
status.

Steps for Assessment for K0200A, Height
1. Base height on the most recent height since the most recent admission/entry or reentry.
Measure and record height in inches.
2. Measure height consistently over time in accordance with the facility policy and procedure,
which should reflect current standards of practice (shoes off, etc.).
3. For subsequent assessments, check the medical record. If the last height recorded was more
than one year ago, measure and record the resident’s height again.

Coding Instructions for K0200A, Height
•
•

Record height to the nearest whole inch.
Use mathematical rounding (i.e., if height measurement is X.5 inches or greater, round
height upward to the nearest whole inch. If height measurement number is X.1 to X.4
inches, round down to the nearest whole inch). For example, a height of 62.5 inches would
be rounded to 63 inches and a height of 62.4 inches would be rounded to 62 inches.

Steps for Assessment for K0200B, Weight

1. Base weight on the most recent measure in the last 30 days.
2. Measure weight consistently over time in accordance with facility policy and procedure,
which should reflect current standards of practice (shoes off, etc.).
3. For subsequent assessments, check the medical record and enter the weight taken within 30
days of the ARD of this assessment.
4. If the last recorded weight was taken more than 30 days prior to the ARD of this assessment
or previous weight is not available, weigh the resident again.
5. If the resident’s weight was taken more than once during the preceding month, record the
most recent weight.

Coding Instructions for K0200B, Weight
•

Use mathematical rounding (i.e., If weight is X.5 pounds [lbs] or more, round weight
upward to the nearest whole pound. If weight is X.1 to X.4 lbs, round down to the nearest
whole pound). For example, a weight of 152.5 lbs would be rounded to 153 lbs and a
weight of 152.4 lbs would be rounded to 152 lbs.

October 2024

Page K-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0200: Height and Weight (cont.)
•

If a resident cannot be weighed, for example because of extreme pain, immobility, or risk
of pathological fractures, use the standard no-information code (-) and document rationale
on the resident’s medical record.

K0300: Weight Loss

Item Rationale

DEFINITIONS

Health-related Quality of Life

•
•

•

Weight loss can result in debility and adversely affect
health, safety, and quality of life.
For persons with morbid obesity, controlled and careful
weight loss can improve mobility and health status.
For persons with a large volume (fluid) overload,
controlled and careful diuresis can improve health
status.

Planning for Care
•
•

Weight loss may be an important indicator of a change
in the resident’s health status or environment.
If significant weight loss is noted, the interdisciplinary
team should review for possible causes of changed
intake, changed caloric need, change in medication
(e.g., diuretics), or changed fluid volume status.
Weight should be monitored on a continuing basis;
weight loss should be assessed and care planned at the
time of detection and not delayed until the next MDS
assessment.

10% WEIGHT LOSS IN
180 DAYS
Start with the resident’s
weight closest to 180 days
ago and multiply it by .90 (or
90%). The resulting figure
represents a 10% loss from
the weight 180 days ago. If
the resident’s current weight
is equal to or less than the
resulting figure, the resident
has lost 10% or more body
weight.

•

5% WEIGHT LOSS IN 30
DAYS
Start with the resident’s
weight closest to 30 days ago
and multiply it by .95 (or
95%). The resulting figure
represents a 5% loss from
the weight 30 days ago. If the
resident’s current weight is
equal to or less than the
resulting figure, the resident
has lost more than 5% body
weight.

Steps for Assessment

This item compares the resident’s weight in the current observation period with their weight at
two snapshots in time:
•
•

At a point closest to 30-days preceding the current weight.
At a point closest to 180-days preceding the current weight.

October 2024

Page K-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0300: Weight Loss (cont.)
This item does not consider weight fluctuation outside of these two time points, although the
resident’s weight should be monitored on a continual basis and weight loss assessed and
addressed on the care plan as necessary.

For a New Admission

1. Ask the resident, family, or significant other about weight
loss over the past 30 and 180 days.
2. Consult the resident’s physician, review transfer
documentation, and compare with admission weight.
3. If the admission weight is less than the previous weight,
calculate the percentage of weight loss.
4. Complete the same process to determine and calculate
weight loss comparing the admission weight to the weight
30 and 180 days ago.

For Subsequent Assessments

PHYSICIANPRESCRIBED WEIGHTLOSS REGIMEN
A weight reduction plan
ordered by the resident’s
physician with the care plan
goal of weight reduction. May
employ a calorie-restricted
diet or other weight loss diets
and exercise. Also includes
planned diuresis. It is
important that weight loss is
intentional.
BODY MASS INDEX
(BMI)
Number calculated from a
person’s weight and height.
BMI is used as a screening
tool to identify possible
weight problems for adults.
Visit
http://www.cdc.gov/healthyw
eight/assessing/bmi/adult_b
mi/index.html.

Coding Instructions

1. From the medical record, compare the resident’s weight in
the current observation period to their weight in the
observation period 30 days ago.
2. If the current weight is less than the weight in the
observation period 30 days ago, calculate the percentage of
weight loss.
3. From the medical record, compare the resident’s weight in
the current observation period to their weight in the
observation period 180 days ago.
4. If the current weight is less than the weight in the
observation period 180 days ago, calculate the percentage
of weight loss.

DEFINITIONS

Mathematically round weights as described in Section K0200B before completing the weight loss
calculation.
•

Code 0, no or unknown: if the resident has not experienced weight loss of 5% or

•

Code 1, yes on physician-prescribed weight-loss regimen: if the resident
has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the
last 180 days, and the weight loss was planned and pursuant to a physician’s order. In
cases where a resident has a weight loss of 5% or more in 30 days or 10% or more in 180
days as a result of any physician ordered diet plan or expected weight loss due to loss of
fluid with physician orders for diuretics, K0300 can be coded as 1.

more in the past 30 days or 10% or more in the last 180 days or if information about prior
weight is not available.

October 2024

Page K-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0300: Weight Loss (cont.)
•

Code 2, yes, not on physician-prescribed weight-loss regimen: if the

resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more
in the last 180 days, and the weight loss was not planned and prescribed by a physician.

Coding Tips
•
•

•

A resident may experience weight variances in between the snapshot time periods.
Although these require follow up at the time, they are not captured on the MDS.
If the resident is losing a significant amount of weight, the facility should not wait for the
30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month,
7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the
resident’s nutritional status.
To code K0300 as 1, yes, the expressed goal of the weight loss diet or the expected
weight loss of edema through the use of diuretics must be documented.
On occasion, a resident with normal BMI or even low BMI is placed on a diabetic or
otherwise calorie-restricted diet. In this instance, the intent of the diet is not to induce
weight loss, and it would not be considered a physician-ordered weight-loss regimen.

•

Examples

1. Resident J has been on a physician ordered calorie-restricted diet for the past year. They and
their physician agreed to a plan of weight reduction. Their current weight is 169 lbs. Their
weight 30 days ago was 172 lbs. Their weight 180 days ago was 192 lbs.
Coding: K0300 would be coded 1, yes, on physician-prescribed weightloss regimen.
Rationale:

•

October 2024

•

30-day calculation: 172 x 0.95 = 163.4. Since the resident’s current weight of
169 lbs is more than 163.4 lbs, which is the 5% point, they have not lost 5%
body weight in the last 30 days.
180-day calculation: 192 x .90 = 172.8. Since the resident’s current weight of
169 lbs is less than 172.8 lbs, which is the 10% point, they have lost 10% or
more of body weight in the last 180 days.

Page K-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0300: Weight Loss (cont.)
2. Resident S has had increasing need for assistance with eating over the past 6 months. Their
current weight is 195 lbs. Their weight 30 days ago was 197 lbs. Their weight 180 days ago
was 185 lbs.
Coding: K0300 would be coded 0, No.
Rationale:

•

30-day calculation: 197 x 0.95 = 187.15. Because the resident’s current weight
of 195 lbs is more than 187.15 lbs, which is the 5% point, they have not lost
5% body weight in the last 30 days.
• 180-day calculation: Resident S’s current weight of 195 lbs is greater than their
weight 180 days ago, so there is no need to calculate their weight loss. They have
gained weight over this time period.
3. Resident K underwent a BKA (below the knee amputation). Their preoperative weight 30
days ago was 130 lbs. Their most recent postoperative weight is 102 lbs. The amputated leg
weighed 8 lbs. Their weight 180 days ago was 125 lbs.
Was the change in weight significant? Calculation of change in weight must take into account
the weight of the amputated limb (which in this case is 6% of 130 lbs = 7.8 lbs).
30-day calculation:
Step 1: Add the weight of the amputated limb to the current weight to obtain the
weight if no amputation occurred:
102 lbs (current weight) + 8 lbs (weight of leg) = 110 lbs (current body weight taking
the amputated leg into account)
Step 2: Calculate the difference between the most recent weight (including weight of
the limb) and the previous weight (at 30 days)
130 lbs (preoperative weight) - 110 lbs (present weight if had two legs) = 20 lbs
(weight lost)
Step 3: Calculate the percent weight change relative to the initial weight:
20 lbs (weight change) /130 lbs (preoperative weight) = 15% weight loss
Step 4: The percent weight change is significant if >5% at 30 days
Therefore, the most recent postoperative weight of 102 lbs (110 lbs, taking the
amputated limb into account) is >5% weight loss (significant at 30 days).

•

180-day calculation:
Step 1: Add the weight of the amputated limb to the current weight to obtain the
weight if no amputation occurred:
102 lbs (current weight) + 8 lbs (weight of leg) = 110 lbs (current body weight taking
the amputated leg into account)
Step 2: Calculate the difference between the most recent weight (including weight of
the limb) and the previous weight (at 180 days):
125 lbs (preoperative weight 180 days ago) - 110 lbs (present weight if had two legs) =
15 lbs (weight lost)
Step 3: Calculate the percent weight change relative to the initial weight:
15 lbs (weight change) / 130 lbs (preoperative weight) = 12% weight loss
Step 4: The percent weight change is significant if >10% at 180 days

October 2024

•

Page K-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0300: Weight Loss (cont.)

The most recent postoperative weight of 110 lbs (110 lbs, taking the amputated limb
into account) is >10% weight loss (significant at 180 days).
Present weight of 110 lbs >10% weight loss (significant at 180 days).
Coding: K0300 would be coded 2, yes, weight change is significant; not on
physician-prescribed weight-loss regimen.
Rationale: The resident had a significant weight loss of >5% in 30 days and did have a

weight loss of >10% in 180 days, the item would be coded as 2, yes weight change is
significant; not on physician-prescribed weight–loss regime, with one of the items being
triggered. This item is coded for either a 5% 30-day weight loss or a 10% 180-day weight
loss. In this example both items, the criteria are met but the coding does not change as
long as one of them are met.

K0310: Weight Gain

•

•
•

Weight gain can result in debility and adversely affect
health, safety, and quality of life.

Planning for Care

Weight gain may be an important indicator of a change
in the resident’s health status or environment.
If significant weight gain is noted, the interdisciplinary
team should review for possible causes of changed
intake, changed caloric need, change in medication
(e.g., steroidals), or changed fluid volume status.
Weight should be monitored on a continuing basis;
weight gain should be assessed and care planned at the
time of detection and not delayed until the next MDS
assessment.

Steps for Assessment

This item compares the resident’s weight in the current
observation period with their weight at two snapshots in time:
• At a point closest to 30-days preceding the current
weight.
• At a point closest to 180-days preceding the current
weight.

October 2024

5% WEIGHT GAIN IN 30
DAYS
Start with the resident’s
weight closest to 30 days ago
and multiply it by 1.05 (or
105%). The resulting figure
represents a 5% gain from
the weight 30 days ago. If the
resident’s current weight is
equal to or more than the
resulting figure, the resident
has gained more than 5%
body weight.

•

DEFINITIONS

Item Rationale
Health-related Quality of Life

10% WEIGHT GAIN IN
180 DAYS
Start with the resident’s
weight closest to 180 days
ago and multiply it by 1.10 (or
110%). The resulting figure
represents a 10% gain from
the weight 180 days ago. If
the resident’s current weight
is equal to or more than the
resulting figure, the resident
has gained more than 10%
body weight.

Page K-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0310: Weight Gain (cont.)
This item does not consider weight fluctuation outside of these two time points, although the
resident’s weight should be monitored on a continual basis and weight gain assessed and
addressed on the care plan as necessary.

For a New Admission
1. Ask the resident, family, or significant other about weight gain over the past 30 and 180 days.
2. Consult the resident’s physician, review transfer documentation, and compare with admission
weight.
3. If the admission weight is more than the previous weight, calculate the percentage of weight
gain.
4. Complete the same process to determine and calculate weight gain comparing the admission
weight to the weight 30 and 180 days ago.

For Subsequent Assessments

1. From the medical record, compare the resident’s weight in the current observation period to
their weight in the observation period 30 days ago.
2. If the current weight is more than the weight in the observation period 30 days ago, calculate
the percentage of weight gain.
3. From the medical record, compare the resident’s weight in the current observation period to
their weight in the observation period 180 days ago.
4. If the current weight is more than the weight in the observation period 180 days ago,
calculate the percentage of weight gain.

Coding Instructions

Mathematically round weights as described in Section K0200B before completing the weight
gain calculation.
•

Code 0, no or unknown: if the resident has not experienced weight gain of 5% or

•

Code 1, yes on physician-prescribed weight-gain regimen: if the resident

•

Code 2, yes, not on physician-prescribed weight-gain regimen: if the

more in the past 30 days or 10% or more in the last 180 days or if information about prior
weight is not available.

has experienced a weight gain of 5% or more in the past 30 days or 10% or more in the
last 180 days, and the weight gain was planned and pursuant to a physician’s order. In
cases where a resident has a weight gain of 5% or more in 30 days or 10% or more in 180
days as a result of any physician ordered diet plan, K0310 can be coded as 1.
resident has experienced a weight gain of 5% or more in the past 30 days or 10% or more
in the last 180 days, and the weight gain was not planned and prescribed by a physician.

Coding Tips
•

A resident may experience weight variances in between the snapshot time periods.
Although these require follow up at the time, they are not captured on the MDS.

October 2024

Page K-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0310: Weight Gain (cont.)
•

If the resident is gaining a significant amount of weight, the facility should not wait for
the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month,
7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the
resident’s nutritional status.

•

To code K0310 as 1, yes, the expressed goal of the weight gain diet must be documented.

K0520: Nutritional Approaches

D
Item Rationale

Health-related Quality of Life

Nutritional approaches that vary from the normal (e.g.,
mechanically altered food) or that rely on alternative
methods (e.g., parenteral/IV or feeding tubes) can
diminish an individual’s sense of dignity and self-worth
as well as diminish pleasure from eating.

•

The resident’s clinical condition may potentially benefit
from the various nutritional approaches included here. It
is important to work with the resident and family
members to establish nutritional support goals that
balance the resident’s preferences and overall clinical
goals.

October 2024

PARENTERAL/IV
FEEDING
Introduction of a nutritive
substance into the
body by means other than
the intestinal tract (e.g.,
subcutaneous, intravenous).

•

DEFINITIONS

FEEDING TUBE
Presence of any type of tube
that can deliver food/
nutritional substances/ fluids
directly into the
gastrointestinal system.
Examples include, but are
not limited to, nasogastric
tubes, gastrostomy tubes,
jejunostomy tubes,
percutaneous endoscopic
gastrostomy (PEG) tubes.

Page K-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0520: Nutritional Approaches (cont.)
Planning for Care

•

Alternative nutritional approaches should be monitored to validate effectiveness.

•

Care planning should include periodic reevaluation of the appropriateness of the
approach.

Steps for Assessment
•

•

Review the medical record to determine if any of the
listed nutritional approaches were performed during the
look-back period.
If none apply, check K0520Z. None of the above.

Coding Instructions

Check all that apply. If none apply, check K0520Z, None of the
above
• K0520A, parenteral/IV feeding.
•

K0520B, feeding tube – nasogastric or abdominal

•

K0520C, mechanically altered diet – require change in

•

texture of food or liquids (e.g., pureed food, thickened
liquids).
K0520D, therapeutic diet (e.g., low salt, diabetic, low
cholesterol).
K0520Z, none of the above.

Coding Instructions for Column 1
•

•

THERAPEUTIC DIET
A therapeutic diet is a diet
intervention prescribed by a
physician or other authorized
nonphysician practitioner that
provides food or nutrients via
oral, enteral, and parenteral
routes as part of treatment of
disease or clinical condition,
to modify, eliminate,
decrease, or increase
identified micro- and macronutrients in the diet (Academy
of Nutrition and Dietetics,
2020).

Check all nutritional approaches performed during the
first 3 days of the SNF PPS Stay.

Coding Instructions for Column 2
•

MECHANICALLY
ALTERED DIET
A diet specifically prepared to
alter the texture or
consistency of food to
facilitate oral intake.
Examples include soft solids,
puréed foods, ground meat,
and thickened liquids. A
mechanically altered diet
should not automatically be
considered a therapeutic diet.

•

(PEG).

DEFINITIONS

Check all nutritional approaches performed prior to
admission/entry or reentry to the facility and within the
7-day look-back period. Leave Column 2 blank if the resident was admitted/entered or
reentered the facility more than 7 days ago.
When completing the Interim Payment Assessment (IPA), the completion of items
K0520A, K0520B, and K0520Z is required.

Coding Instructions for Column 3
•

Check all nutritional approaches performed after admission/entry or reentry to the facility
and within the 7-day look-back period.

October 2024

Page K-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0520: Nutritional Approaches (cont.)
Coding Instructions for Column 4
•

Check all nutritional approaches performed within the last 3 days of the SNF PPS Stay.

Coding Tips for K0520A

K0520A includes any and all nutrition and hydration received by the nursing home resident
during the observation period either at the nursing home, at the hospital as an outpatient or an
inpatient, provided they were administered for nutrition or hydration.
• Parenteral/IV feeding—The following fluids may be included when there is supporting
documentation that reflects the need for additional fluid intake specifically
addressing a nutrition or hydration need. This supporting documentation should be
noted in the resident’s medical record according to State and Federal Regulations
and/or internal facility policy:
— IV fluids or hyperalimentation, including total parenteral nutrition (TPN),
administered continuously or intermittently
— IV fluids running at KVO (Keep Vein Open)
— IV fluids contained in IV Piggybacks
— Hypodermoclysis and subcutaneous ports in hydration therapy
— IV fluids can be coded in K0520A if needed to prevent dehydration if the additional
fluid intake is specifically needed for nutrition and/or hydration. Prevention of
dehydration should be clinically indicated and supporting documentation should be
provided in the medical record.
• The following items are NOT to be coded in K0520A:
— IV Medications—Code these when appropriate in O0110H, IV Medications.
— IV fluids used to reconstitute and/or dilute medications for IV administration.
— IV fluids administered as a routine part of an operative or diagnostic procedure or
recovery room stay.
— IV fluids administered solely as flushes.
— Parenteral/IV fluids administered in conjunction with chemotherapy or dialysis.
• Enteral feeding formulas:
— Should not be coded as a mechanically altered diet.
— Should only be coded as K0520D, Therapeutic Diet when the enteral formula is
altered to manage problematic health conditions, e.g. enteral formulas specific to
residents with diabetes.

Coding Tip for K0520B
•

Only feeding tubes that are used to deliver nutritive substances and/or hydration during
the assessment period are coded in K0520B.

October 2024

Page K-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0520: Nutritional Approaches (cont.)
Coding Tips for K0520C
•

Assessors should not capture a trial of a mechanically altered diet (e.g., pureed food,
thickened liquids) during the observation period in K0520C, mechanically altered diet.

Coding Tips for K0520D
•

•

Examples

Therapeutic diets are not defined by the content of what is provided or when it is served,
but why the diet is required. Therapeutic diets provide the corresponding treatment that
addresses a particular disease or clinical condition which is manifesting an altered
nutritional status by providing the specific nutritional requirements to remedy the
alteration.
A nutritional supplement (house supplement or packaged) given as part of the treatment
for a disease or clinical condition manifesting an altered nutrition status, does not
constitute a therapeutic diet, but may be part of a therapeutic diet. Therefore, supplements
(whether given with, in-between, or instead of meals) are only coded in K0520D,
Therapeutic Diet when they are being administered as part of a therapeutic diet to manage
problematic health conditions (e.g. supplement for protein-calorie malnutrition).
Food elimination diets related to food allergies (e.g. peanut allergy) can be coded as a
therapeutic diet.

1. Resident H was diagnosed in the acute hospital with a soft tissue infection. A treatment
regime was initiated in the acute hospital, including IV antibiotics received every 8 hours
within the last 7 days. Because the resident was assessed in the acute hospital with
inadequate oral fluid intake demonstrating signs and symptoms of dehydration, the acute care
physician ordered that the antibiotic be reconstituted with 250 cc of normal saline rather than
100 cc, which is the minimum amount required for reconstitution. This IV antibiotic and
fluid regimen continues for 7 additional days following admission to the SNF due to
continued infection and decreased oral intake.
Coding: K0520A1, K0520A2, and K0520A3 would be checked. The IV medication
would be coded at IV Medications item (O0110H).
Rationale: The resident’s physician in the acute care hospital ordered additional
volume of dilutant for the IV medication reconstitution to address Resident H’s
inadequate oral fluid intake. The treatment regime continues upon admission to the SNF
to address hydration needs. There is supporting documentation that reflected an identified
need for additional fluid intake for hydration.
2. Resident J is receiving an antibiotic in 100 cc of normal saline via IV. They have a UTI, no
fever, and documented adequate fluid intake. They are placed on the nursing home’s
hydration plan to ensure adequate hydration.
Coding: K0520A1 would NOT be checked. The IV medication would be coded at
IV Medications item (O0110H).
Rationale: Although the resident received the additional fluid, there is no
documentation to support a need for additional fluid intake.

October 2024

Page K-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0520: Nutritional Approaches (cont.)
3. Resident Q will be discharged today following a 16-day stay in the nursing home. They were
receiving rehabilitation services for a stroke. They have longstanding celiac disease and
therefore were placed on a gluten-free diet. Because of their recent stroke, they also have
documented dysphagia requiring a mechanical soft diet and honey-thick liquids to prevent
aspiration and will be discharged on this same diet.
Coding: K0520C3 and K0520C4, as well as K0520D3 and K0520D4, would be
checked.
Rationale: Resident Q required both a mechanically altered diet (i.e., mechanical soft
diet and honey-thick liquids) and a therapeutic diet (i.e., gluten free) for their celiac
disease in the last 7 days as well as at discharge.

4. Resident B will be discharged today after rehabilitation services for multiple fractures
sustained in a car accident. Resident B has been on a regular diet during their entire stay and
has not required any parenteral or enteral nutrition. During the acute hospital stay Resident B
required a mechanical soft diet following the accident. The resident upgraded to a regular
texture diet prior to discharge from the hospital.
Coding: K0520Z3and K0520Z4 would be checked.
Rationale: Resident B had a regular diet their entire stay and did not require any
nutritional modifications.

K0710: Percent Intake by Artificial Route

Complete K0710 only if Column 2 and/or Column 3 are checked for K0520A and/or K0520B.

ft
October 2024

Page K-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0710: Percent Intake by Artificial Route (cont.)
Item Rationale
•

•
•

Health-related Quality of Life

Nutritional approaches that vary from the normal, such as parenteral/IV or feeding tubes,
can diminish an individual’s sense of dignity and self-worth as well as diminish pleasure
from eating.

Planning for Care

The proportion of calories received through artificial routes should be monitored with
periodic reassessment to ensure adequate nutrition and hydration.
Periodic reassessment is necessary to facilitate transition to increased oral intake as
indicated by the resident’s condition.

K0710A, Proportion of Total Calories the Resident Received through
Parental or Tube Feeding

Steps for Assessment

1. Review intake records within the last 7 days to determine actual intake through parenteral or
tube feeding routes.
2. Calculate proportion of total calories received through these routes.
• If the resident took no food or fluids by mouth or took just sips of fluid, stop here and
code 3, 51% or more.
• If the resident had more substantial oral intake than sips of fluid, consult with the
dietician.

Coding Instructions
•

October 2024

Select the best response:
1. 25% or less
2. 26% to 50%
3. 51% or more

Page K-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0710: Percent Intake by Artificial Route (cont.)
Example
1. Calculation for Proportion of Total Calories from IV or Tube Feeding
Resident H has had a feeding tube since their surgery two weeks ago. They are currently
more alert and feeling much better. They have been taking soft solids by mouth, but only in
small to medium amounts. Within the last 7 days, they have been receiving tube feedings for
nutritional supplementation. The dietitian has totaled their calories per day as follows:
Oral and Tube Feeding Intake

Sun.
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Total

Oral
500
250
250
350
500
250
350
2,450

Tube
2,000
2,250
2,250
2,250
2,000
2,250
2,000
15,000

Coding:
K0710A columns 2 and 3 would be coded 3, 51% or more.
Rationale: Total Oral intake is 2,450 calories

Total Tube intake is 15,000 calories
Total calories is 2,450 + 15,000 = 17,450
Calculation of the percentage of total calories by tube feeding:
15,000/17,450 = .859 X 100 = 85.9%
Resident H received 85.9% of their calories by tube feeding, therefore
K0710A code 3, 51% or more is correct.

Steps for Assessment
1.
2.
3.
4.

K0710B, Average Fluid Intake per Day by IV or Tube Feeding

Review intake records from the last 7 days.
Add up the total amount of fluid received each day by IV and/or tube feedings only.
Divide the week’s total fluid intake by 7 to calculate the average of fluid intake per day.
Divide by 7 even if the resident did not receive IV fluids and/or tube feeding on each of the 7
days.

Coding Instructions
Code for the average number of cc per day of fluid the resident received via IV or tube feeding.
Record what was actually received by the resident, not what was ordered.
• Code 1: 500 cc/day or less
•

Code 2: 501 cc/day or more

October 2024

Page K-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0710: Percent Intake by Artificial Route (cont.)
Examples
1. Calculation for Average Daily Fluid Intake
Resident A, a long term care resident, has swallowing difficulties secondary to Huntington’s
disease. They are able to take oral fluids by mouth with supervision, but not enough to
maintain hydration. They received the following daily fluid totals by supplemental tube
feedings (including water, prepared nutritional supplements, juices) within the last 7 days.

IV Fluid Intake
Sun.
1250 cc
Mon.
775 cc
Tues.
925 cc
Wed.
1200 cc
Thurs.
1200 cc
Fri.
500 cc
Sat.
450 cc
Total
6,300 cc

Coding:
K0710B columns 2 and 3 would be coded 2, 501cc/day or more.
Rationale: The total fluid intake by supplemental tube feedings = 6,300 cc

6,300 cc divided by 7 days = 900 cc/day
900 cc is greater than 500 cc, therefore code 2, 501 cc/day or more is
correct.

ft
October 2024

Page K-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [K]

K0710: Percent Intake by Artificial Route (cont.)
2. Resident K has been able to take some fluids orally; however, due to their progressing
multiple sclerosis, their dysphagia is not allowing them to remain hydrated enough.
Therefore, they received the following fluid amounts within the last 7 days via supplemental
tube feedings while in the hospital and after they were admitted to the nursing home.
While in the Hospital
Mon.
Tues.
Wed.
Thurs.

400 cc
520 cc
500 cc
480 cc

Fri.
Sat.
Sun.

510 cc
520 cc
490 cc

1,900 cc

Total

1,520 cc

Total

While in the Nursing
Home

K0710B2 would be coded 2, 501 cc/day or more, and K0710B3 would be
coded 1, 500 cc/day or less.
Rationale: The total fluid intake within the last 7 days while Resident K was a
resident of the nursing home was 1,520 cc (510 cc + 520 cc + 490 cc =
1,520 cc). Average fluid intake while a resident totaled 507 cc (1,520 cc
divided by 3 days). 507 cc is greater than 500 cc, therefore code 2, 501
cc/day or more is correct for K0710B2, While a Resident.
The total fluid intake during the entire 7 days (includes fluid intake while
Resident K was in the hospital AND while Resident K was a resident of
the nursing home) was 3,420 cc (1,900 cc + 1,520 cc). Average fluid
intake during the entire 7 days was 489 cc (3,420 cc divided by 7 days).
489 cc is less than 500 cc, therefore code 1, 500 cc/day or less is correct
for K0710B3, During Entire 7 Days.
Coding:

October 2024

Page K-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [L]

SECTION L: ORAL/DENTAL STATUS
Intent: This item is intended to record any dental problems present in the 7-day look-back
period.

L0200: Dental

D
Item Rationale
•

Poor oral health has a negative impact on:
— quality of life

— overall health

— nutritional status
•

BROKEN NATURAL
TEETH OR TOOTH
FRAGMENT
Very large cavity, tooth
broken off or decayed to gum
line, or broken teeth (from a
fall or trauma).

Assessment can identify periodontal disease that can
contribute to or cause systemic diseases and conditions,
such as aspiration, malnutrition, pneumonia,
endocarditis, and poor control of diabetes.

Planning for Care
•

CAVITY
A tooth with a discolored hole
or area of decay that may
have debris in it.

Health-related Quality of Life

DEFINITIONS

Assessing dental status can help identify residents who
may be at risk for aspiration, malnutrition, pneumonia,
endocarditis, and poor control of diabetes.

ORAL LESIONS
A discolored area of tissue
(red, white, yellow, or
darkened) on the lips, gums,
tongue, palate, cheek lining,
or throat.

EDENTULOUS
Having no natural permanent
teeth in the mouth.
Complete tooth loss.

October 2024

Page L-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [L]

L0200: Dental (cont.)

DEFINITIONS

Steps for Assessment

ORAL MASS
A swollen or raised lump,
bump, or nodule on any oral
surface. May be hard or soft,
and with or without pain.

1. Ask the resident about the presence of chewing problems or
mouth or facial pain/discomfort.
2. Ask the resident, family, or significant other whether the
resident has or recently had dentures or partials. (If resident
or family/significant other reports that the resident recently
ULCER
had dentures or partials, but they do not have them at the
Mouth sore, blister or eroded
area of tissue on any oral
facility, ask for a reason.)
surface.
3. If the resident has dentures or partials, examine for loose
fit. Ask them to remove, and examine for chips, cracks, and
cleanliness. Removal of dentures and/or partials is necessary for adequate assessment.
4. Conduct exam of the resident’s lips and oral cavity with dentures or partials removed, if
applicable. Use a light source that is adequate to visualize the back of the mouth. Visually
observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek
lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The
assessor should use their gloved fingers to adequately feel for masses or loose teeth.
5. If the resident is unable to self-report, then observe them while eating with dentures or
partials, if indicated, to determine if chewing problems or mouth pain are present.
6. Oral examination of residents who are uncooperative and do not allow for a thorough oral
exam may result in medical conditions being missed. Referral for dental evaluation should be
considered for these residents and any resident who exhibits dental or oral issues.

Coding Instructions
•

•

•
•
•
•
•

denture or partial is chipped, cracked, uncleanable, or loose. A denture is coded as loose
if the resident complains that it is loose, the denture visibly moves when the resident
opens their mouth, or the denture moves when the resident tries to talk.
Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the
resident is edentulous/lacks all natural teeth or parts of teeth.

•

Check L0200A, broken or loosely fitting full or partial denture: if the

Check L0200C, abnormal mouth tissue (ulcers, masses, oral lesions):

select if any ulcer, mass, or oral lesion is noted on any oral surface.

Check L0200D, obvious or likely cavity or broken natural teeth: if any

cavity or broken tooth is seen.

Check L0200E, inflamed or bleeding gums or loose natural teeth: if gums

appear irritated, red, swollen, or bleeding. Teeth are coded as loose if they readily move
when light pressure is applied with a fingertip.
Check L0200F, mouth or facial pain or discomfort with chewing: if the
resident reports any pain in the mouth or face, or discomfort with chewing.
Check L0200G, unable to examine: if the resident’s mouth cannot be examined.
Check L0200Z, none of the above: if none of conditions A through F is present.

October 2024

Page L-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [L]

L0200: Dental (cont.)
Coding Tips
Mouth or facial pain coded for this item should also be coded in Section J, items J0100
through J0850, in any items in which the coding requirements of Section J are met.

•

The dental status for a resident who has some, but not all, of their natural teeth that do not
appear damaged (e.g., are not broken, loose, with obvious or likely cavity) and who does
not have any other conditions in L0200A–G, should be coded in L0200Z, none of the
above.

•

Many residents have dentures or partials that fit well and work properly. However, for
individualized care planning purposes, consideration should be taken for these residents
to make sure that they are in possession of their dentures or partials and that they are
being utilized properly for meals, snacks, medication pass, and social activities.
Additionally, the dentures or partials should be properly cared for with regular cleaning
and by assuring that they continue to fit properly throughout the resident’s stay.

•

October 2024

Page L-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

SECTION M: SKIN CONDITIONS
Intent: The items in this section document the risk, presence, appearance, and change of
pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and
documents some treatment categories related to skin injury or avoiding injury. It is important to
recognize and evaluate each resident’s risk factors and to identify and evaluate all areas at risk of
constant pressure. A complete assessment of skin is essential to an effective pressure ulcer
prevention and skin treatment program. Be certain to include in the assessment process, a holistic
approach. It is imperative to determine the etiology of all wounds and lesions, as this will
determine and direct the proper treatment and management of the wound.

CMS is aware of the array of terms used to describe alterations in skin integrity due to pressure.
Some of these terms include: pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and
bed sore. Acknowledging that clinicians may use and documentation may reflect any of these
terms, it is acceptable to code pressure-related skin conditions in Section M if different
terminology is recorded in the clinical record, as long as the primary cause of the skin alteration
is related to pressure. For example, if the medical record reflects the presence of a Stage 2
pressure injury, it should be coded on the MDS as a Stage 2 pressure ulcer.

M0100: Determination of Pressure Ulcer/Injury Risk

Item Rationale
Health-related Quality of Life
•

•

Pressure ulcers/injuries occur when tissue is compressed between a bony prominence and
an external surface. In addition to pressure, shear force, and friction are important
contributors to pressure ulcer/injury development.
The underlying health of a resident’s soft tissue affects how much pressure, shear force,
or friction is needed to damage tissue. Skin and soft tissue changes associated with aging,
illness, small blood vessel disease, and malnutrition increase vulnerability to pressure
ulcers/injuries.
Additional external factors, such as excess moisture, microclimate, and tissue exposure to
urine or feces, can increase risk.

Planning for Care

The care planning process should include efforts to stabilize, reduce, or remove
underlying risk factors; to monitor the impact of the interventions; and to modify the
interventions as appropriate based on the individualized needs of the resident.

October 2024

Page M-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0100: Determination of Pressure Ulcer/Injury Risk (cont.)
•

•

Throughout this section, terminology referring to
DEFINITION
“healed” versus “unhealed” ulcers refers to whether or
HEALED PRESSURE
not the ulcer is “closed” versus “open.” When
ULCER
considering this, recognize that Stage 1, Deep Tissue
Completely closed, fully
Injury (DTI), and unstageable pressure ulcers although
epithelialized, covered
“closed” (i.e., may be covered with tissue, eschar,
completely with epithelial
slough, etc.) would not be considered “healed.”
tissue, or resurfaced with
Facilities should be aware that the resident is at higher
new skin, even if the area
risk of having the area of a closed pressure ulcer open
continues to have some
up due to damage, injury, or pressure, because of the
surface discoloration.
loss of tensile strength of the overlying tissue. Tensile
strength of the skin overlying a closed pressure ulcer is 80% of normal skin tensile
strength. Facilities should put preventative measures in place that will mitigate the
opening of a closed ulcer due to the fragility of the overlying tissue.

Steps for Assessment

DEFINITIONS
PRESSURE ULCER/
INJURY RISK FACTOR
Examples of risk factors
include immobility and
decreased functional ability;
co-morbid conditions such as
end-stage renal disease,
thyroid disease, or diabetes;
drugs such as steroids;
impaired diffuse or localized
blood flow; resident refusal of
care and treatment; cognitive
impairment; exposure of skin
to urinary and fecal
incontinence; microclimate,
malnutrition, and hydration
deficits; and a healed ulcer.

Coding Instructions
For this item, check all that apply:
•

1. Review the medical record, including skin care flow sheets
or other skin tracking forms, nurses’ notes, and pressure
ulcer/injury risk assessments.
2. Speak with the treatment nurse and direct care staff on all
shifts to confirm conclusions from the medical record
review and observations of the resident.
3. Examine the resident and determine whether any ulcers,
injuries, scars, or non-removable dressings/devices are
present. Assess key areas for pressure ulcer/injury
development (e.g., sacrum, coccyx, trochanters, ischial
tuberosities, and heels). Also assess bony prominences (e.g.,
elbows and ankles) and skin that is under braces or
subjected to pressure (e.g., ears from oxygen tubing).

Check A if resident has a Stage 1 or greater
pressure ulcer/injury, a scar over bony
prominence, or a non-removable dressing/
device. Review descriptions of pressure

ulcers/injuries and information obtained during physical
examination and medical record review. Examples of
non-removable dressings/devices include a primary
surgical dressing, a cast, or a brace.

October 2024

PRESSURE ULCER/
INJURY RISK TOOLS
Screening tools that are
designed to help identify
residents who might develop
a pressure ulcer/injury. A
common risk assessment
tool is the Braden Scale for
Predicting Pressure Sore
Risk©.

Page M-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0100: Determination of Pressure Ulcer/Injury Risk (cont.)
•

Check B if a formal assessment has been completed. An example of an

•

Check C if the resident’s risk for pressure ulcer/injury development is
based on clinical assessment. A clinical assessment could include a head-to-toe

established pressure ulcer risk tool is the Braden Scale for Predicting Pressure Sore
Risk©. Other tools may be used.

physical examination of the skin and observation or medical record review of pressure
ulcer/injury risk factors. Examples of risk factors include the following:

•

— impaired/decreased mobility and decreased functional ability
— co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes
mellitus;
— drugs, such as steroids, that may affect wound healing;
— impaired diffuse or localized blood flow (e.g., generalized atherosclerosis or lower
extremity arterial insufficiency);
— resident refusal of some aspects of care and treatment;
— cognitive impairment;
— urinary and fecal incontinence;
— malnutrition and hydration deficits; and
— healed pressure ulcers, especially Stage 3 or 4 which are more likely to have recurrent
breakdown.
Check Z if none of the above apply.

M0150: Risk of Pressure Ulcers/Injuries

Item Rationale

Health-related Quality of Life
•

It is important to recognize and evaluate each resident’s risk factors and to identify and
evaluate all areas at risk of constant pressure.

Planning for Care
•

The care process should include efforts to stabilize, reduce, or remove underlying risk
factors; to monitor the impact of the interventions; and to modify the interventions as
appropriate.

Steps for Assessment
1. Based on the item(s) reviewed for M0100, determine if the resident is at risk for developing a
pressure ulcer/injury.
October 2024

Page M-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0150: Risk of Pressure Ulcers/Injuries (cont.)
2. If the medical record reveals that the resident currently has a pressure ulcer/injury, a scar
over a bony prominence, or a non-removable dressing or device, the resident is at risk for
worsening or new pressure ulcers/injuries.
3. Review formal risk assessment tools to determine the resident’s “risk score.”
4. Review the components of the clinical assessment conducted for evidence of pressure
ulcer/injury risk.

Coding Instructions
•

Code 0, no: if the resident is not at risk for developing pressure ulcers/injuries based on

•

Code 1, yes: if the resident is at risk for developing pressure ulcers/injuries based on a

a review of information gathered for M0100.

review of information gathered for M0100.

M0210: Unhealed Pressure Ulcers/Injuries

Item Rationale
•

•
•

Pressure ulcers/injuries and other wounds or lesions
affect quality of life for residents because they may
limit activity, may be painful, and may require timeconsuming treatments and dressing changes.

Planning for Care

DEFINITION
PRESSURE
ULCER/INJURY
A pressure ulcer/injury is
localized injury to the skin
and/or underlying tissue,
usually over a bony
prominence, as a result of
intense and/or prolonged
pressure or pressure in
combination with shear. The
pressure ulcer/injury can
present as intact skin or an
open ulcer and may be
painful.

The pressure ulcer/injury definitions used in the RAI
Manual have been adapted from those recommended by
the National Pressure Ulcer Advisory Panel (NPUAP)
2016 Pressure Injury Staging System.
An existing pressure ulcer/injury identifies residents at
risk for further complications or skin injury. Risk
factors described in M0100 should be addressed.
For MDS assessment, initial numerical staging of
pressure ulcers and the initial numerical staging of ulcers after debridement, or DTI that
declares itself, should be coded in terms of what is assessed (seen or palpated, i.e. visible
tissue, palpable bone) during the look-back period. Nursing homes may adopt the
NPUAP guidelines in their clinical practice and nursing documentation. However, since
CMS has adapted the NPUAP guidelines for MDS purposes, the definitions do not
perfectly correlate with each stage as described by NPUAP. Therefore, you must code the
MDS according to the instructions in this manual.

October 2024

•

Health-related Quality of Life

Page M-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0210: Unhealed Pressure Ulcers/Injuries (cont.)
•

•

Pressure ulcer/injury staging is an assessment system that provides a description and
classification based on visual appearance and/or anatomic depth of soft tissue damage. This
tissue damage can be visible or palpable in the ulcer bed. Pressure ulcer/injury staging also
informs expectations for healing times.
The comprehensive care plan should be reevaluated to ensure that appropriate
preventative measures and pressure ulcer/injury management principles are being
adhered to when new pressure ulcers/injuries develop or when existing pressure
ulcers/injuries worsen.

Steps for Assessment

1. Review the medical record, including skin care flow sheets or other skin tracking forms.
2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical
record review.
3. Examine the resident and determine whether any skin ulcers/injuries are present.
• Key areas for pressure ulcer/injury development include the sacrum, coccyx, trochanters,
ischial tuberosities, and heels. Other areas, such as bony deformities, skin under braces,
and skin subjected to excess pressure, shear, or friction, are also at risk for pressure
ulcers/injuries.
• Without a full body skin assessment, a pressure ulcer/injury can be missed.
• Examine the resident in a well-lit room. Adequate lighting is important for detecting skin
changes. For any pressure ulcers/injuries identified, measure and record the deepest
anatomical stage.
4. Identify any known or likely unstageable pressure ulcers/injuries.

Coding Instructions

Code based on the presence of any pressure ulcer/injury (regardless of stage) in the past 7 days.
•

Code 0, no: if the resident did not have a pressure ulcer/injury in the 7-day look-back

•

Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or

unstageable) in the 7-day look-back period. Proceed to M0300, Current Number of
Unhealed Pressure Ulcers/Injuries at Each Stage.

Coding Tips
•
•
•

period. Then skip to M1030, Number of Venous and Arterial Ulcers.

If an ulcer/injury arises from a combination of factors that are primarily caused by
pressure, then the area should be included in this section as a pressure ulcer/injury.
Mucosal ulcers caused by pressure should not be coded in Section M. Oral mucosal
ulcers are captured in item L0200C, Abnormal mouth tissue.
Mucosal pressure ulcers are not staged using the skin pressure ulcer staging system
because anatomical tissue comparisons cannot be made. Therefore, mucosal ulcers (for
example, those related to nasogastric tubes, nasal oxygen tubing, endotracheal tubes,
urinary catheters, etc.) should not be coded here.

October 2024

Page M-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0210: Unhealed Pressure Ulcers/Injuries (cont.)
•
•
•
•

•

If a pressure ulcer is surgically closed with a flap or graft, it should be coded as a surgical
wound and not as a pressure ulcer. If the flap or graft fails, continue to code it as a
surgical wound until healed.
Residents with diabetes mellitus (DM) can have a pressure, venous, arterial, or diabetic
neuropathic ulcer. The primary etiology should be considered when coding whether a
resident with DM has an ulcer/injury that is caused by pressure or other factors.
If a resident with DM has a heel ulcer/injury from pressure and the ulcer/injury is present
in the 7-day look-back period, code 1 and proceed to code items in M0300 as appropriate
for the pressure ulcer/injury.
If a resident with DM has an ulcer on the plantar (bottom) surface of the foot closer to the
metatarsals and the ulcer is present in the 7-day look-back period, code 0 and proceed to
M1040 to code the ulcer as a diabetic foot ulcer. It is not likely that pressure is the primary
cause of the resident’s ulcer when the ulcer is in this location.
Scabs and eschar are different both physically and chemically. Eschar is a collection of
dead tissue within the wound that is flush with the surface of the wound. A scab is made
up of dried blood cells and serum, sits on the top of the skin, and forms over exposed
wounds such as wounds with granulating surfaces (like pressure ulcers, lacerations,
evulsions, etc.). A scab is evidence of wound healing. A pressure ulcer that was staged as
a 2 and now has a scab indicates it is a healing stage 2, and therefore, staging should not
change. Eschar characteristics and the level of damage it causes to tissues is what makes it
easy to distinguish from a scab. It is extremely important to have staff who are trained in
wound assessment and who are able to distinguish scabs from eschar.
If two pressure ulcers/injuries occur on the same bony prominence and are separated, at
least superficially, by skin, then count them as two separate pressure ulcers/injuries. Stage
and measure each pressure ulcer/injury separately.
If a resident had a pressure ulcer/injury that healed during the look-back period of the
current assessment, do not code the ulcer/injury on the assessment.

•

Skin changes at the end of life (SCALE), also referred to as Kennedy Terminal Ulcers
(KTUs) and skin failure, are not primarily caused by pressure and are not coded in Section
M.

October 2024

•

Page M-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300: Current Number of Unhealed Pressure Ulcers/Injuries at
Each Stage
Steps for completing M0300A–G
Step 1: Determine Deepest Anatomical Stage
For each pressure ulcer, determine the deepest anatomical stage. At admission, code based on
findings from the first skin assessment that is conducted on or after and as close to the admission
as possible. Do not reverse or back stage. Consider current and historical levels of tissue
involvement.

1. Observe and palpate the base of any identified pressure ulcers present to determine the
anatomic depth of soft tissue damage involved.
2. Ulcer staging should be based on the ulcer’s deepest anatomic soft tissue damage that is
visible or palpable. If a pressure ulcer’s tissues are obscured such that the depth of soft tissue
damage cannot be observed, it is considered to be unstageable (see Step 2 below).
3. Review the history of each pressure ulcer in the medical record. If the stageable pressure
ulcer has ever been classified at a higher numerical stage than what is observed now, it
should continue to be classified at the higher numerical stage until healed unless it becomes
unstageable. Nursing homes that carefully document and track pressure ulcers will be able to
more accurately code this item.
DEFINITIONS
4. Pressure ulcers do not heal in a reverse sequence, that is,
the body does not replace the types and layers of tissue
EPITHELIAL TISSUE
(e.g., muscle, fat, and dermis) that were lost during pressure New skin that is light pink
ulcer development before they re-epithelialize. Stage 3 and
and shiny (even in persons
with darkly pigmented skin).
4 pressure ulcers fill with granulation tissue. This
In Stage 2 pressure ulcers,
replacement tissue is never as strong as the tissue that was
epithelial tissue is seen in the
lost and hence is more prone to future breakdown.
center and at the edges of
5. Clinical standards do not support reverse staging or backthe ulcer. In full thickness
staging as a way to document healing, as it does not
accurately characterize what is occurring physiologically as Stage 3 and 4 pressure
ulcers, epithelial tissue
the ulcer heals. For example, over time, even though a
advances from the edges of
Stage 4 pressure ulcer has been healing and contracting
the wound.
such that it is less deep, wide, and long, the tissues that
were lost (muscle, fat, dermis) will never be replaced with
GRANULATION TISSUE
the same type of tissue. Previous standards using reverse
Red tissue with
staging or back-staging would have permitted identification “cobblestone” or bumpy
of such a pressure ulcer as a Stage 3, then a Stage 2, and so appearance; bleeds easily
on, when it reached a depth consistent with these stages.
when injured.
Clinical standards now would require that this ulcer
continue to be documented as a Stage 4 pressure ulcer until it has completely healed unless it
becomes unstageable. Nursing homes can document the healing of pressure ulcers using
descriptive characteristics of the wound (i.e., depth, width, presence or absence of
granulation tissue, etc.) or by using a validated pressure ulcer healing tool.

October 2024

Page M-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300: Current Number of Unhealed Pressure Ulcers/Injuries at
Each Stage (cont.)
Once a pressure ulcer has healed, it is documented as a healed pressure ulcer at its highest
numerical stage—in this example, a healed Stage 4 pressure ulcer. For care planning
purposes, this healed Stage 4 pressure ulcer would remain at increased risk for future
breakdown or injury and would require continued monitoring and preventative care.
6. A previously closed pressure ulcer that opens again should be reported at its worst stage,
unless currently presenting at a higher stage or unstageable.

Step 2: Identify Unstageable Pressure Ulcers

1. Visualization of the wound bed is necessary for accurate staging.
2. If, after careful cleansing of the pressure ulcer/injury, a pressure ulcer’s/injury’s anatomical
tissues are obscured such that the extent of soft tissue damage cannot be observed or
palpated, the pressure ulcer/injury is considered unstageable.
3. Pressure ulcers that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or
brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized
or palpated in the wound bed, should be classified as unstageable, as illustrated at
https://npiap.com/page/PressureInjuryStages.
4. If the wound bed is only partially covered by eschar or slough, and the anatomical depth of
tissue damage can be visualized or palpated, numerically stage the ulcer, and do not code this
as unstageable.
5. A pressure injury with intact skin that is a deep tissue injury (DTI) should not be coded as a
Stage 1 pressure injury. It should be coded as unstageable, as illustrated at
https://npiap.com/page/PressureInjuryStages.
6. Known pressure ulcers/injuries covered by a non-removable dressing/device (e.g., primary
surgical dressing, cast) should be coded as unstageable. “Known” refers to when
documentation is available that says a pressure ulcer/injury exists under the non-removable
dressing/device.

Step 3: Determine “Present on Admission”

For each pressure ulcer/injury, determine if the pressure
ulcer/injury was present at the time of admission/entry or
reentry and not acquired while the resident was in the care of
the nursing home. Consider current and historical levels of
tissue involvement.

DEFINITION

ON ADMISSION
As close to the actual time of
admission as possible.

1. Review the medical record for the history of the ulcer/injury.
2. Review for location and stage at the time of admission/entry or reentry.
3. If the pressure ulcer/injury was present on admission/entry or reentry and subsequently
increased in numerical stage during the resident’s stay, the pressure ulcer is coded at that
higher stage, and that higher stage should not be considered as “present on admission.”
4. If the pressure ulcer/injury was present on admission/entry or reentry and becomes
unstageable due to slough or eschar, during the resident’s stay, the pressure ulcer/injury is
coded at M0300F and should not be coded as “present on admission.”

October 2024

Page M-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300: Current Number of Unhealed Pressure Ulcers/Injuries at
Each Stage (cont.)

5. If the pressure ulcer/injury was unstageable on admission/entry or reentry, then becomes
numerically stageable later, it should be considered as “present on admission” at the stage
at which it first becomes numerically stageable. If it subsequently increases in numerical
stage, that higher stage should not be coded as “present on admission.”
6. If a resident who has a pressure ulcer/injury that was originally acquired in the facility is
hospitalized and returns with that pressure ulcer/injury at the same numerical stage, the
pressure ulcer/injury should not be coded as “present on admission” because it was present
and acquired at the facility prior to the hospitalization.
7. If a resident who has a pressure ulcer/injury that was “present on admission” (not acquired
in the facility) is hospitalized and returns with that pressure ulcer/injury at the same
numerical stage, the pressure ulcer is still coded as “present on admission” because it was
originally acquired outside the facility and has not changed in stage.
8. If a resident who has a pressure ulcer/injury is hospitalized and the ulcer/injury increases in
numerical stage or becomes unstageable due to slough or eschar during the hospitalization, it
should be coded as “present on admission” upon reentry.
9. If a pressure ulcer was numerically staged, then became unstageable, and is subsequently
debrided sufficiently to be numerically staged, compare its numerical stage before and after it
was unstageable. If the numerical stage has increased, code this pressure ulcer as not present
on admission.
10. If a resident has a pressure ulcer/injury that was documented on admission then closed that
reopens at the same stage (i.e., not a higher stage), the ulcer/injury is coded as “present on
admission.”
11. If two pressure ulcers merge, that were both “present on admission,” continue to code the
merged pressure ulcer as “present on admission.” Although two merged pressure ulcers
might increase the overall surface area of the ulcer, there needs to be an increase in numerical
stage or a change to unstageable due to slough or eschar in order for it to be considered not
“present on admission.”

October 2024

Page M-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300: Current Number of Unhealed Pressure Ulcers/Injuries at
Each Stage (cont.)
Examples
1. Resident K is admitted to the facility without a pressure ulcer/injury. During the stay,
they develop a stage 2 pressure ulcer. This is a facility acquired pressure ulcer and was
not “present on admission.” Resident K is hospitalized and returns to the facility with
the same stage 2 pressure ulcer. This pressure ulcer was originally acquired in the
nursing home and should not be considered as “present on admission” when they
return from the hospital.

2. Resident J is a new admission to the facility and is admitted with a stage 2 pressure ulcer.
This pressure ulcer is considered as “present on admission” as it was not acquired in
the facility. Resident J is hospitalized and returns with the same stage 2 pressure ulcer,
unchanged from the prior admission/entry. This pressure ulcer is still considered
“present on admission” because it was originally acquired outside the facility and has
not changed.

October 2024

Page M-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300A: Number of Stage 1 Pressure Injuries

Item Rationale
•

Health-related Quality of Care

DEFINITIONS

Stage 1 pressure injuries may deteriorate to more severe
pressure ulcers/injuries without adequate intervention;
as such, they are an important risk factor for further
tissue damage.

STAGE 1 PRESSURE
INJURY
An observable, pressurerelated alteration of intact
skin whose indicators, as
compared to an adjacent or
opposite area on the body,
may include changes in one
or more of the following
parameters: skin temperature
(warmth or coolness); tissue
consistency (firm or boggy);
sensation (pain, itching);
and/or a defined area of
persistent redness in lightly
pigmented skin, whereas in
darker skin tones, the injury
may appear with persistent
red, blue, or purple hues.

Planning for Care

•

Development of a Stage 1 pressure injury should be one
of multiple factors that initiate pressure ulcer/injury
prevention interventions.

Steps for Assessment

1. Perform head-to-toe assessment. Conduct a full body skin
assessment focusing on bony prominences and pressurebearing areas (sacrum, buttocks, heels, ankles, etc.).
2. For the purposes of coding, determine that the lesion being
assessed is primarily related to pressure and that other
conditions have been ruled out. If pressure is not the
primary cause, do not code here.
NON-BLANCHABLE
3. Reliance on only one descriptor is inadequate to determine
Reddened areas of tissue
the staging of a pressure injury between Stage 1 and deep
that do not turn white or pale
tissue injury (see definition of “deep tissue injury” on page
when pressed firmly with a
M-24). The descriptors are similar for these two types of
finger or device.
injuries (e.g., temperature [warmth or coolness]; tissue
consistency [firm or boggy]).
4. Check any reddened areas for ability to blanch by firmly pressing a finger into the reddened
tissues and then removing it. In non-blanchable reddened areas, there is no loss of skin color
or pressure-induced pallor at the compressed site.
5. Search for other areas of skin that differ from surrounding tissue that may be painful, firm,
soft, warmer, or cooler compared to adjacent tissue. Stage 1 may be difficult to detect in
individuals with dark skin tones. Visible blanching may not be readily apparent in darker skin
tones. Look for temperature or color changes as well as surrounding tissue that may be
painful, firm, or soft.

October 2024

Page M-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300A: Number of Stage 1 Pressure Injuries (cont.)
Coding Instructions for M0300A
•

Enter the number of Stage 1 pressure injuries that are currently present.

•

Enter 0 if no Stage 1 pressure injuries are currently present.

M0300B: Stage 2 Pressure Ulcers

Item Rationale

Health-related Quality of Life
Stage 2 pressure ulcers may worsen without proper
interventions.

•

These residents are at risk for further complications or
skin injury.

STAGE 2 PRESSURE
ULCER
Partial thickness loss of
dermis presenting as a
shallow open ulcer with a
red-pink wound bed, without
slough or bruising.
May also present as an intact
or open/ ruptured blister.

•

DEFINITION

Planning for Care

Most Stage 2 pressure ulcers should heal in a
reasonable time frame (e.g., 60 days).

•

If a pressure ulcer fails to show some evidence toward healing within 14 days, the
pressure ulcer (including potential complications) and the patient’s overall clinical
condition should be reassessed.

•

Stage 2 pressure ulcers are often related to friction and/or shearing force, and the care
plan should incorporate efforts to limit these forces on the skin and tissues.

•

Stage 2 pressure ulcers may be more likely to heal with treatment than higher stage
pressure ulcers.

•

The care plan should include individualized interventions and evidence that the
interventions have been monitored and modified as appropriate.

October 2024

•

Page M-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300B: Stage 2 Pressure Ulcers (cont.)
Steps for Assessment

1. Perform head-to-toe assessment. Conduct a full body skin assessment focusing on bony
prominences and pressure-bearing areas (sacrum, buttocks, heels, ankles, etc.).
2. For the purposes of coding, determine that the lesion being assessed is primarily related to
pressure and that other conditions have been ruled out. If pressure is not the primary cause,
do not code here.
3. Examine the area adjacent to or surrounding an intact blister for evidence of tissue
damage. If other conditions are ruled out and the tissue adjacent to or surrounding the
blister demonstrates signs of tissue damage (e.g., color change, tenderness, bogginess or
firmness, warmth or coolness), these characteristics suggest a deep tissue injury (DTI)
rather than a Stage 2 pressure ulcer.
4. Stage 2 pressure ulcers will generally lack the surrounding characteristics found with a deep
tissue injury.
5. Identify the number of these pressure ulcers that were present on admission/entry or reentry
(see instructions on page M-8).

Coding Instructions for M0300B
M0300B1

Enter the number of pressure ulcers that are currently present and whose deepest
anatomical stage is Stage 2.

•

Enter 0 if no Stage 2 pressure ulcers are present and skip to M0300C, Stage 3.

•

M0300B2
•

admission/entry AND—for residents who are reentering the facility after a hospital stay,
enter the number of Stage 2 pressure ulcers that were acquired during the hospitalization
(i.e., the Stage 2 pressure ulcer was not acquired in the nursing facility prior to admission
to the hospital).

•

Enter the number of these Stage 2 pressure ulcers that were first noted at the time of

Enter 0 if no Stage 2 pressure ulcers were first noted at the time of admission/entry or

reentry.

Coding Tips
•

Stage 2 pressure ulcers by definition have partial thickness loss of the dermis.
Granulation tissue, slough, and eschar are not present in Stage 2 pressure ulcers.

•

Do not code skin tears, tape burns, moisture associated skin damage, or excoriation here.

•

When a pressure ulcer presents as an intact blister, examine the adjacent and surrounding
area for signs of deep tissue injury. When a deep tissue injury is determined, do not code
as a Stage 2.

October 2024

Page M-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300C: Stage 3 Pressure Ulcers

Item Rationale
•

Health-related Quality of Life

DEFINITION

Pressure ulcers affect quality of life for residents
because they may limit activity, may be painful, and
may require time-consuming treatments and dressing
changes.

STAGE 3 PRESSURE
ULCER
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 or tunneling
(see definition of
undermining and tunneling
on page M-19).

Planning for Care

Pressure ulcers at more advanced stages typically
require more aggressive interventions, including more
frequent repositioning, attention to nutritional status,
and care that may be more time or staff intensive.

•

An existing pressure ulcer may put residents at risk for
further complications or skin injury.

•

If a pressure ulcer fails to show some evidence toward healing within 14 days, the
pressure ulcer (including potential complications) and the resident’s overall clinical
condition should be reassessed.

•

Tissue characteristics of pressure ulcers should be considered when determining
treatment options and choices.

•

Changes in tissue characteristics over time are indicative of wound healing or
degeneration.

Steps for Assessment

•

October 2024

Page M-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300C: Stage 3 Pressure Ulcers (cont.)
Coding Instructions for M0300C
M0300C1
•

Enter the number of pressure ulcers that are currently present and whose deepest
anatomical stage is Stage 3.

•

Enter 0 if no Stage 3 pressure ulcers are present and skip to M0300D, Stage 4.

M0300C2
•

Enter the number of these Stage 3 pressure ulcers that were first noted at Stage 3 at

the time of admission/entry AND—for residents who are reentering the facility after a
hospital stay, enter the number of Stage 3 pressure ulcers that were acquired during the
hospitalization (i.e., the Stage 3 pressure ulcer was not acquired in the nursing facility
prior to admission to the hospital).

•

Enter 0 if no Stage 3 pressure ulcers were first noted at the time of admission/entry or

reentry.

Coding Tips

The depth of a Stage 3 pressure ulcer varies by anatomical location. Stage 3 pressure
ulcers can be shallow, particularly on areas that do not have subcutaneous tissue, such as
the bridge of the nose, ear, occiput, and malleolus.

•

In contrast, areas of significant adiposity can develop extremely deep Stage 3 pressure
ulcers. Therefore, observation and assessment of skin folds should be part of overall skin
assessment. Do not code moisture-associated skin damage or excoriation here.

•

Bone/tendon/muscle is not visible or directly palpable in a Stage 3 pressure ulcer.

•

October 2024

Page M-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300C: Stage 3 Pressure Ulcers (cont.)
Examples
1. A pressure ulcer described as a Stage 2 was noted and documented in the resident’s medical
record on admission. On a later assessment, the wound is noted to be a full thickness ulcer
without exposed bone, tendon, or muscle, thus it is now a Stage 3 pressure ulcer in the same
location.

Coding: The admission coding would be M0300B1 as 1, and M0300B2 as 1,
present upon admission/entry or reentry. On the current assessment, the coding
for the Stage 2 data elements would be M0300B1 as 0, and M0300B2 is skipped,
since there is no longer a Stage 2 pressure ulcer. The Stage 3 pressure ulcer
currently assessed would be coded at M0300C1 as 1, and at M0300C2 as 0, not
present on admission/entry or reentry.
Rationale: The designation of “present on admission” requires that the pressure ulcer

be at the same location and not have increased in numerical stage or become
unstageable due to slough or eschar. This pressure ulcer worsened from Stage 2 to Stage
3 after admission. M0300C1 is coded as 1 and M0300C2 is coded as 0 on
the current assessment because the ulcer was not a Stage 3 pressure ulcer on
admission.

2. A resident develops a Stage 2 pressure ulcer while at the nursing facility. The resident is
discharged to an acute-care hospital and was hospitalized. The resident returns to the nursing
facility with a Stage 3 pressure ulcer in the same location.
Coding: The Stage 3 pressure ulcer, assessed on reentry, would be coded at M0300C1
as 1, and at M0300C2 as 1, present on admission/entry or reentry.
Rationale: The resident developed a Stage 2 pressure ulcer while at the nursing facility.

This is a “facility acquired” pressure ulcer and was not “present on admission.” The
resident is hospitalized and returns with a pressure ulcer in the same location, which has
now worsened to a Stage 3. Although the pressure ulcer was originally acquired in the
nursing facility, it is coded as “present on admission/entry or reentry,” because it
increased in numerical stage while the resident was in the hospital.

October 2024

Page M-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300C: Stage 3 Pressure Ulcers (cont.)
3. On admission, the resident has three small Stage 2 pressure ulcers on their coccyx. Two
weeks later, the coccyx is assessed. Two of the Stage 2 pressure ulcers have merged and the
third has increased in numerical stage to a Stage 3 pressure ulcer.
Coding: The admission coding would be M0300B1 as 3, and M0300B2 as 1,
present on admission/entry or reentry. On the subsequent assessment, the two
merged pressure ulcers would be coded at M0300B1 as 1, and at M0300B2 as 1,
present on admission/entry or reentry. The Stage 3 pressure ulcer would be
coded at M0300C1 as 1, and at M0300C2 as 0, not present on
admission/entry or reentry.
Rationale: On the subsequent assessment, two of the pressure ulcers on the coccyx

have merged, but have remained at the same stage as they were at the time of admission;
therefore, M0300B1 and M0300B2 would be coded as 1; the pressure ulcer that
increased in numerical stage to a Stage 3 is coded in M0300C1 as 1 and in
M0300C2 as 0, not present on admission/entry or reentry since the Stage 3 ulcer was
not present on admission/entry or reentry and developed a deeper level of tissue damage
in the time since admission.

4. A resident was admitted with no pressure ulcers/injuries and developed two Stage 2 pressure
ulcers during their stay; one on the coccyx and the other on the left lateral malleolus. At some
point they are hospitalized and return with two pressure ulcers. One is the previous Stage 2
on the coccyx, which has not changed; the other is a new Stage 3 on the left trochanter. The
Stage 2 previously on the left lateral malleolus has healed.
Coding: On admission, the resident had no pressure ulcers/injuries. The two Stage 2
pressure ulcers developed during the stay and are coded at M0300B1 as 2, and
M0300B2 as 0, when the resident is discharged to the hospital. On return from the

hospital, the Stage 2 pressure ulcer on the coccyx, which was present prior to the
resident’s discharge, would be coded at M0300B1 as 1, and at M0300B2 as 0,
not present on admission/entry or reentry; the Stage 3 pressure ulcer, which
was identified upon reentry, is new and would be coded at M0300C1 as 1, and at
M0300C2 as 1, present on admission/entry or reentry.
Rationale: The Stage 2 pressure ulcers that were facility acquired are coded as not
present on admission when the resident is discharged to the hospital. When the resident
returns to the facility, the Stage 2 pressure ulcer on the coccyx was present prior to
hospitalization and therefore would be not be considered as present on reentry. The Stage
3 pressure ulcer developed during hospitalization and is coded in M0300C2 as present on
admission/entry or reentry. The Stage 2 pressure ulcer on the left lateral malleolus has
healed and is therefore no longer coded on the assessment.

October 2024

Page M-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300C: Stage 3 Pressure Ulcers (cont.)
5. A resident is admitted to a nursing facility with a short leg cast to the right lower extremity.
They have no visible wounds on admission but arrives with documentation that a pressure
ulcer/injury exists under the cast. Two weeks after admission to the nursing facility, the cast
is removed by the physician. Following removal of the cast, a Stage 3 pressure ulcer is
observed on the right heel, which remains until the subsequent assessment.
Coding: On admission, code M0300E1 and M0300E2 as 1, present on
admission, entry or reentry. On subsequent assessment, code M0300C1 as 1,
and M0300C2 as 1, present on admission/entry or reentry.
Rationale: Because the resident was admitted to the nursing facility with

documentation that a pressure ulcer/injury was present under the cast, and the cast could
not be removed for the first two weeks, the pressure ulcer is coded on the Admission
assessment as an unstageable pressure ulcer/injury due to non-removable dressing/device.
On the subsequent assessment the pressure ulcer is coded as present on admission/entry
or reentry as a Stage 3, the stage at which it was first able to be assessed after the removal
of the cast.

6. Resident P was admitted to the nursing facility with a blood-filled blister on the right heel.
After further assessment of the surrounding tissues, it is determined that the heel blister is a
DTI. Three weeks after admission, the right-heel blister is drained and conservatively
debrided at the bedside. After debridement, the right heel is staged as a Stage 3 pressure
ulcer. On the subsequent assessment, the right heel remains at Stage 3.
Coding: Code M0300C1 as 1, and M0300C2 as 1, present on admission/entry or

reentry.

Rationale: This resident was admitted with an unstageable DTI that subsequently was

debrided and could be numerically staged. The first numerical stage was 3, and it
remained a Stage 3 for the subsequent assessment; therefore, it is coded as present on
admission/entry or reentry.

ft
October 2024

Page M-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300C: Stage 3 Pressure Ulcers (cont.)
7. Resident H was admitted with a known pressure ulcer/injury under a non-removable
dressing/device. Ten days after admission, the surgeon removed the dressing, and a Stage 2
pressure ulcer was identified. Two weeks later the pressure ulcer is determined to be a full
thickness ulcer and is at that point assessed as a Stage 3. It remained a Stage 3 at the time of
the next assessment.
Coding: On admission, code M0300E1 as 1, unstageable pressure
ulcer/injury due to non-removable dressing/device, and M0300E2 as 1,
present on admission/entry or reentry. On the subsequent assessment, code
M0300C1 as 1, Stage 3 pressure ulcer, and M0300C2 as 0, not present
on admission/entry reentry.

Rationale: Resident H was admitted with a documented pressure ulcer/injury that was
unstageable due to a non-removable dressing/device. The dressing was removed to reveal
a Stage 2 pressure ulcer, and this is the first numerical stage documented in the medical
record. Subsequent to this first documented stage, the ulcer worsened to Stage 3 and
remained a Stage 3 until the next assessment. On the next assessment, because this
pressure ulcer was previously staged as Stage 2 upon initial removal of the dressing, and
it increased in numerical stage to a Stage 3, it is not considered as present on
admission/entry or reentry.

M0300D: Stage 4 Pressure Ulcers

Item Rationale
•

Pressure ulcers affect quality of life for residents
because they may limit activity, may be painful, and
may require time-consuming treatments and dressing
changes.

October 2024

DEFINITION

Health-related Quality of Life

STAGE 4 PRESSURE
ULCER
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.

Page M-19

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300D: Stage 4 Pressure Ulcers (cont.)
Planning for Care
•

Pressure ulcers at more advanced stages typically require more aggressive interventions,
including more frequent repositioning, attention to nutritional status, more frequent
dressing changes, and treatment that is more time-consuming than with routine preventive
care.

•

An existing pressure ulcer may put residents at risk for further complications or skin
injury.

•

Steps for Assessment

Coding Instructions for M0300D
M0300D1
•

Enter the number of pressure ulcers that are

•

UNDERMINING
The destruction of tissue or
ulceration extending under
the skin edges (margins) so
that the pressure ulcer is
larger at its base than at the
skin surface.

currently present and whose deepest anatomical stage is
Stage 4.

Enter 0 if no Stage 4 pressure ulcers are present and skip to M0300E, Unstageable –

Non-removable dressing.

M0300D2
•

TUNNELING
A passage way of tissue
destruction under the skin
surface that has an opening
at the skin level from the
edge of the wound.

•

DEFINITIONS

Enter the number of these Stage 4 pressure ulcers that were first noted at Stage 4 at
the time of admission/entry AND—for residents who are reentering the facility after a
hospital stay, enter the number of Stage 4 pressure ulcers that were acquired during the
hospitalization (i.e., the Stage 4 pressure ulcer was not acquired in the nursing facility
prior to admission to the hospital).
Enter 0 if no Stage 4 pressure ulcers were first noted at the time of admission/entry or
reentry.

October 2024

Page M-20

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300D: Stage 4 Pressure Ulcers (cont.)
Coding Tips
The depth of a Stage 4 pressure ulcer varies by anatomical location. The bridge of the
nose, ear, occiput, and malleolus do not have subcutaneous tissue, and these ulcers can be
shallow.

•

Stage 4 pressure ulcers can extend into muscle and/or supporting structures (e.g., fascia,
tendon, or joint capsule) making osteomyelitis possible.

•

Exposed bone/tendon/muscle is visible or directly palpable.

•

Cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that
have exposed cartilage should be classified as a Stage 4.

•

Assessment of the pressure ulcer for tunneling and undermining is an important part of
the complete pressure ulcer assessment. Measurement of tunneling and undermining is
not recorded on the MDS, but should be assessed, monitored, and treated as part of the
comprehensive care plan.

•

M0300E: Unstageable Pressure Ulcers/Injuries Related to Nonremovable Dressing/Device

Item Rationale

Health-related Quality of Life
•

Planning for Care
•

NON-REMOVABLE
DRESSING/ DEVICE
Includes, for example, a
primary surgical dressing that
cannot be removed, an
orthopedic device, or cast.

Although the wound bed cannot be visualized, and
hence the pressure ulcer/injury cannot be staged, the
pressure ulcer/injury may affect quality of life for
residents because it may limit activity and may be
painful.

DEFINITION

Although the pressure ulcer/injury itself cannot be observed, the surrounding area is
monitored for signs of redness, swelling, increased drainage, or tenderness to touch, and
the resident is monitored for adequate pain control.

October 2024

Page M-21

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300E: Unstageable Pressure Ulcers/Injuries Related to Nonremovable Dressing/Device (cont.)
Steps for Assessment
1. Review the medical record for documentation of a pressure ulcer/injury covered by a nonremovable dressing/device.
2. Determine the number of documented pressure ulcers/injuries covered by a non-removable
dressing/device. Examples of non-removable dressings/devices include a dressing or an
orthopedic device that is not to be removed per physician’s order, or a cast.
3. Identify the number of these pressure ulcers/injuries that were present on admission/entry or
reentry (see page M-8 for assessment process).

Coding Instructions for M0300E

M0300E1

•

Enter the number of pressure ulcers/injuries that are unstageable related to non-

removable dressing/device.

Enter 0 if no unstageable pressure ulcers/injuries related to non-removable

dressing/device are present and skip to M0300F, Unstageable – Slough and/or eschar.

•

M0300E2

Enter the number of these unstageable pressure ulcers/injuries related to a non-

removable dressing/device that were first noted at the time of admission/entry AND—for
residents who are reentering the facility after a hospital stay, that were acquired during the
hospitalization (i.e., the unstageable pressure ulcer/injury related to a non-removable
dressing/device was not acquired in the nursing facility prior to admission to the hospital).
Enter 0 if no unstageable pressure ulcers/injuries related to non-removable
dressing/device were first noted at the time of admission/entry or reentry.

ft
October 2024

Page M-22

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300F: Unstageable Pressure Ulcers Related to Slough and/or
Eschar

Item Rationale
Health-related Quality of Life
•

Although the wound bed cannot be visualized, and
hence the pressure ulcer cannot be staged, the pressure
ulcer may affect quality of life for residents because it
may limit activity, may be painful, and may require
time-consuming treatments and dressing changes.

•

Visualization of the wound bed is necessary for
accurate staging.
The presence of pressure ulcers and other skin changes
should be accounted for in the interdisciplinary care
plan.
Pressure ulcers that present as unstageable require care
planning that includes, in the absence of ischemia,
debridement of necrotic and dead tissue and restaging
once this tissue is removed.

SLOUGH TISSUE
Non-viable yellow, tan, gray,
green or brown tissue;
usually moist, can be soft,
stringy and mucinous in
texture. Slough may be
adherent to the base of the
wound or present in clumps
throughout the wound bed.
ESCHAR TISSUE
Dead or devitalized tissue
that is hard or soft in texture;
usually black, brown, or tan in
color, and may appear scablike. Necrotic tissue and
eschar are usually firmly
adherent to the base of the
wound and often the sides/
edges of the wound.

•

Planning for Care

DEFINITIONS

Steps for Assessment

1. Determine the number of pressure ulcers that are
unstageable due to slough and/or eschar.
2. Identify the number of these pressure ulcers that were present on admission/entry or reentry
(see page M-8 for assessment process).

October 2024

Page M-23

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300F: Unstageable Pressure Ulcers Related to Slough and/or
Eschar (cont.)
Coding Instructions for M0300F
M0300F1
•
•

Enter the number of pressure ulcers that are unstageable related to slough and/or

eschar.

Enter 0 if no unstageable pressure ulcers related to slough and/or eschar are present and
skip to M0300G, Unstageable – Deep tissue injury.

M0300F2
•

Enter the number of these unstageable pressure ulcers related to slough and/or eschar

that were first noted at the time of admission/entry AND—for residents who are reentering
the facility after a hospital stay that were acquired during the hospitalization (i.e., the
unstageable pressure ulcer related to slough and/or eschar was not acquired in the nursing
facility prior to admission to the hospital).
Enter 0 if no unstageable pressure ulcers related to slough and/or eschar were first noted
at the time of admission/entry or reentry.

•

DEFINITION

Coding Tips

Pressure ulcers that are covered with slough and/or
FLUCTUANCE
eschar, and the wound bed cannot be visualized, should
Used to describe the texture
be coded as unstageable because the true anatomic
of wound tissue indicative of
depth of soft tissue damage (and therefore stage) cannot underlying unexposed fluid.
be determined. Only until enough slough and/or eschar
is removed to expose the anatomic depth of soft tissue damage involved, can the stage of
the wound be determined.

•

Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heels
serves as “the body’s natural (biological) cover” and should only be removed after careful
clinical consideration, including ruling out ischemia, and consultation with the resident’s
physician, or nurse practitioner, physician assistant, or clinical nurse specialist if
allowable under state licensure laws.

•

Once the pressure ulcer is debrided of slough and/or eschar such that the anatomic depth
of soft tissue damage involved can be determined, then code the ulcer for the reclassified
stage. The pressure ulcer does not have to be completely debrided or free of all slough
and/or eschar tissue in order for reclassification of stage to occur.

October 2024

•

Page M-24

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300F: Unstageable Pressure Ulcers Related to Slough and/or
Eschar (cont.)
Examples
1. A resident is admitted with a sacral pressure ulcer that is 100% covered with black eschar.
Coding: The pressure ulcer would be coded at M0300F1 as 1, and at M0300F2
as 1, present on admission/entry or reentry.
Rationale: The pressure ulcer depth is not observable because the pressure ulcer is

covered with eschar. This pressure ulcer is unstageable and was present on admission.

2. A pressure ulcer on the sacrum was present on admission and was 100% covered with black
eschar. On the admission assessment, it was coded as unstageable and present on admission.
The pressure ulcer is later debrided using conservative methods and after 4 weeks the ulcer
has 50% to 75% eschar present. The assessor can now see that the damage extends down to
the bone.
Coding: The ulcer is reclassified as a Stage 4 pressure ulcer. On the subsequent MDS, it
is coded at M0300D1 as 1, and at M0300D2 as 1, present on
admission/entry or reentry.
Rationale: After debridement, the pressure ulcer is no longer unstageable because bone

is visible in the wound bed. Therefore, this ulcer can be classified as a Stage 4 pressure
ulcer and should be coded at M0300D.

3. Miss J. was admitted with one small Stage 2 pressure ulcer. Despite treatment, it is not
improving. In fact, it now appears deeper than originally observed, and the wound bed is
covered with slough.
Coding: Code M0300F1 as 1, and M0300F2 as 0, not present on
admission/entry or reentry.
Rationale: The pressure ulcer depth is not observable because it is covered with slough.

This pressure ulcer is unstageable and is not coded in M0300F2 as present on
admission/entry or reentry because it can no longer be coded as a Stage 2.

October 2024

Page M-25

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300F: Unstageable Pressure Ulcers Related to Slough and/or
Eschar (cont.)
4. Resident M was admitted to the nursing facility with pressure ulcers that were unstageable
due to eschar on both heels, as well as a Stage 2 pressure ulcer on the coccyx. Resident M’s
pressure ulcers were reassessed before the subsequent assessment, and it was noted in the
medical record that the Stage 2 coccyx pressure ulcer had healed. The left-heel eschar
became fluctuant, showed signs of infection, and had to be debrided at the bedside. The left
heel was subsequently numerically staged as a Stage 4 pressure ulcer. The right-heel eschar
remained stable and dry (i.e., remained unstageable).

Coding: On admission, code M0300B1, Stage 2 as 1, M0300B2, present on
admission/entry or reentry as 1; and M0300F1 Unstageable due to
slough/eschar as 2 and M0300F2 as 2, present on admission, entry or
reentry. On the subsequent assessment, code M0300D1 as 1, and M0300D2 as 1,
present on admission/entry or reentry; and M0300F1 as 1, and M0300F2
as 1, present on admission/entry or reentry.
Rationale: Since both of Resident M’s heels cannot be numerically staged, because the

level of tissue damage cannot be determined as a result of the eschar present, they are
coded on admission as unstageable pressure ulcers due to slough/eschar. The left heel
eschar was subsequently debrided and is coded as a Stage 4 on the subsequent
assessment—since the left heel eschar was debrided, and the first time an unstageable
ulcer/injury is staged, it is considered as present on admission/entry or reentry at the stage
at which it is initially assessed. The other heel eschar remained unstageable and is coded
as present on admission/entry or reentry, and the Stage 2 pressure ulcer on the coccyx
healed, so it is not coded on the subsequent assessment.

October 2024

Page M-26

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300G: Unstageable Pressure Injuries Related to Deep Tissue
Injury

Item Rationale
Health-related Quality of Life
Deep tissue injury may precede the development of a
Stage 3 or 4 pressure ulcer even with optimal treatment.

•

Quality health care begins with prevention and risk
assessment, and care planning begins with prevention.
Appropriate care planning is essential in optimizing a
resident’s ability to avoid, as well as recover from,
pressure (as well as all) wounds/injuries. Deep tissue
injuries may sometimes indicate severe damage.
Identification and management of deep tissue injury
(DTI) is imperative.

DEFINITION
DEEP TISSUE INJURY
Purple or maroon area of
discolored intact skin due to
damage of underlying soft
tissue. The area may be
preceded by tissue that is
painful, firm, mushy, boggy,
warmer or cooler as
compared to adjacent tissue.

•

Planning for Care
•

Deep tissue injury requires vigilant monitoring because of the potential for rapid
deterioration. Such monitoring should be reflected in the care plan.

ft
October 2024

Page M-27

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300G: Unstageable Pressure Injuries Related to Deep Tissue
Injury (cont.)
Steps for Assessment

1. Perform head-to-toe assessment. Conduct a full body skin assessment focusing on bony
prominences and pressure-bearing areas (sacrum, buttocks, heels, ankles, etc.).
2. For the purposes of coding, determine that the lesion being assessed is primarily a result of
pressure and that other conditions have been ruled out. If pressure is not the primary cause,
do not code here.
3. Examine the area adjacent to, or surrounding, an intact blister for evidence of tissue damage.
If the tissue adjacent to, or surrounding, the blister does not show signs of tissue damage
(e.g., color change, tenderness, bogginess or firmness, warmth or coolness), do not code as a
deep tissue injury.
4. In dark-skinned individuals, the area of injury is probably not purple/maroon, but rather
darker than the surrounding tissue.
5. Determine the number of pressure injuries that are unstageable related to deep tissue injury.
6. Identify the number of these pressure injuries that were present on admission/entry or reentry
(see page M-8 for instructions).
7. Clearly document assessment findings in the resident’s medical record, and track and
document appropriate wound care planning and management.

Coding Instructions for M0300G
M0300G1
•

•

Enter the number of unstageable pressure injuries related to deep tissue injury. Based

on skin tone, the injured tissue area may present as a darker tone than the surrounding
intact skin. These areas of discoloration are potentially areas of deep tissue injury.

Enter 0 if no unstageable pressure injuries related to deep tissue injury are present and
skip to M1030, Number of Venous and Arterial Ulcers.

•

M0300G2

Enter the number of these unstageable pressure injuries related to deep tissue injury

that were first noted at the time of admission/entry AND—for residents who are reentering
the facility after a hospital stay, that were acquired during the hospitalization (i.e., the
unstageable pressure injury related to deep tissue injury was not acquired in the nursing
facility prior to admission to the hospital).
Enter 0 if no unstageable pressure injuries related to deep tissue injury were first noted

at the time of admission/entry or reentry.

October 2024

Page M-28

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M0300G: Unstageable Pressure Injuries Related to Deep Tissue
Injury (cont.)
Coding Tips
•

Once deep tissue injury has opened to an ulcer, reclassify the ulcer into the appropriate
stage. Then code the ulcer for the reclassified stage.

•

Deep tissue injury may be difficult to detect in individuals with dark skin tones.

•

Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

•

When a lesion due to pressure presents with an intact blister AND the surrounding or
adjacent soft tissue does NOT have the characteristics of deep tissue injury, do not code
here (see definition of Stage 2 pressure ulcer on page M-12).

Example

1. A resident is admitted with a blood-filled blister on the right heel. After further assessment of
the surrounding tissues, it is determined that the heel blister is a DTI. Four days after
admission, the right heel blister is drained and conservatively debrided at the bedside. After
debridement, the right heel is assessed and staged as a Stage 3 pressure ulcer. On the
subsequent assessment, the right heel remains a Stage 3.

Coding: On admission, the pressure injury to the right heel would be coded at
M0300G1 as 1, and at M0300G2 as 1, present on admission/entry or
reentry. On the subsequent assessment, the pressure ulcer is coded at M0300C1,
Stage 3 pressure ulcer and at M0300C2 as 1, present on admission/entry
or reentry.
Rationale: After a thorough clinical and skin examination, an assessment of the right

heel and surrounding tissues revealed skin injury consistent with a DTI, which was
observed at the time of admission. The heel DTI blister is drained, tissue is debrided, and
the ulcer is subsequently numerically staged as a Stage 3. Because this was the first time
the ulcer was able to be assessed and numerically staged, and it remained at that same
stage at the time of the current assessment, it is considered to have been present on
admission.

October 2024

Page M-29

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1030: Number of Venous and Arterial Ulcers

Item Rationale
Health-related Quality of Life
•

Skin wounds and lesions affect quality of life for residents because they may limit
activity, may be painful, and may require time-consuming treatments and dressing
changes.

Planning for Care
The presence of venous and arterial ulcers should be
accounted for in the interdisciplinary care plan.

•

This information identifies residents at risk for further
complications or skin injury.

•

Steps for Assessment

VENOUS ULCERS
Ulcers caused by peripheral
venous disease, which most
commonly occur proximal to
the medial or lateral
malleolus, above the inner or
outer ankle, or on the lower
calf area of the leg.

1. Review the medical record, including skin care flow sheet
or other skin tracking form.
2. Speak with direct care staff and the treatment nurse to
confirm conclusions from the medical record review.
3. Examine the resident and determine whether any venous or
arterial ulcers are present.

DEFINITIONS

Key areas for venous ulcer development include the
area proximal to the lateral and medial malleolus (e.g.,
above the inner and outer ankle area).

•

Key areas for arterial ulcer development include the
distal part of the foot, dorsum or tops of the foot, or tips
and tops of the toes.

•

ARTERIAL ULCERS
Ulcers caused by peripheral
arterial disease, which
commonly occur on the tips
and tops of the toes, tops of
the foot, or distal to the
medial malleolus.

•

Venous ulcers may or may not be painful and are
typically shallow with irregular wound edges, a red
granular (e.g., bumpy) wound bed, minimal to moderate
amounts of yellow fibrinous material, and moderate to
large amounts of exudate. The surrounding tissues may
be erythematous or reddened, or appear brown-tinged
due to hemosiderin staining. Leg edema may also be
present.

•

Arterial ulcers are often painful and have a pale pink
wound bed, necrotic tissue, minimal exudate, and
minimal bleeding.

October 2024

DEFINITION

HEMOSIDERIN
An intracellular storage form
of iron; the granules consist
of an ill-defined complex of
ferric hydroxides,
polysaccharides, and
proteins having an iron
content of approximately
33% by weight. It appears as
a dark yellow-brown pigment.

Page M-30

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1030: Number of Venous and Arterial Ulcers (cont.)
Coding Instructions
Pressure ulcers coded in M0210 through M0300 should not be coded here.
•

Enter the number of venous and arterial ulcers present.

•

Enter 0: if there were no venous or arterial ulcers present.

Coding Tips
Arterial Ulcers
•

Trophic skin changes (e.g., dry skin, loss of hair growth, muscle atrophy, brittle nails)
may also be present. The wound may start with some kind of minor trauma, such as
hitting the leg on a wheelchair. The wound does not typically occur over a bony
prominence, however, can occur on the tops of the toes. Pressure forces play virtually no
role in the development of the ulcer, however, for some residents, pressure may play a
part. Ischemia is the major etiology of these ulcers. Lower extremity and foot pulses may
be diminished or absent.

Venous Ulcers

The wound may start with some kind of minor trauma, such as hitting the leg on a
wheelchair. The wound does not typically occur over a bony prominence, and pressure
forces play virtually no role in the development of the ulcer.

Example

•

1. A resident has three toes on their right foot that have black tips. They do not have diabetes,
but have been diagnosed with peripheral vascular disease.
Coding: Code M1030 as 3.
Rationale: Ischemic changes point to the ulcer being vascular.

ft
October 2024

Page M-31

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1040: Other Ulcers, Wounds and Skin Problems

D
Item Rationale

Health-related Quality of Life

•

Skin wounds and lesions affect quality of life for residents because they may limit
activity, may be painful, and may require time-consuming treatments and dressing
changes.
Many of these ulcers, wounds and skin problems can worsen or increase risk for local and
systemic infections.

•

Planning for Care
•

•

October 2024

•

This list represents only a subset of skin conditions or changes that nursing homes will
assess and evaluate in residents.
The presence of wounds and skin changes should be accounted for in the interdisciplinary
care plan.
This information identifies residents at risk for further complications or skin injury.

Page M-32

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1040: Other Ulcers, Wounds and Skin Problems (cont.)
Steps for Assessment
1. Review the medical record, including skin care flow sheets
or other skin tracking forms.
2. Speak with direct care staff and the treatment nurse to
confirm conclusions from the medical record review.
3. Examine the resident and determine whether any ulcers,
wounds, or skin problems are present.
•

Key areas for diabetic foot ulcers include the plantar
(bottom) surface of the foot, especially the metatarsal
heads (the ball of the foot).

Coding Instructions

Check all that apply in the last 7 days. If there is no evidence
of such problems in the last 7 days, check none of the above.
Pressure ulcers/injuries coded in items M0200 through M0300
should not be coded here.
•

M1040A, Infection of the foot (e.g., cellulitis, purulent

•

M1040B, Diabetic foot ulcer(s)

•

M1040C, Other open lesion(s) on the foot (e.g., cuts,

•

M1040D, Open lesion(s) other than ulcers, rashes, cuts

fissures)

(e.g., bullous pemphigoid)
M1040E, Surgical wound(s)
M1040F, Burn(s)(second or third degree)
M1040G, Skin tear(s)
M1040H, Moisture Associated Skin Damage (MASD)
(e.g., incontinence-associated dermatitis (IAD),
perspiration, drainage)
M1040Z, None of the above were present

SURGICAL WOUNDS
Any healing and non-healing,
open or closed surgical
incisions, skin grafts or
drainage sites.
OPEN LESION(S)
OTHER THAN ULCERS,
RASHES, CUTS
Most typically skin lesions
that develop as a result of
diseases and conditions such
as syphilis and cancer.

•

DIABETIC FOOT
ULCERS
Ulcers caused by the
neuropathic and small blood
vessel complications of
diabetes. Diabetic foot ulcers
typically occur over the
plantar (bottom) surface of
the foot on load bearing
areas such as the ball of the
foot. Ulcers are usually deep,
with necrotic tissue,
moderate amounts of
exudate, and callused wound
edges. The wounds are very
regular in shape and the
wound edges are even with a
punched-out appearance.
These wounds are typically
not painful.

•
•
•
•

drainage)

DEFINITIONS

BURNS (SECOND OR
THIRD DEGREE)
Skin and tissue injury caused
by heat or chemicals and
may be in any stage of
healing.

October 2024

Page M-33

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1040: Other Ulcers, Wounds and Skin Problems (cont.)
Coding Tips
M1040B Diabetic Foot Ulcers
Diabetic neuropathy affects the lower extremities of individuals with diabetes. Individuals
with diabetic neuropathy can have decreased awareness of pain in their feet. This means
they are at high risk for foot injury, such as burns from hot water or heating pads, cuts or
scrapes from stepping on foreign objects, and blisters from inappropriate or tight-fitting
shoes. Because of decreased circulation and sensation, the resident may not be aware of
the wound.

•

Neuropathy can also cause changes in the structure of the bones and tissue in the foot.
This means the individual with diabetes experiences pressure on the foot in areas not
meant to bear pressure. Neuropathy can also cause changes in normal sweating, which
means the individual with diabetes can have dry, cracked skin on their other foot.

•

Do not include pressure ulcers/injuries that occur on residents with diabetes mellitus
here. For example, an ulcer caused by pressure on the heel of a diabetic resident is a
pressure ulcer and not a diabetic foot ulcer.

M1040D Open Lesion(s) Other than Ulcers, Rashes, Cuts
Open lesions that develop as part of a disease or condition and are not coded elsewhere
on the MDS, such as wounds, boils, cysts, and vesicles, should be coded in this item.

•

Do not code rashes, abrasions, or cuts/lacerations here. Although not recorded on the
MDS assessment, these skin conditions should be considered in the plan of care.

•

Do not code pressure ulcers/injuries, venous or arterial ulcers, diabetic foot ulcers, or
skin tears here. These conditions are coded in other items on the MDS.

•

M1040E Surgical Wounds

This category does not include healed surgical sites and healed stomas or lacerations that
require suturing or butterfly closure as surgical wounds. PICC sites, central line sites, and
peripheral IV sites are not coded as surgical wounds.

•

Code pressure ulcers that require surgical intervention for closure with graft and/or flap
procedures in this item (e.g., excision of pressure ulcer with myocutaneous flap). Once a
pressure ulcer is excised and a graft and/or flap is applied, it is no longer considered a
pressure ulcer, but a surgical wound.

October 2024

•

Page M-34

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1040: Other Ulcers, Wounds and Skin Problems (cont.)
M1040F Burns (Second or Third Degree)
•

Do not include first degree burns (changes in skin color only).

M1040G Skin Tear(s)
•

Skin tears are a result of shearing, friction or trauma to the skin that causes a separation of
the skin layers. They can be partial or full thickness. Code all skin tears in this item, even
if already coded in Item J1900B.

•

Do not code cuts/lacerations or abrasions here. Although not recorded on the MDS, these
skin conditions should be considered in the plan of care.

M1040H Moisture Associated Skin Damage (MASD)
MASD is also referred to as maceration and includes
incontinence-associated dermatitis, intertriginous
dermatitis, periwound moisture-associated dermatitis,
and peristomal moisture-associated dermatitis.

•

DEFINITION
MOISTURE
ASSOCIATED SKIN
DAMAGE
Is superficial skin damage
caused by sustained
exposure to moisture such as
incontinence, wound
exudate, or perspiration.

Moisture exposure and MASD are risk factors for
pressure ulcer/injury development. Provision of optimal
skin care and early identification and treatment of minor
cases of MASD can help avoid progression and skin
breakdown.

•

MASD without skin erosion is characterized by
red/bright red color (hyperpigmentation), and the
surrounding skin may be white (hypopigmentation). The skin damage is usually
blanchable and diffuse and has irregular edges. Inflammation of the skin may also be
present.

•

MASD with skin erosion has superficial/partial thickness skin loss and may have hyperor hypopigmentation; the tissue is blanchable and diffuse and has irregular edges.
Inflammation of the skin may also be present. Necrosis is not found in MASD.

•

If pressure and moisture are both present, code the skin damage as a pressure ulcer/injury
in M0300.

•

If there is tissue damage extending into the subcutaneous tissue or deeper and/or necrosis
is present, code the skin damage as a pressure ulcer in M0300.

October 2024

•

Page M-35

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1040: Other Ulcers, Wounds and Skin Problems (cont.)
Examples
1. A resident with diabetes mellitus presents with an ulcer on the heel that is due to pressure.
Coding: This ulcer is not checked at M1040B. This ulcer should be coded where
appropriate under the Pressure Ulcers items (M0210–M0300).
Rationale: Persons with diabetes can still develop pressure ulcers.

2. A resident is readmitted from the hospital after myocutaneous flap surgery to excise and
close their sacral pressure ulcer.
Coding: Check M1040E, Surgical Wound.
Rationale: A surgical flap procedure was used to close the resident’s pressure ulcer.

The pressure ulcer is now considered a surgical wound.

3. Resident J was reaching over to get a magazine off of their bedside table and sustained a skin
tear on their wrist from the edge of the table when they pulled the magazine back towards
them.
Coding: Check M1040G, Skin Tear(s).
Rationale: The resident sustained a skin tear while reaching for a magazine.

4. Resident S who is incontinent, is noted to have a large, red and excoriated area on their
buttocks and interior thighs with serous exudate which is starting to cause skin glistening.
Coding: Check M1040H, Moisture Associated Skin Damage (MASD).
Rationale: Resident S skin assessment reveals characteristics of incontinence-

associated dermatitis.

5. Resident F complained of discomfort of their right great toe and when their stocking and
shoe was removed, it was noted that their toe was red, inflamed and had pus draining from
the edge of their nail bed. The podiatrist determined that Resident F has an infected ingrown
toenail.
Coding: Check M1040A, Infection of the foot.
Rationale: Resident F has an infected right great toe due to an ingrown toenail.

6. Resident G has bullous pemphigoid and requires the application of sterile dressings to the
open and weeping blistered areas.
Coding: Check M1040D, Open lesion other than ulcers, rashes, cuts.
Rationale: Resident G has open bullous pemphigoid blisters.

7. Resident A was just admitted to the nursing home from the hospital burn unit after sustaining
second and third degree burns in a house fire. They are here for continued treatment of their
burns and for rehabilitative therapy.
Coding: Check M1040F, Burns (second or third degree).
Rationale: Resident A has second and third degree burns, therefore, burns (second or

third degree) should be checked.

October 2024

Page M-36

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1200: Skin and Ulcer/Injury Treatments

D
Item Rationale

Health-related Quality of Life

•

Appropriate prevention and treatment of skin changes
and ulcers reduce complications and promote healing.

PRESSURE REDUCING
DEVICE(S)
Equipment that aims to
relieve pressure away from
areas of high risk. May
include foam, air, water gel,
or other cushioning placed on
a chair, wheelchair, or bed.
Include pressure relieving,
pressure reducing, and
pressure redistributing
devices. Devices are
available for use with beds
and seating.

Planning for Care

DEFINITION

These general skin treatments include basic pressure
ulcer/injury prevention and skin health interventions
that are a part of providing quality care and consistent
with good clinical practice for those with skin health
problems.

•

These general treatments should guide more
individualized and specific interventions in the care
plan.

•

If skin changes are not improving or are worsening, this
information may be helpful in determining more appropriate care.

Steps for Assessment

•

1. Review the medical record, including treatment records and health care provider orders for
documented skin treatments during the past 7 days. Some skin treatments may be part of
routine standard care for residents, so check the nursing facility’s policies and procedures and
indicate here if administered during the look-back period.
2. Speak with direct care staff and the treatment nurse to confirm conclusions from the medical
record review.
3. Some skin treatments can be determined by observation. For example, observation of the
resident’s wheelchair and bed will reveal if the resident is using pressure-reducing devices for
the bed or wheelchair.

October 2024

Page M-37

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1200: Skin and Ulcer/Injury Treatments (cont.)
Coding Instructions
Check all that apply in the last 7 days. Check Z, None of the above were provided, if none
applied in the past 7 days.
M1200A, Pressure reducing device for chair

•

M1200B, Pressure reducing device for bed

•

M1200C, Turning/repositioning program

•

M1200D, Nutrition or hydration intervention to manage skin problems

•

M1200E, Pressure ulcer/injury care

•

M1200F, Surgical wound care

•

M1200G, Application of non-surgical dressings (with or without topical medications)
other than to feet. Non- surgical dressings do not include Band-Aids.

•

M1200H, Application of ointments/medications other than to feet

•

M1200I, Application of dressings to feet (with or without topical medications)

•

M1200Z, None of the above were provided

•

October 2024

Page M-38

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1200: Skin and Ulcer/Injury Treatments (cont.)
Coding Tips
M1200A/M1200B Pressure Reducing
Devices
•

•
•

Pressure reducing devices redistribute pressure so that
there is some relief on or near the area of the
ulcer/injury. The appropriate pressure reducing device
should be selected based on the individualized needs of
the resident.
Do not include egg crate cushions of any type in this
category.
Do not include doughnut or ring devices in chairs.

M1200C Turning/Repositioning Program

•

M1200D Nutrition or Hydration
Intervention to Manage Skin Problems
•

TURNING/
REPOSITIONING
PROGRAM
Includes a consistent
program for changing the
resident’s position and
realigning the body.
“Program” is defined as a
specific approach that is
organized, planned,
documented, monitored, and
evaluated based on an
assessment of the resident’s
needs.
NUTRITION OR
HYDRATION
INTERVENTION TO
MANAGE SKIN
PROBLEMS
Dietary measures received
by the resident for the
purpose of preventing or
treating specific skin
conditions, e.g., wheat-free
diet to prevent allergic
dermatitis, high calorie diet
with added supplementation
to prevent skin breakdown,
high-protein supplementation
for wound healing.

•

The turning/repositioning program is specific as to the
approaches for changing the resident’s position and
realigning the body. The program should specify the
intervention (e.g., reposition on side, pillows between
knees) and frequency (e.g., every 2 hours).
Progress notes, assessments, and other documentation
(as dictated by facility policy) should support that the
turning/repositioning program is monitored and
reassessed to determine the effectiveness of the
intervention.

DEFINITIONS

The determination as to whether or not one should
receive nutritional or hydration interventions for skin
problems should be based on an individualized
nutritional assessment. The interdisciplinary team
should review the resident’s diet and determine if the
resident is taking in sufficient amounts of nutrients and
fluids or are already taking supplements that are fortified with the US Recommended
Daily Intake (US RDI) of nutrients.

October 2024

Page M-39

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1200: Skin and Ulcer/Injury Treatments (cont.)
Additional supplementation above the US RDI has not been proven to provide any further
benefits for management of skin problems including pressure ulcers/injuries. Vitamin and
mineral supplementation should only be employed as an intervention for managing skin
problems, including pressure ulcers/injuries, when nutritional deficiencies are confirmed
or suspected through a thorough nutritional assessment. If it is determined that nutritional
supplementation, that is, adding additional protein, calories, or nutrients is warranted, the
facility should document the nutrition or hydration factors that are influencing skin
problems and/or wound healing and tailor nutritional supplementation to the individual’s
intake, degree of under-nutrition, and relative impact of nutrition as a factor overall; and
obtain dietary consultation as needed.

•

It is important to remember that additional supplementation is not automatically required
for pressure ulcer/injury management. Any interventions should be specifically tailored to
the resident’s needs, condition, and prognosis.

•

M1200E Pressure Ulcer/Injury Care

•

Pressure ulcer care includes any intervention for treating pressure ulcers coded in Current
Number of Unhealed Pressure Ulcers/Injuries at Each Stage (M0300A–G). Examples may
include the use of topical dressings; enzymatic, mechanical or surgical debridement;
wound irrigations; negative pressure wound therapy (NPWT); and/or hydrotherapy.

M1200F Surgical Wound Care

Does not include post-operative care following eye or oral surgery.

•

Surgical debridement of a pressure ulcer does not create a surgical wound. Surgical
debridement is used to remove necrotic or infected tissue from the pressure ulcer in order
to facilitate healing, and thus, any wound care associated with pressure ulcer debridement
would be coded in M1200E, Pressure Ulcer Care. The only time a surgical wound
would be created is if the pressure ulcer itself was excised and a flap and/or graft used to
close the pressure ulcer.

•

Surgical wound care may include any intervention for treating or protecting any type of
surgical wound. Examples may include topical cleansing, wound irrigation, application of
antimicrobial ointments, application of dressings of any type, suture/staple removal, and
warm soaks or heat application.

•

Surgical wound care for pressure ulcers that require surgical intervention for closure (e.g.,
excision of pressure ulcer with flap and/or graft coverage) can be coded in this item, as
once a pressure ulcer is excised and flap and/or graft applied, it is no longer considered a
pressure ulcer, but a surgical wound.

October 2024

•

Page M-40

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1200: Skin and Ulcer/Injury Treatments (cont.)
M1200G Application of Non-surgical Dressings (with or without
Topical Medications) Other than to Feet
Do not code application of non-surgical dressings for pressure ulcers/injuries other than
to feet in this item; use M1200E, Pressure ulcer/injury care.

•

Dressings do not have to be applied daily in order to be coded on the MDS assessment. If
any dressing meeting the MDS definitions was applied even once during the 7-day lookback period, the assessor should check that MDS item.

•

This category may include, but is not limited to, dry gauze dressings, dressings moistened
with saline or other solutions, transparent dressings, hydrogel dressings, and dressings
with hydrocolloid or hydroactive particles used to treat a skin condition, compression
bandages, etc. Non-surgical dressings do not include adhesive bandages (e.g., BANDAID® bandages, wound closure strips).

•

M1200H Application of Ointments/Medications Other than to
Feet
Do not code application of ointments/medications (e.g., chemical or enzymatic
debridement) for pressure ulcers here; use M1200E, Pressure ulcer/injury care.

•

This category may include ointments or medications used to treat a skin condition
(e.g., cortisone, antifungal preparations, chemotherapeutic agents).

•

Ointments/medications may include topical creams, powders, and liquid sealants used to
treat or prevent skin conditions.

•

This category does not include ointments used to treat non-skin conditions
(e.g., nitropaste for chest pain, testosterone cream).

•

M1200I Application of Dressings to the Feet (with or without
Topical Medications)
•

Includes interventions to treat any foot wound or ulcer other than a pressure
ulcer/injury.

•

Do not code application of dressings to pressure ulcers/injuries on the foot; use M1200E,
Pressure ulcer/injury care.

•

Do not code application of dressings to the ankle. The ankle is not considered part of the
foot.

October 2024

Page M-41

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1200: Skin and Ulcer/Injury Treatments (cont.)
Examples

1. A resident is admitted with a Stage 3 pressure ulcer on the sacrum. Care during the last 7
days has included one debridement by the wound care consultant, application of daily
dressings with enzymatic ointment for continued debridement, nutritional
supplementation, and use of a pressure reducing pad on the resident’s wheelchair. The
medical record documents delivery of care and notes that the resident is on a two-hour
turning/repositioning program that is organized, planned, documented, monitored, and
evaluated based on an individualized assessment of their needs. The physician documents,
after reviewing the resident’s nutritional intake, healing progress of the resident’s
pressure ulcer, dietician’s nutritional assessment, and laboratory results, that the resident
has protein-calorie malnutrition. In order to support proper wound healing, the physician
orders an oral supplement that provides all recommended daily allowances for protein,
calories, nutrients, and micronutrients. All mattresses in the nursing home are pressure
reducing mattresses.
Coding: Check items M1200A, M1200B, M1200C, M1200D, and M1200E.
Rationale: Interventions include pressure reducing pad on the wheelchair (M1200A)

and pressure reducing mattress on the bed (M1200B), turning and repositioning program
(M1200C), nutritional supplementation (M1200D), enzymatic debridement and
application of dressings (M1200E).

2. A resident has a venous ulcer on the right leg. During the last 7 days the resident has had
a three-layer compression-bandaging system applied once (orders are to reapply the
compression bandages every 5 days). The resident also has a pressure reducing mattress
and pad for the wheelchair.
Coding: Check items M1200A, M1200B, and M1200G.
Rationale: Treatments include pressure reducing mattress (M1200B) and pad

(M1200A) in the wheelchair and application of the compression-bandaging system
(M1200G).

3. Resident S has a diagnosis of right-sided hemiplegia from a previous stroke. As part of
their assessment, it was noted that while in bed Resident S is able to tolerate pressure on
each side for approximately 3 hours before showing signs of the effects of pressure on
their skin. Staff assist them to turn every 3 hours while in bed. When they are in their
wheelchair, it is difficult for them to offload the pressure to their buttocks. Their
assessment indicates that their skin cannot tolerate pressure for more than 1 hour without
showing signs of the effect of the pressure when they are sitting, and therefore,
Resident S is assisted hourly by staff to stand for at least 1 full minute to relieve pressure.
Staff document all of these interventions in the medical record and note the resident’s
response to the interventions.

Coding: Check M1200C.
Rationale: Treatments meet the criteria for a turning/repositioning program (i.e., it is

organized, planned, documented, monitored, and evaluated), that is based on an
assessment of the resident’s unique needs.

October 2024

Page M-42

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

M1200: Skin and Ulcer/Injury Treatments (cont.)
4. Resident J has a diagnosis of Advanced Alzheimer’s and is totally dependent on staff for
all of their care. Their care plan states that they are to be turned and repositioned, per
facility policy, every 2 hours.
Coding: Do not check item M1200C.
Rationale: Treatments provided do not meet the criteria for a turning/repositioning

program. There is no notation in the medical record about an assessed need for
turning/repositioning, nor is there a specific approach or plan related to positioning and
realigning of the body. There is no reassessment of the resident’s response to turning and
repositioning. There are not any skin or ulcer treatments being provided.

Scenarios for Pressure Ulcer Coding

Example M0100-M1200

5-Day PPS:
Coding:

•
•
•
•
•
•
•

1. Resident P was admitted to the nursing home on 10/23/2019 for a Medicare stay. In
completing the PPS 5-day assessment (ARD of 10/28/2019), it was noted that the resident
had a head-to-toe skin assessment and their skin was intact, but upon assessment using the
Braden scale, was found to be at risk for skin breakdown. The resident was noted to have a
Stage 2 pressure ulcer that was identified on their coccyx on 11/1/2019. This Stage 2 pressure
ulcer was noted to have pink tissue with some epithelialization present in the wound bed.
Dimensions of the ulcer were length 01.1 cm, width 00.5 cm, and no measurable depth.
Resident P does not have any arterial or venous ulcers, wounds, or skin problems. They are
receiving ulcer care with application of a dressing applied to the coccygeal ulcer. Resident P
also has pressure reducing devices on both their bed and chair and has been placed on a 1½
hour turning and repositioning schedule per tissue tolerance. In order to stay closer to their
family, Resident P was discharged to another nursing home on 11/5/2019. This was a
planned discharge (A0310G = 2), and their OBRA Discharge assessment was coded at
A0310F as 10, Discharge assessment – return not anticipated.

M0100B (Formal assessment instrument), Check box.
M0100C (Clinical assessment), Check box.

M0150 (Risk of Pressure Ulcers/Injuries), Code 1.

M0210 (One or more unhealed pressure ulcers/injuries), Code 0 and skip to M1030

(Number of Venous and Arterial Ulcers).
M1030 (Number of Venous and Arterial Ulcers), Code 0.
M1040 (Other ulcers, wounds and skin problems), Check Z (None of the above).
M1200 (Skin and Ulcer Treatments), Check Z (None of the above were provided).

October 2024

Page M-43

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [M]

Scenarios for Pressure Ulcer Coding (cont.)
Rationale: The resident had a formal assessment using the Braden scale and also had a

head-to-toe skin assessment completed. Pressure ulcer risk was identified via formal
assessment. Upon assessment the resident’s skin was noted to be intact, therefore, M0210
was coded 0. M1030 was coded 0 due to the resident not having any of these conditions.
M1040Z was checked since none of these problems were noted. M1200Z was checked
because none of these treatments were provided.
Discharge Assessment:
Coding:

•

•
•

•
•
•

M0100A (Resident has a pressure ulcer/injury, a scar over bony prominence, or a nonremovable dressing/device), Check box.
M0210 (Unhealed Pressure Ulcers/Injuries), Code 1.
M0300B1 (Number of Stage 2 pressure ulcers), Code 1.
M0300B2 (Number of these Stage 2 pressure ulcers present on admission/entry or
reentry), Code 0.
M0300C1 (Number of Stage 3 pressure ulcers), Code 0 and skip to M0300D
(Stage 4).
M0300D1 (Number of Stage 4 pressure ulcers), Code 0 and skip to M0300E
(Unstageable – Non-removable dressing/device).
M0300E1 (Unstageable – Non-removable dressing/device), Code 0 and skip to
M0300F (Unstageable – Slough and/or eschar).
M0300F1 (Unstageable – Slough and/or eschar), Code 0 and skip to M0300G
(Unstageable – Deep tissue injury).
M0300G1 (Unstageable – Deep tissue injury), Code 0 and skip to M1030 (Number of
Venous and Arterial Ulcers).

Rationale: The resident has a pressure ulcer. On the 5-day PPS assessment, the resident’s

skin was noted to be intact; however, on the Discharge assessment, it was noted that the
resident had a new Stage 2 pressure ulcer. Since the resident has had both a 5-day PPS and
Discharge assessment completed, the Discharge assessment would be coded 0 at A0310E.
This is because the Discharge assessment is not the first assessment since the most recent
admission/entry or reentry.

October 2024

Page M-44

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

SECTION N: MEDICATIONS
Intent: The intent of the items in this section is to record the number of days, during the last 7
days (or since admission/entry or reentry if less than 7 days) that any type of injection, insulin,
and/or select medications were received by the resident.
In addition, two medication sections have been added. The first is an Antipsychotic Medication
Review. Including this information will assist facilities to evaluate the use and management of
these medications. Each aspect of antipsychotic medication use and management has important
associations with the quality of life and quality of care of residents receiving these medications.
The second is a series of data elements addressing Drug Regimen Review. These data elements
document whether a drug regimen review was conducted upon the start of a SNF PPS stay
through the end of the SNF PPS stay and whether any clinically significant medication issues
identified were addressed in a timely manner.

D
N0300: Injections

Item Rationale

Health-related Quality of Life
•

Frequency of administration of medication via injection can be an indication of stability
of a resident’s health status and/or complexity of care needs.

Planning for Care

Monitor for adverse effects of injected medications.

•

Although antigens and vaccines are not considered to be medications per se, it is
important to track when they are given to monitor for localized or systemic reactions.

Steps for Assessment

•

1. Review the resident’s medication administration records for the 7-day look-back period (or
since admission/entry or reentry if less than 7 days).
2. Review documentation from other health care locations where the resident may have
received injections while a resident of the nursing home (e.g., flu vaccine in a physician’s
office, in the emergency room – as long as the resident was not admitted).
3. Determine if any medications were received by the resident via injection. If received,
determine the number of days during the look-back period they were received.

October 2024

Page N-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0300: Injections (cont.)
Coding Instructions
Record the number of days during the 7-day look-back period (or since admission/entry or
reentry if less than 7 days) that the resident received any type of medication, antigen, vaccine,
etc., by injection.
Insulin injections are counted in this item as well as in Item N0350.
•

Count the number of days that the resident received any type of injection while a
resident of the nursing home.

•

Record the number of days that any type of injection (e.g., subcutaneous, intramuscular,
or intradermal) was received in Item N0300.

Coding Tips and Special Populations
For subcutaneous pumps, code only the number of days that the resident actually required
a subcutaneous injection to restart the pump.

•

If an antigen or vaccination is provided on one day, and another vaccine is provided on
the next day, the number of days the resident received injections would be coded as 2
days.

•

If two injections were administered on the same day, the number of days the resident
received injections would be coded as 1 day.

Examples

•

1. During the 7-day look-back period, Resident T received an influenza shot on Monday, a PPD
test (for tuberculosis) on Tuesday, and a Vitamin B 12 injection on Wednesday.

back period.

Coding: N0300 would be coded 3.
Rationale: The resident received injections on 3 separate days during the 7-day look-

2. During the 7-day look-back period, Resident C received both an influenza shot and their
vitamin B 12 injection on Thursday.

Coding: N0300 would be coded 1.
Rationale: The resident received injections on one day during the 7-day look-back

period.

October 2024

Page N-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0350: Insulin

Item Rationale
Health-related Quality of Life
Insulin is a medication used to treat diabetes mellitus (DM).

•

Individualized meal plans should be created with the resident’s input to ensure
appropriate meal intake. Residents are more likely to be compliant with their DM diet if
they have input related to food choices.

•

Planning for Care

Orders for insulin may have to change depending on the resident’s condition (e.g., fever
or other illness) and/or laboratory results.

•

Ensure that dosage and time of injections take into account meals, activity, etc., based on
individualized resident assessment.

•

Monitor for adverse effects of insulin injections (e.g., hypoglycemia).

•

Monitor HbA1c and blood glucose levels to ensure appropriate amounts of insulin are
being administered.

•

Steps for Assessment

1. Review the resident’s medication administration records for the 7-day look-back period (or
since admission/entry or reentry if less than 7 days).
2. Determine if the resident received insulin injections during the look-back period.
3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse
specialist if allowable under state licensure laws) changed the resident’s insulin orders during
the look-back period.
4. Count the number of days insulin injections were received and/or insulin orders changed.

Coding Instructions for N0350A
•

Enter in Item N0350A, the number of days during the 7-day look-back period (or since
admission/entry or reentry if less than 7 days) that insulin injections were received.

Coding Instructions for N0350B
•

Enter in Item N0350B, the number of days during the 7-day look-back period (or since
admission/entry or reentry if less than 7 days) that the physician (nurse practitioner,
physician assistant, or clinical nurse specialist if allowable under state licensure laws)
changed the resident’s insulin orders.

October 2024

Page N-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0350: Insulin (cont.)
Coding Tips and Special Populations
•

For sliding scale orders:
— A sliding scale dosage schedule that is written to cover different dosages depending
on lab values does not count as an order change simply because a different dose is
administered based on the sliding scale guidelines.
— If the sliding scale order is new, discontinued, or is the first sliding scale order for the
resident, these days can be counted and coded.

•

For subcutaneous insulin pumps, code only the number of days that the resident actually
required a subcutaneous injection to restart the pump.

N0415: High-Risk Drug Classes: Use and Indication

October 2024

Page N-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0415: High-Risk Drug Classes: Use and Indication (cont.)
Item Rationale
Health-related Quality of Life
•

•

Medications are an integral part of the care provided to
residents of nursing homes. They are administered to
try to achieve various outcomes, such as curing an
illness, diagnosing a disease or condition, arresting or
slowing a disease’s progress, reducing or eliminating
symptoms, or preventing a disease or symptom.

Residents taking medications in these medication
categories and pharmacologic classes are at risk of side
effects that can adversely affect health, safety, and
quality of life.
While assuring that only those medications required to
treat the resident’s assessed condition are being used, it
is important to assess the need to reduce these
medications wherever possible and ensure that the
medication is the most effective for the resident’s
assessed condition.

•

As part of all medication management, it is important
for the interdisciplinary team to consider nonpharmacological approaches. Educating the nursing
home staff and providers about non-pharmacological
approaches in addition to and/or in conjunction with the
use of medication may minimize the need for
medications or reduce the dose and duration of those
medications.

ADVERSE
CONSEQUENCE
An unpleasant symptom or
event that is caused by or
associated with a medication,
impairment or decline in an
individual's physical
condition, mental, functional
or psychosocial status. It may
include various types of
adverse drug reactions
(ADR) and interactions (e.g.,
medication-medication,
medication-food, and
medication-disease).

•

DEFINITIONS

NONPHARMACOLOGICAL
INTERVENTION
Approaches that do not
involve the use of medication
to address a medical
condition.

ft
October 2024

Page N-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0415: High-Risk Drug Classes: Use and Indication (cont.)
•

•

DEFINITIONS

The indications for initiating, withdrawing, or
withholding medication(s), as well as the use of nonpharmacological interventions, are determined by
assessing the resident’s underlying condition, current
signs and symptoms, and preferences and goals for
treatment. This includes, where possible, the
identification of the underlying cause(s), since a
diagnosis alone may not warrant treatment with
medication.

INDICATION

Target symptoms and goals for use of these medications
should be established for each resident. Progress toward
meeting the goals should be evaluated routinely.

DOSE
The total amount/strength/
concentration of a medication
given at one time or over a
period of time. The individual
dose is the amount/strength/
concentration received at
each administration. The
amount received over a 24hour period may be referred
to as the “daily dose.”

Planning for Care

Possible adverse effects of these medications should be
well understood by nursing staff. Educate nursing home
staff to be observant for these adverse effects.

•

Implement systematic monitoring of each resident
taking any of these medications to identify adverse
consequences early.

•

The identified, documented
clinical rationale for
administering a medication
that is based upon a
physician’s (or prescriber’s)
assessment of the resident’s
condition and therapeutic
goals.

Steps for Assessment

Coding Instructions
•

1. Review the resident’s medical record for documentation
that any of these medications were received by the resident
and for the indication of their use during the 7-day lookback period (or since admission/entry or reentry if less than
7 days).
2. Review documentation from other health care settings
where the resident may have received any of these
medications while a resident of the nursing home (e.g.,
valium given in the emergency room).
Code all high-risk drug class medications according to
their pharmacological classification, not how they are
being used.
o

MONITORING
The ongoing collection and
analysis of information (such
as observations and
diagnostic test results) and
comparison to baseline and
current data in order to
ascertain the individual's
response to treatment and
care, including progress or
lack of progress toward a
goal. Monitoring can detect
any improvements,
complications, or adverse
consequences of the
condition or the treatments
and support decisions about
adding, modifying,
continuing, or discontinuing
any interventions.

Column 1: Check if the resident is taking any
medications by pharmacological classification
during the 7-day observation period (or since
admission/entry or reentry if less than 7 days).

o Column 2: If Column 1 is checked, check if there is an indication noted for all
medications in the drug class.

October 2024

Page N-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0415: High-Risk Drug Classes: Use and Indication (cont.)
•
•
•
•

N0415A1. Antipsychotic: Check if an antipsychotic medication was taken by the

•

•
•
•

N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular
weight heparin): Check if an anticoagulant medication was taken by the resident at

•

resident at any time during the 7-day look-back period (or since admission/entry or
reentry if less than 7 days).
N0415A2. Antipsychotic: Check if there is an indication noted for all antipsychotic
medications taken by the resident any time during the observation period (or since
admission/entry or reentry if less than 7 days).
N0415B1. Antianxiety: Check if an anxiolytic medication was taken by the resident
at any time during the 7-day look-back period (or since admission/entry or reentry if less
than 7 days).
N0415B2. Antianxiety: Check if there is an indication noted for all anxiolytic
medications taken by the resident any time during the observation period (or since
admission/entry or reentry if less than 7 days).
N0415C1. Antidepressant: Check if an antidepressant medication was taken by the
resident at any time during the 7-day look-back period (or since admission/entry or
reentry if less than 7 days).
N0415C2. Antidepressant: Check if there is an indication noted for all
antidepressant medications taken by the resident any time during the observation period
(or since admission/entry or reentry if less than 7 days).
N0415D1. Hypnotic: Check if a hypnotic medication was taken by the resident at any
time during the 7-day look-back period (or since admission/entry or reentry if less than 7
days).
N0415D2. Hypnotic: Check if there is an indication noted for all hypnotic
medications taken by the resident any time during the observation period (or since
admission/entry or reentry if less than 7 days).

any time during the 7-day look-back period (or since admission/entry or reentry if less
than 7 days).
N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant
medications taken by the resident any time during the observation period (or since
admission/entry or reentry if less than 7 days).
N0415F1. Antibiotic: Check if an antibiotic medication was taken by the resident at
any time during the 7-day look-back period (or since admission/entry or reentry if less
than 7 days).
N0415F2. Antibiotic: Check if there is an indication noted for all antibiotic
medications taken by the resident any time during the observation period (or since
admission/entry or reentry if less than 7 days).
N0415G1. Diuretic: Check if a diuretic medication was taken by the resident at any
time during the 7-day look-back period (or since admission/entry or reentry if less than 7
days).

October 2024

Page N-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0415: High-Risk Drug Classes: Use and Indication (cont.)
•
•
•
•

N0415G2. Diuretic: Check if there is an indication noted for all diuretic medications

•
•

•
•
•

•

received by the resident any time during the observation period (or since admission/entry
or reentry if less than 7 days).
N0415H1. Opioid: Check if an opioid medication was taken by the resident at any
time during the 7-day look-back period (or since admission/entry or reentry if less than 7
days).
N0415H2. Opioid: Check if there is an indication noted for all opioid medications
taken by the resident any time during the observation period (or since admission/entry or
reentry if less than 7 days).
N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended
release, dipyridamole, clopidogrel) was taken by the resident at any time during the 7-day
observation period (or since admission/entry or reentry if less than 7 days).
N0415I2. Antiplatelet: Check if there is an indication noted for all antiplatelet
medications taken by the resident any time during the observation period (or since
admission/entry or reentry if less than 7 days).
N0415J1. Hypoglycemic (including insulin): Check if a hypoglycemic
medication was taken by the resident at any time during the 7-day observation period (or
since admission/entry or reentry if less than 7 days).
N0415J2. Hypoglycemic (including insulin): Check if there is an indication
noted for all hypoglycemic medications taken by the resident any time during the
observation period (or since admission/entry or reentry if less than 7 days).
N0415K1. Anticonvulsant: Check if an anticonvulsant medication was taken by the
resident at any time during the 7-day observation period (or since admission/entry or
reentry if less than 7 days).
N0415K2. Anticonvulsant: Check if there is an indication noted for all
anticonvulsant medications taken by the resident any time during the observation period
(or since admission/entry or reentry if less than 7 days).
N0415Z1. None of the above: Check if none of the medications above were taken
by the resident at any time during the observation period (or since admission/entry or
reentry if less than 7 days).

Coding Tips and Special Populations
•

Code medications in Item N0415 according to the medication’s therapeutic category
and/or pharmacological classification, not how it is used. For example, although
oxazepam may be prescribed for use as a hypnotic, it is categorized as an antianxiety
medication. Therefore, in this section, it would be coded as an antianxiety medication and
not as a hypnotic.

October 2024

Page N-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0415: High-Risk Drug Classes: Use and Indication (cont.)
•

•
•
•

•

October 2024

•

•
•
•

Medications that have more than one therapeutic category and/or pharmacological
classification should be coded in all categories/classifications assigned to the medication,
regardless of how it is being used. For example, prochlorperazine is dually classified as
an antipsychotic and an antiemetic. Therefore, in this section, it would be coded as an
antipsychotic, regardless of how it is used.
Include any of these medications given to the resident by any route in any setting (e.g., at
the nursing home, in a hospital emergency room) while a resident of the nursing home.
Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or
clopidogrel as N0415E, Anticoagulant.
Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs), which may or
may not require laboratory monitoring, should be coded in N0415E, Anticoagulant.
Do not code flushes to keep an IV access patent.
Code a medication even if it was given only once during the look-back period.
Count long-acting medications, such as fluphenazine decanoate or haloperidol decanoate,
that are given every few weeks or monthly only if they are given during the 7-day lookback period (or since admission/entry or reentry if less than 7 days).
Transdermal patches are generally worn for and release medication over a period of
several days. To code N0415, only capture the medication if the transdermal patch was
applied to the resident’s skin during the observation period. For example, if, during the 7day look-back period, a fentanyl patch was applied on days 1, 4, and 7, N0415H Opioid
would be checked, because the application occurred during the look-back period.
Combination medications should be coded in all categories/pharmacologic classes that
constitute the combination. For example, if the resident receives a single tablet that
combines an antipsychotic and an antidepressant, then both antipsychotic and
antidepressant categories should be coded.
Over-the-counter sleeping medications are not coded as hypnotics, as they are not
categorized as hypnotic medications.
In circumstances where reference materials vary in identifying a medication’s therapeutic
category and/or pharmacological classification, consult the resources/links cited in this
section or consult the medication package insert, which is available through the facility’s
pharmacy or the manufacturer’s website. If necessary, request input from the consulting
pharmacist.
Herbal and alternative medicine products are considered to be dietary supplements by the
Food and Drug Administration (FDA). These products are not regulated by the FDA
(e.g., they are not reviewed for safety and effectiveness like medications) and their
composition is not standardized (e.g., the composition varies among manufacturers).
Therefore, they should not be counted as medications (e.g., melatonin, chamomile,
valerian root). Keep in mind that, for clinical purposes, it is important to document a
resident’s intake of such herbal and alternative medicine products elsewhere in the
medical record and to monitor their potential effects as they can interact with medications
the resident is currently taking. For more information consult the FDA website
http://www.fda.gov/food/dietarysupplements/usingdietarysupplements/.

Page N-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0415: High-Risk Drug Classes: Use and Indication (cont.)
•

•

•
•

October 2024

•

Opioid medications can be an effective intervention in a resident’s pain management
plan, but also carry risks such as overuse and constipation. A thorough assessment and
root-cause analysis of the resident’s pain should be conducted prior to initiation of an
opioid medication and re-evaluation of the resident’s pain, side effects, and medication
use and plan should be ongoing.
Residents who are on antidepressants should be closely monitored for worsening of
depression and/or suicidal ideation/behavior, especially during initiation or change of
dosage in therapy. Stopping antidepressants abruptly puts one at higher risk of suicidal
ideation and behavior.
When residents are having difficulty sleeping, nursing
DEFINITION
home staff should explore non-pharmacological
interventions (e.g., sleep hygiene approaches that
SLEEP HYGIENE
individualize the sleep and wake times to accommodate Practices, habits and
the person’s wishes and prior customary routine) to try
environmental factors that
to improve sleep prior to initiating pharmacologic
promote and/or improve
interventions. If residents are currently on sleepsleep patterns.
enhancing medications, nursing home staff can try nonpharmacologic interventions to help reduce the need for these medications or eliminate
them.
Many psychoactive medications increase confusion, sedation, and falls. For those
residents who are already at risk for these conditions, nursing home staff should develop
plans of care that address these risks.
Doses of psychoactive medications differ in acute and long-term treatment. Doses should
always be the lowest possible to achieve the desired therapeutic effects and be deemed
necessary to maintain or improve the resident’s function, well-being, safety, and quality
of life. Duration of treatment should also be in accordance with pertinent literature,
including clinical practice guidelines.
Since medication issues continue to evolve and new medications are being approved
regularly, it is important to refer to a current authoritative source for detailed medication
information, such as indications and precautions, dosage, monitoring, or adverse
consequences.

Page N-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0415: High-Risk Drug Classes: Use and Indication (cont.)
•

Example

DEFINITION
MEDICATION
INTERACTION
The impact of medication or
other substance (such as
nutritional supplements
including herbal products,
food, or substances used in
diagnostic studies) upon
another medication. The
interactions may alter
absorption, distribution,
metabolism, or elimination.
These interactions may
decrease the effectiveness of
the medication or increase
the potential for adverse
consequences.

Anticoagulants must be monitored with dosage
frequency determined by clinical circumstances and
duration of use. Certain anticoagulants require
monitoring via laboratory results (e.g., Prothrombin
Time [PT]/International Normalization Ratio [INR]).
— Multiple medication interactions exist with use of
anticoagulants (information on common
medication-medication interactions can be found in
the State Operations Manual, Appendix PP,
Guidance to Surveyors for Long Term Care
Facilities [the State Operations Manual can be
found at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/index.html]), which
may
○ significantly increase PT/INR results to levels
associated with life-threatening bleeding, or
○ decrease PT/INR results to ineffective levels, or
increase or decrease the serum concentration of
the interacting medication.

1. The Medication Administration Record for Resident P reflects the following during the 7-day
observation period:
• Risperidone 0.5 mg PO BID PRN: Received once a day on Monday, Wednesday, and
Thursday for bipolar disorder.
• Lorazepam 1 mg PO QAM: Received every day for bipolar disorder.
• Temazepam 15 mg PO QHS PRN: Received at bedtime on Tuesday and Wednesday only.
Coding: Medications in N0415, would be coded as follows: N0415A1 and
N0415A2. Antipsychotic = checked; risperidone is an antipsychotic
medication and indication of use for bipolar disorder noted. N0415B1 and
N0415B2. Antianxiety = checked; lorazepam is an antianxiety medication and
indication of use for bipolar disorder noted. N0415D1. Hypnotic = checked;
temazepam is a hypnotic medication. N0415D2. Hypnotic = not checked;
indication for use of temazepam was not noted.
Please note: if a resident is receiving medications in all three of these high-risk drug
classes simultaneously there must be a clear clinical indication for the use of these
medications. Administration of these types of medications, particularly in this
combination, could be interpreted as chemically restraining the resident. Adequate
documentation is essential in justifying their use.

October 2024

Page N-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0415: High-Risk Drug Classes: Use and Indication (cont.)
Additional information on psychoactive medications can be found in the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (or subsequent editions)
(https://www.psychiatry.org/psychiatrists/practice/dsm), and the State Operations Manual,
Appendix PP, Guidance to Surveyors for Long Term Care Facilities [the State Operations
Manual can be found at (https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/index.html)].
The following resources and tools provide information on medications including classifications,
warnings, appropriate dosing, drug interactions, and medication safety information.
•
•

GlobalRPh Drug Reference, http://globalrph.com/drug-A.htm
USP Pharmacological Classification of Drugs, http://www.usp.org/usp-healthcareprofessionals/usp-medicare-model-guidelines/medicare-model-guidelines-v50v40#Guidelines6. Directions: Scroll to the bottom of this webpage and click on the pdf
download for “USP Medicare Model Guidelines (With Example Part D Drugs)”
Medline Plus, https://www.nlm.nih.gov/medlineplus/druginformation.html

•

The above resource list is not all-inclusive, and use of these resources is not required for MDS
completion. The resources are being provided as a convenience, for informational purposes only,
and CMS is not responsible for their accessibility, content, or accuracy. Providers are responsible
for coding each medication’s pharmacological/therapeutic classification accurately. Caution
should be exercised when using lists of medication categories, and providers should always refer
to the details concerning each medication when determining its medication classification.
NOTE: References to non-CMS sources do not constitute or imply endorsement of these
organizations or their programs by CMS or the U.S. Department of Health and Human Services
and were current as of the date of this publication.

ft
October 2024

Page N-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0450: Antipsychotic Medication Review

D
October 2024

Page N-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0450: Antipsychotic Medication Review (cont.)
Item Rationale
Health-related Quality of Life
•

The use of unnecessary medications in long term care settings can have a profound effect
on the resident’s quality of life.

•

Antipsychotic medications are associated with increased risks for adverse outcomes that
can affect health, safety, and quality of life.

•

In addition to assuring that antipsychotic medications are being utilized to treat the
resident’s condition, it is also important to assess the need to reduce these medications
whenever possible.

Planning for Care

•

Identify residents receiving antipsychotic medications to ensure that each resident is
receiving the lowest possible dose to achieve the desired therapeutic effects.

•

Monitor for appropriate clinical indications for continued use.

•

Implement a system to ensure gradual dose reductions (GDR) are attempted at
recommended intervals unless clinically contraindicated.

Steps for Assessment

1. Review the resident’s medication administration records to determine if the resident received
an antipsychotic medication since admission/entry or reentry or the prior OBRA assessment,
whichever is more recent.
2. If the resident received an antipsychotic medication, review the medical record to determine
if a gradual dose reduction has been attempted.
3. If a gradual dose reduction was not attempted, review the medical record to determine if
there is physician documentation that the GDR is clinically contraindicated.

Coding Instructions for N0450A
•

Code 0, no: if antipsychotics were not received: Skip N0450B, N0450C, N0450D and

•

Code 1, yes: if antipsychotics were received on a routine basis only: Continue to N0450B,
Has a GDR been attempted?

•

Code 2, yes: if antipsychotics were received on a PRN basis only: Continue to

•

Code 3, yes: if antipsychotics were received on a routine and PRN basis: Continue to

N0450E.

N0450B, Has a GDR been attempted?

October 2024

Page N-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0450: Antipsychotic Medication Review (cont.)
Coding Tips and Special Populations
•

Any medication that has a pharmacological classification or therapeutic category of
antipsychotic medication must be recorded in this section, regardless of why the
medication is being used.

Coding Instructions for N0450B
•

Code 0, no: if a GDR has not been attempted. Skip to N0450D, Physician documented

•

Code 1, yes: if a GDR has been attempted. Continue to N0450C, Date of last

GDR as clinically contraindicated.

attempted GDR.

Coding Instructions for N0450C
•

Enter the date of the last attempted Gradual Dose Reduction.

Coding Tips and Special Populations (N0450B and N0450C)
Within the first year in which a resident is admitted on an antipsychotic medication or
after the facility has initiated an antipsychotic medication, the facility must attempt a
GDR in two separate quarters (with at least one month between the attempts), unless
physician documentation is present in the medical record indicating that a GDR is
clinically contraindicated. After the first year, a GDR must be attempted at least annually,
unless clinically contraindicated. Information on GDR and tapering of medications can be
found in the State Operations Manual, Appendix PP, Guidance to Surveyors for
Long Term Care Facilities (see F758). The State Operations Manual can be found at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-OnlyManuals-IOMs-Items/CMS1201984.

•

In N0450B and N0450C, include GDR attempts conducted since the resident was
admitted to the facility, if the resident was receiving an antipsychotic medication at the
time of admission, OR since the resident was started on the antipsychotic medication, if
the medication was started after the resident was admitted.

•

Do not include gradual dose reductions that occurred prior to admission to the facility
(e.g., GDRs attempted during the resident’s acute care stay prior to admission to the
facility).

•

If the resident was admitted to the facility with a documented GDR attempt in progress
and the resident received the last dose(s) of the antipsychotic medication of the GDR in
the facility, then the GDR would be coded in N0450B and N0450C.

•

If the resident received a dose or doses of an antipsychotic medication that was not part
of a documented GDR attempt, such as if the resident received a dose or doses of the
medication PRN or one or two doses were ordered for the resident for a specific day or
procedure, these are not coded as a GDR attempt in N0450B and N0450C.

•

October 2024

Page N-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0450: Antipsychotic Medication Review (cont.)
•

•

Prior to discontinuing a psychoactive medication,
residents may need a GDR or tapering to avoid
withdrawal syndrome (e.g., for medications such as
selective serotonin reuptake inhibitors [SSRIs], tricyclic
antidepressants [TCAs], etc.).
Discontinuation of an antipsychotic medication, even
without a GDR process, should be coded in N0450B
and N0450C as a GDR, as the medication was
discontinued. When an antipsychotic medication is
discontinued without a gradual dose reduction, the date
of the GDR in N0450C is the first day the resident did
not receive the discontinued antipsychotic medication.

DEFINITION
GRADUAL DOSE
REDUCTION (GDR)
Step-wise tapering of a dose
to determine whether or not
symptoms, conditions, or
risks can be managed by a
lower dose or whether or not
the dose or medication can
be discontinued.

Do not count as a GDR an antipsychotic medication reduction performed for the purpose
of switching the resident from one antipsychotic medication to another.

•

The start date of the last attempted GDR should be entered in N0450C, Date of last
attempted GDR. The GDR start date is the first day the resident received the reduced
dose of the antipsychotic medication.

•

In cases in which a resident is or was receiving multiple antipsychotic medications on a
routine basis and one medication was reduced or discontinued, record the date of the
reduction attempt or discontinuation in N0450C.

•

If multiple dose reductions have been attempted since admission OR since initiation of
the antipsychotic medication, record the date of the most recent reduction attempt in
N0450C.

•

Federal requirements regarding GDRs are found at 42 CFR 483.45(d) Unnecessary drugs
and 483.45(e) Psychotropic drugs.

•

October 2024

Page N-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N0450: Antipsychotic Medication Review (cont.)
Coding Instructions for N0450D
•

Code 0, no: if a GDR has not been documented by a physician as clinically

•

Code 1, yes: if a GDR has been documented by a physician as clinically

contraindicated. Skip N0450E Date physician documented GDR as clinically
contraindicated.

contraindicated. Continue to N0450E, Date physician documented GDR as clinically
contraindicated.

Coding Instructions for N0450E
•

Enter date the physician documented GDR attempts as clinically contraindicated.

Coding Tips and Special Populations (N0450D and N0450E)
•
•

•

In this section, the term physician also includes physician assistant, nurse practitioner, or
clinical nurse specialist.
In N0450D and N0450E, include physician documentation that a GDR attempt is
clinically contraindicated since the resident was admitted to the facility, if the resident
was receiving an antipsychotic medication at the time of admission, OR since the
resident was started on the antipsychotic medication, if the medication was started after
the resident was admitted to the facility.
Physician documentation indicating dose reduction attempts are clinically contraindicated
must include the clinical rationale for why an attempted dose reduction is inadvisable.
This decision should be based on the fact that tapering of the medication would not
achieve the desired therapeutic effects and the current dose is necessary to maintain or
improve the resident’s function, well-being, safety, and quality of life.

October 2024

Page N-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2001: Drug Regimen Review
Complete only if A0310B = 01.

Item Rationale
Health-related Quality of Life
•

•

Potential and actual resident medication adverse consequences and errors are prevalent in
health care settings and often occur during transitions in care.
Adverse consequences related to medications may result in serious harm or death,
emergency department visits, and rehospitalizations and affect the resident’s health,
safety, and quality of life.
Drug regimen review is intended to improve resident
DEFINITION
safety by identifying and addressing potential and
actual clinically significant medication issues at the
DRUG REGIMEN
time of a resident’s admission (start of SNF PPS stay)
REVIEW
and throughout the resident’s stay (through Part A PPS
A drug regimen review
discharge).
includes medication

Planning for Care
•
•

•

October 2024

•

Drug regimen review is an important component of the
overall management and monitoring of a resident’s
medication regimen.
Prevention and timely identification of potential and
actual medication-related adverse consequences reduces
the resident’s risk for harm and improves quality of life.
Educate staff in proper medication administration
techniques and adverse effects of medications, as well
as to be observant for these adverse effects.
Implement a system to ensure that each resident’s
medication usage is evaluated upon admission and on
an ongoing basis and that risks and problems are
identified and acted upon.

reconciliation, a review of all
medications a resident is
currently using, and a review
of the drug regimen to
identify, and if possible,
prevent potential clinically
significant medication
adverse consequences.
The drug regimen review
includes all medications,
prescribed and over the
counter (OTC), nutritional
supplements, vitamins, and
homeopathic and herbal
products, administered by
any route. It also includes
total parenteral nutrition
(TPN) and oxygen.

Page N-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2001: Drug Regimen Review (cont.)
Steps for Assessment
1. Complete a drug regimen review upon admission (start of SNF PPS stay) or as close to
the actual time of admission as possible to identify any potential or actual clinically
significant medication issues.

2. Review medical record documentation to determine whether a drug regimen review was
conducted upon admission (start of SNF PPS stay), or as close to the actual time of
admission as possible, to identify any potential or actual clinically significant medication
issues.
Medical record sources include medical records received from facilities where the resident
received health care, the resident’s most recent history and physical, transfer documents,
discharge summaries, medication lists/records, clinical progress notes, and other resources as
available.
3. Discussions (including with the acute care hospital, other staff and clinicians responsible for
completing the drug regimen review, the resident, and the resident’s family/significant other)
may supplement and/or clarify the information gleaned from the resident’s medical records.
4. Clinically significant medication issues may include, but are not limited to:
• Medication prescribed despite documented medication allergy or prior adverse reaction.
• Excessive or inadequate dose.
• Adverse reactions to medication.
• Ineffective drug therapy.
• Drug interactions (serious drug-drug, drug-food, and drug-disease interactions).
• Duplicate therapy (for example, generic-name and brand-name equivalent drugs are both
prescribed).
• Wrong resident, drug, dose, route, and time errors.
• Medication dose, frequency, route, or duration not consistent with resident’s condition,
manufacturer’s instructions, or applicable standards of practice.
• Use of a medication without evidence of adequate indication for use.
• Presence of a medical condition that may warrant medication therapy (e.g., a resident
with primary hypertension does not have an antihypertensive medication prescribed).
• Omissions (medications missing from a prescribed regimen).
• Nonadherence (purposeful or accidental).

October 2024

Page N-19

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2001: Drug Regimen Review (cont.)
Coding Instructions
•
•
•

Code 0, No: if no clinically significant medication

issues were identified during the drug regimen review.
Code 1, Yes: if one or more clinically significant

medication issues were identified during the drug
regimen review.
Code 9, NA: if the resident was not taking any
medications at the time of the drug regimen review.

Coding Tips
A dash (–) value is a valid response for this item;
however, CMS expects dash use to be a rare
occurrence.
The drug regimen review includes all medications,
prescribed and over the counter (OTC), including
nutritional supplements, vitamins, and homeopathic and
herbal products, administered by any route. The drug
regimen review also includes total parenteral nutrition
(TPN) and oxygen.
Adverse drug reaction (ADR) is a form of adverse
consequence. It may be either a secondary effect of a
medication that is usually undesirable and different
from the therapeutic effect of the medication or any
response to a medication that is noxious and unintended
and occurs in doses for prophylaxis, diagnosis, or
treatment. The term “side effect” is often used
interchangeably with ADR; however, side effects are
but one of five ADR categories, the others being
hypersensitivity, idiosyncratic response, toxic reactions,
and adverse medication interactions. A side effect is an
expected, well-known reaction that occurs with a
predictable frequency and may or may not constitute an
adverse consequence.

•

POTENTIAL OR
ACTUAL CLINICALLY
SIGNIFICANT
MEDICATION ISSUE
A clinically significant
medication issue is a
potential or actual issue that,
in the clinician’s professional
judgment, warrants physician
(or physician-designee)
communication and
completion of
prescribed/recommended
actions by midnight of the
next calendar day at the
latest.
“Clinically significant” means
effects, results, or
consequences that materially
affect or are likely to affect an
individual’s mental, physical,
or psychosocial well-being,
either positively, by
preventing a condition or
reducing a risk, or negatively,
by exacerbating, causing, or
contributing to a symptom,
illness, or decline in status.
Any circumstance that does
not require this immediate
attention is not considered a
potential or actual clinically
significant medication issue
for the purpose of the drug
regimen review items.

•

DEFINITIONS

October 2024

Page N-20

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2001: Drug Regimen Review (cont.)
Examples
1. The admitting nurse reviewed and compared the acute care hospital discharge medication
orders and the physician’s admission medication orders for Resident D. The nurse
interviewed Resident D, who confirmed the medications they were taking for their current
medical conditions. The nurse found no discrepancies between the acute care hospital
discharge medications and the admitting physician’s medication orders. After the nurse
contacted the pharmacy to request the medication, the pharmacist reviewed and confirmed
the medication orders as appropriate for Resident D. As a result of this collected and
communicated information, the nurse determined that there were no potential or actual
clinically significant medication issues.
Coding: N2001 would be coded 0, No—No issues found during review.

Rationale: The admitting nurse reviewed and compared Resident D’s discharge

medication records from the acute care hospital with the physician’s admission
medication orders, collaborated with the pharmacist, and interviewed the resident. The
nurse determined there were no potential or actual clinically significant medication
issues.

2. Resident H was admitted to the nursing facility after undergoing cardiac surgery for mitral
valve replacement. The acute care hospital discharge information indicated that Resident H
had a mechanical mitral heart valve and was to continue receiving anticoagulant medication.
While completing a review and comparison of Resident H’s discharge records from the
hospital with the physician’s admission medication orders and admission note, the nurse noted
that the admitting physician had ordered Resident H’s anticoagulation medication to be held if
the international normalized ratio (INR) was below 1.0, however, the physician’s admission
note indicated that the desired therapeutic INR parameters for Resident H was 2.5–3.5. The
nurse questioned the INR level listed on the admitting physician’s order, based on the
therapeutic parameters of 2.5–3.5 documented in the physician’s admission note, which
prompted the nurse to call the physician immediately to address the issue.
Coding: N2001 would be coded 1, Yes—Issues found during review.
Rationale: The admitting nurse reviewed and compared Resident H’s discharge health

care records from the acute care hospital with the nursing facility physician’s admission
medication orders and admission note. The nurse identified a discrepancy between the
physician’s documented therapeutic INR level (2.5–3.5) for Resident H in the admission
note and the physician’s order to hold anticoagulation medication for an INR level of 1.0.
The nurse considered this discrepancy to be a potential clinically significant medication
issue that could lead to potential clotting issues for Resident H.

October 2024

Page N-21

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2003: Medication Follow-up

Item Rationale

DEFINITION

Health-related Quality of Life
•

•

Integral to the process of safe medication
administration practice is timely communication with a
physician when a potential or actual clinically
significant medication issue has been identified.
Physician-prescribed/recommended actions in
response to identified potential or actual clinically
significant medication issues must be completed by the
clinician in a time frame that maximizes the reduction
in risk for medication errors and resident harm.

MEDICATION FOLLOWUP
The process of contacting a
physician to communicate an
identified medication issue
and completing all physicianprescribed/recommended
actions by midnight of the
next calendar day at the
latest.

Planning for Care

When a potential or actual clinically significant medication issue is identified, prompt
communication with the physician and implementation of prescribed actions is necessary
to protect the health and safety of the resident.

•

Steps for Assessment

This item is completed if one or more potential or actual clinically significant medication issues
were identified during the admission drug regimen review (N2001 = 1).
1. Review the resident’s medical record to determine whether the following criteria were met
for any potential or actual clinically significant medication issues that were identified upon
admission:
• Two-way communication between the clinician(s) and the physician was completed by
midnight of the next calendar day, AND
• All physician-prescribed/-recommended actions were completed by midnight of the next
calendar day.
Medical record sources include medical records received from facilities where the resident
received health care, the resident’s most recent history and physical, transfer documents,
discharge summaries, medication lists/records, clinical progress notes, and other resources as
available.
Discussions (including with the acute care hospital, other staff and clinicians responsible for
completing the drug regimen review, the resident, and the resident’s family/significant other)
may supplement and/or clarify the information gleaned from the resident’s medical records.

October 2024

Page N-22

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2003: Medication Follow-up (cont.)
Coding Instructions
•

•

Code 0, No: if the facility did not contact the

physician and complete prescribed/recommended
actions in response to each identified potential or actual
clinically significant medication issue by midnight of
the next calendar day.
Code 1, Yes: if the facility contacted the physician
AND completed the prescribed/recommended actions
by midnight of the next calendar day after each
potential or actual clinically significant medication
issue was identified.

D
Coding Tips
•

DEFINITION
CONTACT WITH
PHYSICIAN
•

Communication with the
physician to convey an
identified potential or
actual clinically significant
medication issue, and a
response from the
physician to convey
prescribed/recommended
actions in response to the
medication issue.

•

October 2024

If the physician prescribes/recommends an action that
• Communication can be in
will take longer than midnight of the next calendar day
person, by telephone,
to complete, then code 1, Yes, should still be
voice mail, electronic
entered, if by midnight of the next calendar day the
means, facsimile, or any
other means that
facility has taken the appropriate steps to comply with
appropriately conveys the
the prescribed/recommended action.
resident’s status.
— Example of a physician-recommended action that
would take longer than midnight of the next
calendar day to complete:
o The physician writes an order instructing the clinician to monitor the medication
issue over the next three days and call if the problem persists.
— Examples of by midnight of the next calendar day:
o A clinically significant medication issue is identified at 10:00 AM on 9/12/2017.
The physician-prescribed/-recommended action is completed on or before 11:59
PM on 9/13/2017.
o A clinically significant medication issue is identified at 11:00 PM on 9/12/2017.
The physician-prescribed/-recommended action is completed on or before 11:59
PM on 9/13/2017.
A dash (–) value is a valid response for this item; however, CMS expects dash use to be a
rare occurrence.

Page N-23

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2003: Medication Follow-up (cont.)
Examples

1. Resident P was admitted to the nursing facility with active diagnoses of pneumonia and atrial
fibrillation. The acute care facility medication record indicated that Resident P was on a
seven-day course of antibiotics and had three remaining days of this treatment plan. The
nurse reviewing the discharge records from the acute care facility and the nursing facility
admission medication orders noted that Resident P had an order for an anticoagulant
medication that required INR monitoring, as well as the antibiotic. On the date of admission,
the nurse contacted the physician responsible for Resident P and communicated a concern
about a potential increase in Resident P’s INR with this combination of medications that
could place them at greater risk for bleeding. The physician provided orders for laboratory
testing so that Resident P’s INR levels would be monitored over the next three days, starting
that day. However, the nurse did not request the first INR laboratory test until after midnight
of the next calendar day.
Coding: N2003 would be coded 0, No.
Rationale: A potential clinically significant medication issue was identified during the

drug regimen review; the staff did contact the physician before midnight of the next
calendar day, but did not complete, to the extent possible, the physician-prescribed
actions related to the INR laboratory test until after midnight of the next calendar day.
2. Resident S was admitted to the facility from an acute care hospital. During the admitting
nurse’s review of Resident S’s hospital discharge records, it was noted that Resident S had
been prescribed metformin. However, laboratory tests at admission indicated that Resident S
had a serum creatinine of 2.4, consistent with renal insufficiency. The admitting nurse
contacted the physician to ask whether this medication would be contraindicated with
Resident S’s current serum creatinine level. Three hours after Resident S’s admission to the
facility, the physician provided orders to discontinue the metformin and start Resident S on a
short-acting sulfonylurea for ongoing diabetes management. These medication changes were
implemented within the hour.
Coding: N2003 would be coded 1, Yes.
Rationale: A potential clinically significant medication issue was identified during the
drug regimen review; the physician communication occurred, and the nurse completed
the physician-prescribed actions, by midnight of the next calendar day.

October 2024

Page N-24

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2005: Medication Intervention
Complete only if A0310H = 1.

Item Rationale
Health-related Quality of Life
•

Integral to the process of safe medication administration practice is timely
communication with a physician when a potential or actual clinically significant
medication issue has been identified.
Physician-prescribed/-recommended actions in response to identified potential or actual
clinically significant medication issues must be completed by the clinician in a time
frame that maximizes the reduction in risk for medication errors and resident harm.
Potential or actual clinically significant medication issues can occur throughout the
resident’s stay.

•
•

•

Planning for Care

Every time a potential or actual clinically significant medication issue is identified
throughout the resident’s stay, it must be communicated to a physician, and the
physician-prescribed/-recommended actions must be completed by the clinician in a time
frame that maximizes the reduction in risk for medication errors and resident harm.

Steps for Assessment

The observation period for this item is from the date of admission (start of SNF PPS stay)
through discharge (Part A PPS discharge).
1. Review the resident’s medical record to determine whether the following criteria were met
for any potential and actual clinically significant medication issues that were identified upon
admission or at any time during the resident’s stay:
• Two-way communication between the clinician(s) and the physician was completed by
midnight of the next calendar day, AND
• All physician-prescribed/-recommended actions were completed by midnight of the next
calendar day.
• Medical record sources include medical records received from facilities where the resident
received health care, the resident’s most recent history and physical, transfer documents,
discharge summaries, medication lists/records, clinical progress notes, and other resources as
available.
• Discussions (including with the acute care hospital, other staff and clinicians responsible for
completing the drug regimen review, the resident, and the resident’s family/significant other)
may supplement and/or clarify the information gleaned from the resident’s medical records.

October 2024

Page N-25

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2005: Medication Intervention (cont.)
Coding Instructions
•

•

Code 0, No: if the facility did not contact the physician and complete prescribed/
recommended actions by midnight of the next calendar day each time a potential or actual
clinically significant medication issue was identified since admission (start of SNF PPS
stay).
Code 1, Yes: if the facility contacted the physician and completed prescribed/
recommended actions by midnight of the next calendar day each time a potential or actual
clinically significant medication issue was identified since admission (start of SNF PPS
stay).
Code 9, NA: if there were no potential or actual clinically significant medication issues
identified at admission or throughout the resident’s stay or the resident was not taking
any medications at admission or at any time throughout the stay.

Coding Tips
•

•

October 2024

If the physician prescribes an action that will take longer than midnight of the next
calendar day to complete, then code 1, Yes, should still be entered, if by midnight of
the next calendar day, the clinician has taken the appropriate steps to comply with the
recommended action.
— Example of a physician-recommended action that would take longer than
midnight of the next calendar day to complete:
o The physician writes an order instructing the clinician to monitor the medication
issue over the next three days and call if the problem persists.
— Examples of by midnight of the next calendar day:
o A clinically significant medication issue is identified at 10:00 AM on 9/12/2017.
The physician-prescribed/-recommended action is completed on or before 11:59
PM on 9/13/2017.
o A clinically significant medication issue is identified at 11:00 PM on 9/12/2017.
The physician-prescribed/-recommended action is completed on or before 11:59
PM on 9/13/2017.
A dash (–) value is a valid response for this item; however, CMS expects dash use to be a
rare occurrence.

Page N-26

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2005: Medication Intervention (cont.)
Examples

1. At the end of the resident’s Part A PPS stay, the discharging nurse reviewed Resident T’s
medical records, from the time of admission (start of SNF PPS stay) through their entire Part
A PPS stay (Part A PPS discharge) and noted that a clinically significant medication issue
was documented during the admission assessment. Resident T’s medical records indicated
that a nurse had attempted to contact the assigned physician several times about the clinically
significant medication issue. After midnight of the second calendar day, the physician
communicated to the nurse, via telephone, orders for changes to Resident T’s medications to
address the clinically significant medication issue. The nurse implemented the physician’s
orders. Upon further review of Resident T’s medical records, the discharging nurse
determined that no additional issues had been recorded throughout the remainder of
Resident T’s stay.
Coding: N2005 would be coded 0, No—the facility did not contact the physician and
complete prescribed/recommended actions by midnight of the next calendar day each
time a potential or actual clinically significant medication issue was identified since the
resident’s admission (start of SNF PPS stay).
Rationale: Coding of this item includes all potential or actual clinically significant
medication issues identified at any time during the resident’s stay. When reviewing
Resident T’s medical record at discharge, the nurse found that a clinically significant
medication issue was identified during the admission (start of SNF PPS stay) drug
regimen review, but the facility did not communicate with the physician and complete
prescribed actions by midnight of the next calendar day. Although no other potential or
actual clinically significant medication issues were identified during the remainder of the
resident’s stay, the facility did not communicate with the physician and complete
prescribed/recommended actions by midnight of the next calendar day each time a
potential or actual clinically significant medication issue was identified during the
resident’s SNF PPS stay.

October 2024

Page N-27

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [N]

N2005: Medication Intervention (cont.)

2. At discharge, the nurse completing a review of Resident K’s medical records found that two
clinically significant medication issues had been identified during the resident’s stay. During
the admission drug regimen review, the admitting nurse had identified a clinically significant
medication issue, contacted the physician, and implemented new orders provided by the
physician on the same day. Another potentially significant medication issue was identified on
day 12 of Resident K’s stay; the nurse communicated with the physician and carried out the
orders within one hour of identifying the potential issue. Both medication issues identified
during Resident K’s stay were communicated to the physician and resolved by midnight of
the next calendar day after identification. There were no other clinically significant
medication issues identified during Resident K’s stay.
Coding: N2005 would be coded as 1, Yes—all potential or actual clinically significant
medication issues identified at any time during the resident’s stay (admission through
discharge) were communicated to the physician and prescribed/recommended actions
were completed by midnight of the next calendar day after each issue was identified.
Rationale: While a medication issue was identified as a clinically significant
medication issue at admission, it was resolved by midnight of the next day. During
Resident K’s stay, an additional clinically significant medication issue was identified; it
too was resolved by midnight of the following day. Each time a clinically significant
medication issue was identified (at admission and during the stay), it was communicated
to the physician and resolved through completion of prescribed/recommended actions by
midnight of the next calendar day after identification.

October 2024

Page N-28

CMS’s RAI Version 3.0 Manual

SECTION O:

CH 3: MDS Items [O]

SPECIAL TREATMENTS, PROCEDURES, AND
PROGRAMS

Intent: The intent of the items in this section is to identify any special treatments, procedures,
and programs that the resident received or performed during the specified time periods.

O0110: Special Treatments, Procedures, and Programs
Facilities may code treatments, programs and procedures that the resident performed themselves
independently or after set-up by facility staff. Do not code services that were provided solely in
conjunction with a surgical procedure or diagnostic procedure, such as IV medications or
ventilators. Surgical procedures include routine pre- and post-operative procedures.

D
October 2024

Page O-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0110: Special Treatments, Procedures, and Programs (cont.)

D
Item Rationale
•

Health-related Quality of Life

The treatments, procedures, and programs listed in Item O0110, Special Treatments,
Procedures, and Programs, can have a profound effect on an individual’s health status,
self-image, dignity, and quality of life.

Planning for Care

Reevaluation of special treatments and procedures the resident received or performed, or
programs that the resident was involved in during the 14-day look-back period is important
to ensure the continued appropriateness of the treatments, procedures, or programs.

•

Residents who perform any of the treatments, programs, and/or procedures below should
be educated by the facility on the proper performance of these tasks, safety and use of
any equipment needed, and be monitored for appropriate use and continued ability to
perform these tasks.

October 2024

•

Page O-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0110: Special Treatments, Procedures, and Programs (cont.)
Steps for Assessment
1. Review the resident’s medical record to determine whether or not the resident received or
performed any of the treatments, procedures, or programs within the assessment period
defined for each column.

Coding Instructions for Column a. On Admission
Check all treatments, procedures, and programs received by, performed on, or participated in by
the resident on days 1–3 of the SNF PPS Stay starting with A2400B. If no treatments,
procedures, or programs were received or performed in the 3-day assessment period, check Z,
None of the above.

Coding Instructions for Column b. While a Resident

Check all treatments, procedures, and programs that the resident received or performed after
admission/entry or reentry to the facility and within the last 14 days. If no treatments, procedures
or programs were received by, performed on, or participated in by the resident within the last 14
days or since admission/entry or reentry, check Z, None of the above.

Coding Instructions for Column c. At Discharge

Check all treatments, procedures, and programs received by, performed on, or participated in by
the resident in the last 3 days of the SNF PPS Stay ending with A2400C. If no treatments,
procedures or programs were received by, performed on, or participated in by the resident in the
3-day assessment period, check Z, None of the above.

Coding Tips

Facilities may code treatments, programs and procedures that the resident performed
themselves independently or after set-up by facility staff. Do not code services that were
provided solely in conjunction with a surgical procedure or diagnostic procedure, such as
IV medications or ventilators. Surgical procedures include routine pre- and post-operative
procedures.

•

O0110A1, Chemotherapy

•

Code any type of chemotherapy agent administered as an antineoplastic given by any route in
this item. Each medication should be evaluated to determine its reason for use before coding it
here. Medications coded here are those actually used for cancer treatment. For example,
megestrol acetate is classified as an antineoplastic drug. One of its side effects is appetite
stimulation and weight gain. If megestrol acetate is being given only for appetite stimulation, do
not code it as chemotherapy in this item, as the resident is not receiving the medication for
chemotherapy purposes in this situation. Hormonal and other agents administered to prevent the
recurrence or slow the growth of cancer should not be coded in this item, as they are not
considered chemotherapy for the purpose of coding the MDS. IVs, IV medication, and blood
transfusions administered during chemotherapy are not recorded under items K0520A
(Parenteral/IV), O0110H (IV Medications), or O0110I (Transfusions).

October 2024

Page O-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0110: Special Treatments, Procedures, and Programs (cont.)
Example: Resident J was diagnosed with estrogen receptor–positive breast cancer and was
treated with chemotherapy and radiation. After their cancer treatment, Resident J was prescribed
tamoxifen (a selective estrogen receptor modulator) to decrease the risk of recurrence and/or
decrease the growth rate of cancer cells. Since the hormonal agent is being administered to
decrease the risk of cancer recurrence, it cannot be coded as chemotherapy.
‒ O0110A2, IV
Check if chemotherapy was administered intravenously.
‒

O0110A3, Oral

Check if chemotherapy was administered orally (e.g., pills, capsules, or liquids the
patient swallows). This sub-element also applies if the chemotherapy is administered
through a feeding tube/PEG (i.e., enterally).

‒

O0110A10, Other

Check if chemotherapy was given in a way other than intravenously or orally (e.g.,
intramuscular, intraventricular/intrathecal, intraperitoneal, or topical routes).

•

O0110B1, Radiation

Code intermittent radiation therapy, as well as radiation administered via radiation implant in this
item.
• O0110C1, Oxygen therapy
Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a
resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway
Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. Do not code hyperbaric
oxygen for wound therapy in this item. This item may be coded if the resident places or removes
their own oxygen mask, cannula.
‒

O0110C2, Continuous

‒

O0110C3, Intermittent

Check if oxygen therapy was continuously delivered for 14 hours or greater per day.

Check if oxygen therapy was intermittent (i.e., not delivered continuously for at least
14 hours per day).
‒

O0110C4, High-concentration

Check if oxygen therapy was provided via a high-concentration delivery system. A
high-concentration oxygen delivery system is one that delivers oxygen at a
concentration that exceeds a fraction of inspired oxygen FiO2 of 40% (i.e., exceeding
that of simple low-flow nasal cannula at a flow rate of 4 liters per minute).
A high-concentration delivery system can include either high- or low-flow systems
(e.g., simple face masks, partial and nonrebreather masks, face tents, venturi masks,
aerosol masks, and high-flow cannula or masks).

October 2024

Page O-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0110: Special Treatments, Procedures, and Programs (cont.)
These devices may also include invasive mechanical ventilators, non-invasive
mechanical ventilators, or trach masks, if the delivered FiO2 of these systems exceeds
40%.
Oxygen-conserving nasal cannula systems with reservoirs (e.g., mustache, pendant)
should be included only if they are used to deliver an FiO2 of greater than 40%.
•

O0110D1, Suctioning

Code only tracheal and/or nasopharyngeal suctioning in this item. Do not code oral suctioning
here. This item may be coded if the resident performs their own tracheal and/or nasopharyngeal
suctioning.
‒

O0110D2, Scheduled

Check if suctioning was scheduled. Scheduled suctioning is performed when the
resident is assessed as clinically benefiting from regular interventions, such as every
hour or once per shift. Scheduled suctioning applies to medical orders for performing
suctioning at specific intervals and/or implementation of facility-based clinical
standards, protocols, and guidelines.

‒

O0110D3, As needed

•

Check if suctioning was performed on an as-needed basis, as opposed to at regular
scheduled intervals, such as when secretions become so prominent that gurgling or
choking is noted or a sudden desaturation occurs from a mucus plug.

O0110E1, Tracheostomy care

Code cleansing of the tracheostomy and/or cannula in this item. This item may be coded if the
resident performs their own tracheostomy care. This item includes laryngectomy tube care.
•

O0110F1, Invasive Mechanical Ventilator (ventilator or respirator)

Code any type of electrically or pneumatically powered closed-system mechanical ventilator
support device that ensures adequate ventilation in the resident who is or who may become (such
as during weaning attempts) unable to support their own respiration in this item. During
invasive mechanical ventilation the resident’s breathing is controlled by the ventilator. Residents
receiving closed-system ventilation include those residents receiving ventilation via an
endotracheal tube (e.g., nasally or orally intubated) or tracheostomy. A resident who has been
weaned off of a respirator or ventilator in the last 14 days or is currently being weaned off a
respirator or ventilator, should also be coded here. Do not code this item when the ventilator or
respirator is used only as a substitute for BiPAP or CPAP.
Example: Resident J is connected to a ventilator via tracheostomy (invasive mechanical
ventilation) 24 hours a day while a resident, because of an irreversible neurological injury and
inability to breathe on their own. O0110F1b should be checked, as Resident J is using an
invasive mechanical ventilator because they are unable to initiate spontaneous breathing on their
own and the ventilator is controlling their breathing.

October 2024

Page O-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0110: Special Treatments, Procedures, and Programs (cont.)
• O0110G1, Non-invasive Mechanical Ventilator
Code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing
by delivering slightly pressurized air through a mask or other device continuously or via
electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the
individual to support their own spontaneous respiration by providing enough pressure when
the individual inhales to keep their airways open, unlike ventilators that “breathe” for the
individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here.
This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device.
‒

O0110G2, BiPAP

Check if the non-invasive mechanical ventilator support was BiPAP.
O0110G3, CPAP

‒

Check if the non-invasive mechanical ventilator support was CPAP.

• O0110H1, IV medications
Code any drug or biological given by intravenous push, epidural pump, or drip through a central
or peripheral port in this item. Do not code flushes to keep an IV access port patent, or IV fluids
without medication here. Epidural, intrathecal, and baclofen pumps may be coded here, as they
are similar to IV medications in that they must be monitored frequently and they involve
continuous administration of a substance. Subcutaneous pumps are not coded in this item. Do
not include IV medications of any kind that were administered during dialysis or chemotherapy.
Lactated Ringers given IV is not considered a medication and should not be coded here.
Resources and tools providing information on medications are available in Section N of this
manual (see the end of item N0415 following the Example).
‒ O0110H2, Vasoactive medications
Check when at least one of the IV medications was an IV vasoactive medication.
‒ O0110H3, Antibiotics

Check when at least one of the IV medications was an IV antibiotic.
‒

O0110H4, Anticoagulation

Check when at least one of the IV medications was an IV anticoagulant. Do not
include subcutaneous administration of anticoagulant medications.
‒

O0110H10, Other

Check when at least one of the IV medications was not an IV vasoactive medication,
IV antibiotic, or IV anticoagulant. Examples include IV analgesics (e.g., morphine)
and IV diuretics (e.g., furosemide).

October 2024

Page O-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0110: Special Treatments, Procedures, and Programs (cont.)
•

O0110I1, Transfusions

Code transfusions of blood or any blood products (e.g., platelets, synthetic blood products), that
are administered directly into the bloodstream in this item. Do not include transfusions that were
administered during dialysis or chemotherapy.
•

O0110J1, Dialysis

Code peritoneal or renal dialysis which occurs at the nursing home or at another facility, record
treatments of hemofiltration, Slow Continuous Ultrafiltration (SCUF), Continuous Arteriovenous
Hemofiltration (CAVH), and Continuous Ambulatory Peritoneal Dialysis (CAPD) in this item.
IVs, IV medication, and blood transfusions administered during dialysis are considered part of
the dialysis procedure and are not to be coded under items K0520A (Parenteral/IV), O0110H (IV
medications), or O0110I (transfusions). This item may be coded if the resident performs their
own dialysis.
‒

O0110J2, Hemodialysis

Check when the dialysis was hemodialysis. In hemodialysis the patient’s blood is
circulated directly through a dialysis machine that uses special filters to remove waste
products and excess fluid from the blood.
O0110J3, Peritoneal dialysis

‒

Check when the dialysis was peritoneal dialysis. In peritoneal dialysis, dialysate is
infused into the peritoneal cavity and the peritoneum (the membrane that surrounds
many of the internal organs of the abdominal cavity) serves as a filter to remove the
waste products and excess fluid from the blood.
•

O0110K1, Hospice care

Code residents identified as being in a hospice program for terminally ill persons where an array
of services is provided for the palliation and management of terminal illness and related
conditions. The hospice must be licensed by the state as a hospice provider and/or certified under
the Medicare program as a hospice provider.

October 2024

Page O-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0110: Special Treatments, Procedures, and Programs (cont.)
•

O0110M1, Isolation or quarantine for active infectious disease (does not include
standard body/fluid precautions)

Code only when the resident requires transmission-based precautions and single room isolation
(alone in a separate room) because of active infection (i.e., symptomatic and/or have a positive
test and are in the contagious stage) with highly transmissible or epidemiologically significant
pathogens that have been acquired by physical contact or airborne or droplet transmission. Do
not code this item if the resident only has a history of infectious disease (e.g., s/p MRSA or s/p
C-Diff - no active symptoms). Do not code this item if the precautions are standard precautions,
because these types of precautions apply to everyone. Standard precautions include hand hygiene
compliance, glove use, and additionally may include masks, eye protection, and gowns.
Examples of when the isolation criterion would not apply include urinary tract infections,
encapsulated pneumonia, and wound infections.
Code for “single room isolation” only when all of the following conditions are met:

1. The resident has active infection with highly transmissible or epidemiologically significant
pathogens that have been acquired by physical contact or airborne or droplet transmission.
2. Precautions are over and above standard precautions. That is, transmission-based precautions
(contact, droplet, and/or airborne) must be in effect.
3. The resident is in a room alone because of active infection and cannot have a roommate. This
means that the resident must be in the room alone and not cohorted with a roommate
regardless of whether the roommate has a similar active infection that requires isolation.
4. The resident must remain in their room. This requires that all services be brought to the
resident (e.g. rehabilitation, activities, dining, etc.).
The following resources are being provided to help the facility interdisciplinary team determine
the best method to contain and/or prevent the spread of infectious disease based on the type of
infection and clinical presentation of the resident related to the specific communicable disease.
The CDC guidelines also outline isolation precautions and go into detail regarding the different
types of Transmission-Based Precautions (Contact, Droplet, and Airborne).

•

2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

•

SHEA/APIC Guideline: Infection Prevention and Control in the Long Term Care Facility
http://www.apic.org/Resource_/TinyMceFileManager/Practice_Guidance/id_APICSHEA_GuidelineforICinLTCFs.pdf

As the CDC guideline notes, there are psychosocial risks associated with such restriction, and it
has been recommended that psychosocial needs be balanced with infection control needs in the
long-term care setting.
If a facility transports a resident who meets the criteria for single room isolation to another
healthcare setting to receive medically needed services (e.g. dialysis, chemotherapy, blood
transfusions, etc.) which the facility does not or cannot provide, they should follow CDC
guidelines for transport of patients with communicable disease, and may still code O0110M for
single room isolation since it is still being maintained while the resident is in the facility.

October 2024

Page O-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0110: Special Treatments, Procedures, and Programs (cont.)
Finally, when coding for isolation, the facility should review the resident’s status and determine if
the criteria for a Significant Change of Status Assessment (SCSA) is met based on the effect the
infection has on the resident’s function and plan of care. The definition and criteria of “significant
change of status” is found in Chapter 2, Section 2.6, 03. Significant Change in Status Assessment
(SCSA) (A0310A = 04). Regardless of whether the resident meets the criteria for an SCSA, a
modification of the resident’s plan of care will likely need to be completed.
•

O0110O1, IV Access

Code IV access, which refers to a catheter inserted into a vein for a variety of clinical reasons,
including long-term medication administration, large volumes of blood or fluid, frequent access
for blood samples, intravenous fluid administration, total parenteral nutrition (TPN), or, in some
instances, the measurement of central venous pressure. An arteriovenous (AV) fistula does not
meet the definition of IV Access for O0110O1.
‒

O0110O2, Peripheral

Check when IV access was peripheral access (catheter is placed in a peripheral vein)
and remains peripheral.

‒

O0110O3, Midline

‒

Check when IV access was midline access. Midline catheters are inserted into the
antecubital (or other upper arm) vein and do not reach all the way to a central vein
such as the superior vena cava.
O0110O4, Central (e.g., PICC, tunneled, port)

Check when IV access was centrally located (e.g., PICC, tunneled, port).
•

O0110Z1, None of the above

Code if none of the above treatments, procedures, or programs were received or performed by
the resident.

ft
October 2024

Page O-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0110: Special Treatments, Procedures, and Programs (cont.)
Examples
1. Resident R, who was admitted five days ago, has advanced prostate cancer and is receiving
radiation and docetaxel (IV) via a port in their right upper chest to treat their prostate cancer.
They were admitted to the SNF following an inpatient stay for an acute pulmonary
embolism.
Coding: Check boxes O0110A1a (Chemotherapy, On Admission), O0110A1b

(Chemotherapy, While a Resident), and O0110A2a (IV, On Admission); O0110B1a
(Radiation, On Admission) and O0110B1b (Radiation, While a Resident); and O0110O1a
(IV Access, On Admission), O0110O1b (IV Access, While a Resident), and O0110O4a
(Central, On Admission).

Rationale: The resident received intravenous therapy via a port (i.e., a central line in

their right upper chest) and radiation during their first three days of their SNF PPS stay
and while a resident.

2. Resident M was admitted to the SNF for rehabilitation following cardiac surgery three weeks
ago. They have sleep apnea and require a CPAP device nightly. While in the SNF, the staff
set up the humidifier element of the CPAP, and Resident M put on the CPAP mask prior to
falling asleep each night through their discharge to home.
Coding: Check boxes O0110G1b (Non-invasive Mechanical Ventilator, While a

Resident), O0110G1c (Non-invasive Mechanical Ventilator, At Discharge), and
O0110G3c (CPAP, On Discharge).

Rationale: Resident M can breathe on their own but requires CPAP while sleeping to

manage their sleep apnea. CPAP was used while a resident, including during the threeday discharge assessment period.

3. Resident D was admitted 10 days ago to the SNF for rehabilitation following spinal surgery.
They have sleep apnea and require a CPAP device while sleeping. The staff set-up the water
receptacle and humidifier element of the machine. Each night since admission, Resident D
puts on the CPAP mask and starts the machine prior to falling asleep.
Coding: Check O0110G1a (Non-invasive Mechanical Ventilator, On Admission),

O0110G1b (Non-invasive Mechanical Ventilator, While a Resident) and O0110G3a (CPAP,
On Admission).
Rationale: Resident D can breathe on their own but requires CPAP while sleeping to

manage their sleep apnea. CPAP was used while a resident, including during the three-day
admission assessment period.

October 2024

Page O-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0250: Influenza Vaccine

Item Rationale

Health-related Quality of Life
When infected with influenza, older adults and persons with underlying health problems
are at increased risk for complications and are more likely than the general population to
require hospitalization.

•

An institutional Influenza A outbreak can result in up to 60 percent of the population
becoming ill, with 25 percent of those affected developing complications severe enough
to result in hospitalization or death.

•

Influenza-associated mortality results not only from pneumonia, but also from subsequent
events arising from cardiovascular, cerebrovascular, and other chronic or
immunocompromising diseases that can be exacerbated by influenza.

•

Planning for Care

Influenza vaccines have been proven effective in preventing hospitalizations.

•

A vaccine, like any other medicine, could possibly cause serious problems, such as severe
allergic reactions. The risk of a vaccine causing serious harm, or death, is extremely
small.

•

Serious problems from inactivated influenza vaccine are very rare. The viruses in
inactivated influenza vaccine have been killed, so individuals cannot get influenza from
the vaccine.

•

— Mild problems: soreness, redness or swelling where the shot was given; hoarseness;
sore, red or itchy eyes; cough; fever; aches; headache; itching; and/or fatigue. If these
problems occur, they usually begin soon after the shot and last 1-2 days.
— Severe problems:
○ Life-threatening allergic reactions from vaccines are very rare. If they do occur, it
is usually within a few minutes to a few hours after the shot.

October 2024

Page O-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0250: Influenza Vaccine (cont.)
○ In 1976, a type of inactivated influenza (swine flu) vaccine was associated with
Guillain-Barré Syndrome (GBS). Since then, influenza vaccines have not been
clearly linked to GBS. However, if there is a risk of GBS from current influenza
vaccines, it would be no more than 1 or 2 cases per million people vaccinated.
This is much lower than the risk of severe influenza, which can be prevented by
vaccination.
People who are moderately or severely ill should usually wait until they recover before
getting the influenza vaccine. People with mild illness can usually get the vaccine.

•

Influenza vaccine may be given at the same time as other vaccines, including
pneumococcal vaccine.

•

The safety of vaccines is always being monitored. For more information, visit: Vaccine
Safety Monitoring and Vaccine Safety Activities of the CDC:
http://www.cdc.gov/vaccinesafety/ensuringsafety/monitoring/index.html

•

Steps for Assessment

1. Review the resident’s medical record to determine whether an influenza vaccine was received
in the facility for this year’s influenza vaccination season. If vaccination status is unknown,
proceed to the next step.
2. Ask the resident if they received an influenza vaccine outside of the facility for this year’s
influenza vaccination season. If vaccination status is still unknown, proceed to the next step.
3. If the resident is unable to answer, then ask the same question of the responsible party/legal
guardian and/or primary care physician. If influenza vaccination status is still unknown,
proceed to the next step.
4. If influenza vaccination status cannot be determined, administer the influenza vaccine to the
resident according to standards of clinical practice.

October 2024

Page O-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0250: Influenza Vaccine (cont.)
Coding Instructions for O0250A, Did the resident receive the influenza
vaccine in this facility for this year’s influenza vaccination
season?
•

•

Code 0, no: if the resident did NOT receive the influenza vaccine in this

facility during this year’s influenza vaccination season. Proceed to If influenza vaccine
not received, state reason (O0250C).
Code 1, yes: if the resident did receive the influenza vaccine in this facility

during this year’s influenza season. Continue to Date influenza vaccine received
(O0250B).

Coding Instructions for O0250B, Date influenza vaccine received
•

Enter the date that the influenza vaccine was received. Do not leave any boxes blank.
— If the month contains only a single digit, fill in the first box of the month with a “0”.
For example, January 17, 2014 should be entered as 01-17-2014.

— If the day only contains a single digit, then fill the first box of the day with the “0”.
For example, October 6, 2013 should be entered as 10-06-2013. A full 8 character
date is required.
— A full 8 character date is required. If the date is unknown or the information is not
available, only a single dash needs to be entered in the first box.

Coding Instructions for O0250C, If influenza vaccine not received,
state reason

If the resident has not received the influenza vaccine for this year’s influenza vaccination season
(i.e., O0250A=0), code the reason from the following list:
• Code 1, Resident not in this facility during this year's influenza
vaccination season: resident was not in this facility during this year’s influenza
vaccination season.
• Code 2, Received outside of this facility: includes influenza vaccinations
administered in any other setting (e.g., physician office, health fair, grocery store,
hospital, fire station) during this year’s influenza vaccination season.
• Code 3, Not eligible—medical contraindication: if influenza vaccine not
received due to medical contraindications. Influenza vaccine is contraindicated for a
resident with severe reaction (e.g., respiratory distress) to a previous dose of influenza
vaccine or to a vaccine component. Precautions for influenza vaccine include moderate to
severe acute illness with or without fever (influenza vaccine can be administered after the
acute illness) and history of Guillain-Barré Syndrome within six weeks after previous
influenza vaccination.
• Code 4, Offered and declined: resident or responsible party/legal guardian has
been informed of the risks and benefits of receiving the influenza vaccine and chooses
not to accept vaccination.

October 2024

Page O-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0250: Influenza Vaccine (cont.)
•

Code 5, Not offered: resident or responsible party/legal guardian not offered the

•

Code 6, Inability to obtain influenza vaccine due to a declared
shortage: vaccine is unavailable at this facility due to a declared influenza vaccine

influenza vaccine.

shortage.
•

Code 9, None of the above: if none of the listed reasons describe why the influenza

vaccine was not administered. This code is also used if the answer is unknown.

Coding Tips and Special Populations
•
•

•

•
•

October 2024

•

Once the influenza vaccination has been administered to a resident for the current
influenza season, this value is carried forward until the new influenza season begins.
Influenza can occur at any time, but most influenza occurs from October through May.
However, residents should be immunized as soon as the vaccine becomes available. More
information about when facilities must offer residents the influenza vaccine is available
in 42 CFR 483.80(d), Influenza and pneumococcal immunizations, which can be found in
Appendix PP of the State Operations Manual: https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf#page=708.
Information about the current influenza season can be obtained by accessing the CDC
Seasonal Influenza (Flu) website. This website provides information on influenza activity
and has an interactive map that shows geographic spread of influenza:
http://www.cdc.gov/flu/weekly/fluactivitysurv.htm,
http://www.cdc.gov/flu/weekly/usmap.htm.
Facilities can also contact their local health department website for local influenza
surveillance information.
The annual supply of inactivated influenza vaccine and the timing of its distribution
cannot be guaranteed in any year. Therefore, in the event that a declared influenza
vaccine shortage occurs in your geographical area, residents should still be vaccinated
once the facility receives the influenza vaccine.
A “high dose” inactivated influenza vaccine is available for people 65 years of age and
older. Consult with the resident’s primary care physician (or nurse practitioner) to
determine if this high dose is appropriate for the resident.

Page O-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0250: Influenza Vaccine (cont.)
Examples
1. Resident J received the influenza vaccine in the facility during this year’s influenza
vaccination season, on January 7, 2014.
Coding: O0250A would be coded 1, yes; O0250B would be coded 01-07-2014,

and O0250C would be skipped.
Rationale: Resident J received the vaccine in the facility on January 7, 2014, during
this year’s influenza vaccination season.

2. Resident R did not receive the influenza vaccine in the facility during this year’s influenza
vaccination season due to their known allergy to egg protein.

Coding: O0250A would be coded 0, no; O0250B is skipped, and O0250C would be
coded 3, not eligible-medical contraindication.
Rationale: Allergies to egg protein is a medical contraindication to receiving the

influenza vaccine, therefore, Resident R did not receive the vaccine.

3. Resident T received the influenza vaccine at their doctor’s office during this year’s influenza
vaccination season. Their doctor provided documentation of receipt of the vaccine to the
facility to place in Resident T’s medical record. They also provided documentation that
Resident T was explained the benefits and risks of the influenza vaccine prior to
administration.
Coding: O0250A would be coded 0, no; and O0250C would be coded 2,
received outside of this facility.
Rationale: Resident T received the influenza vaccine at their doctor’s office during this

year’s influenza vaccination season.

4. Resident K wanted to receive the influenza vaccine if it arrived prior to their scheduled
discharge on October 5th. Resident K was discharged prior to the facility receiving their
annual shipment of influenza vaccine, and therefore, Resident K did not receive the influenza
vaccine in the facility.

Resident K was encouraged to receive the influenza vaccine at their next scheduled physician
visit.
Coding: O0250A would be coded 0, no; O0250B is skipped, and O0250C would be
coded 9, none of the above.
Rationale: Resident K was unable to receive the influenza vaccine in the facility due to

the fact that the facility did not receive its shipment of influenza vaccine until after their
discharge. None of the codes in O0250C, Influenza vaccine not received, state
reason, are applicable.

October 2024

Page O-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0300: Pneumococcal Vaccine

Item Rationale
Health-related Quality of Life
•

Pneumococcus is one of the leading causes of community-acquired infections in the
United States, with the highest disease burden among the elderly.

•

Adults 65 years of age and older and those with chronic medical conditions are at
increased risk for invasive pneumococcal disease and have higher case-fatality rates.

•

Pneumococcal vaccines can help reduce the risk of invasive pneumococcal disease and
pneumonia.

Planning for Care

Early detection of outbreaks is essential to control outbreaks of pneumococcal disease in
long-term care facilities.

•

Individuals living in nursing homes and other long-term care facilities with an identified
increased risk of invasive pneumococcal disease or its complications, i.e., those 65 years
of age and older with certain medical conditions, should receive pneumococcal
vaccination.

•

Conditions that increase the risk of invasive pneumococcal disease include decreased
immune function; damaged or no spleen; sickle cell and other hemoglobinopathies;
cerebrospinal fluid (CSF) leak; cochlear implants; and chronic diseases of the heart,
lungs, liver, and kidneys, including dialysis, diabetes, alcoholism, and smoking.

Steps for Assessment

•

1. Review the resident’s medical record to determine whether any pneumococcal vaccines have
been received. If vaccination status is unknown, proceed to the next step.
2. Ask the resident if they received any pneumococcal vaccines outside of the facility. If
vaccination status is still unknown, proceed to the next step.
3. If the resident is unable to answer, ask the same question of the responsible party/legal
guardian and/or primary care physician. If vaccination status is still unknown, proceed to the
next step.

October 2024

Page O-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0300: Pneumococcal Vaccine (cont.)
4. If pneumococcal vaccination status cannot be determined, administer the recommended
vaccine(s) to the resident, according to the standards of clinical practice.
• If the resident has had a severe allergic reaction to a pneumococcal vaccine or its
components, the vaccine should not be administered.
• If the resident has a moderate to severe acute illness, the vaccine should be administered
after the illness.
• If the resident has a minor illness (e.g., a cold) check with the resident’s physician before
administering the vaccine.

Coding Instructions O0300A, Is the Resident’s Pneumococcal
Vaccination Up to Date?
•

Code 0, no: if the resident’s pneumococcal vaccination status is not up to date or

cannot be determined. Proceed to item O0300B, If Pneumococcal vaccine not received,
state reason.

•

Code 1, yes: if the resident’s pneumococcal vaccination status is up to date. Skip to

O0400, Therapies.

Coding Instructions O0300B, If Pneumococcal Vaccine Not Received,
State Reason
If the resident has not received a pneumococcal vaccine, code the reason from the following list:
•

Code 1, Not eligible: if the resident is not eligible due to medical contraindications,

•

Code 2, Offered and declined: resident or responsible party/legal guardian has

•

Code 3, Not offered: resident or responsible party/legal guardian not offered the

including a life-threatening allergic reaction to the pneumococcal vaccine or any vaccine
component(s) or a physician order not to immunize.
been informed of what is being offered and chooses not to accept the pneumococcal
vaccine.

Coding Tips

pneumococcal vaccine.

•

Specific guidance about pneumococcal vaccine recommendations and timing for adults
can be found at https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccinetiming.pdf.

•

“Up to date” in item O0300A means in accordance with current Advisory Committee on
Immunization Practices (ACIP) recommendations.
For up-to-date information on timing and intervals between vaccines, please refer to
ACIP vaccine recommendations available at
— https://www.cdc.gov/vaccines/schedules/hcp/index.html
— http://www.cdc.gov/vaccines/hcp/acip-recs/index.html
— https://www.cdc.gov/pneumococcal/vaccination.html

October 2024

Page O-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0300: Pneumococcal Vaccine (cont.)
•

If a resident has received one or more pneumococcal vaccinations and is indicated to get
an additional pneumococcal vaccination but is not yet eligible for the next vaccination
because the recommended time interval between vaccines has not lapsed, O0300A is
coded 1, yes, indicating the resident’s pneumococcal vaccination is up to date.

Examples
1. Resident L, who is 72 years old, received the PCV13 pneumococcal vaccine at their
physician’s office last year. They had previously been vaccinated with PPSV23 at age 66.
Coding: O0300A would be coded 1, yes; skip to O0400, Therapies.
Rationale: Resident L, who is over 65 years old, has received the recommended
PCV13 and PPSV23 vaccines.

2. Resident B, who is 95 years old, has never received a pneumococcal vaccine. Their physician
has an order stating that they are NOT to be immunized.
Coding: O0300A would be coded 0, no; and O0300B would be coded 1, not
eligible.
Rationale: Resident B has never received the pneumococcal vaccine; therefore, their
vaccine is not up to date. Their physician has written an order for them not to receive a
pneumococcal vaccine, thus they are not eligible for the vaccine.

3. Resident A, who has congestive heart failure, received PPSV23 vaccine at age 62 when they
were hospitalized for a broken hip. They are now 78 years old and were admitted to the
nursing home one week ago for rehabilitation. They were offered and given PCV13 on
admission.
Coding: O0300A would be coded 1, yes; skip to O0400, Therapies.
Rationale: Resident A received PPSV23 before age 65 years because they have a
chronic heart disease and received PCV13 at the facility because they are age 65 years or
older. They should receive another dose of PPSV23 at least 1 year after PCV13 and 5
years after the last PPSV23 dose (i.e., Resident A should receive 1 dose of PPSV23 at
age 79 years, but is currently up to date because they must wait at least 1 year since they
received PCV13).

4. Resident T, who has a long history of smoking cigarettes, received the pneumococcal vaccine
at age 62 when they were living in a congregate care community. They are now 64 years old
and are being admitted to the nursing home for chemotherapy and respite care. They have not
been offered any additional pneumococcal vaccines.
Coding: O0300A would be coded 0, no; and O0300B would be coded 3, Not
offered.
Rationale: Resident T received 1 dose of PPSV23 vaccine prior to 65 years of age
because they are a smoker. Because Resident T is now immunocompromised, they should
receive PCV13 for this indication. They will also need 1 dose of PPSV23 8 weeks after
PCV13 and at least 5 years after their last dose of PPSV23 (i.e., Resident T is eligible to
receive PCV13 now and 1 dose of PPSV23 at age 67).

October 2024

Page O-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0350: Resident’s COVID-19 vaccination is up to date

Item Rationale
Health-related Quality of Life
•
•

•

The intent of this item is to report if a person is up to date with their COVID-19 vaccine
status.
Age is the strongest risk factor for severe coronavirus disease 2019 (COVID-19)
outcomes. In 2020, persons aged 65 years or older accounted for 81 percent of U.S.
COVID-19-related deaths.
Severe illness caused by COVID-19 means that the person with COVID-19 may require
hospitalization, intensive care, or ventilator support for breathing, or may even die.

Planning for Care

•

•
•

October 2024

•

A strong infection prevention and control program is vital to protect both patients and
healthcare personnel.
Remaining up to date with all recommended COVID-19 vaccine doses is critical to
protect both staff and patients from Severe Acute Respiratory Syndrome Coronavirus 2
(SARS-CoV-2) infection.
COVID-19 vaccines currently approved or authorized by the U.S. Food & Drug
Administration are effective in reducing the risk of serious outcomes of COVID-19,
including severe disease, hospitalization, and death.
Efforts to increase the number of people in the United States who are up to date with
their COVID-19 vaccines remain an important strategy for preventing illnesses,
hospitalizations, and deaths from COVID-19.
A vaccine, like any other medicine, could possibly cause serious problems, such as severe
allergic reactions. Serious problems from the COVID-19 vaccine are very rare. More
information about potential side effects of the COVID-19 vaccine, precautions, and
contraindications can be found on the CDC webpage “Interim Clinical Considerations
for Use of COVID-19 Vaccines in the United States” at
https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerationsus.html#contraindications.

Page O-19

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0350: Resident’s COVID-19 vaccination is up to date (cont.)
Steps for Assessment
•

•

Vaccination status may be determined based on information from any available source.
o Review the patient’s medical record or documentation of COVID-19 vaccination
and/or interview the patient, family or other caregivers or healthcare providers to
determine whether the patient is up to date with their COVID-19 vaccine.
If the patient is not up to date, and the facility has the vaccine available, ask the patient if
they would like to receive the COVID-19 vaccine.

Coding Instructions
•

•
•

DEFINITION
UP TO DATE for COVID19 Vaccine
For the definition of “up to
date,” providers should refer
to the CDC webpage “Stay
Up to Date with COVID-19
Vaccines” at
https://www.cdc.gov/coronavi
rus/2019-ncov/vaccines/stayup-to-date.html.

Code 0, No, patient is not up to date if the patient does
not meet the CDC’s definition of up to date.
o This includes patients who have not received
one or more recommended COVID-19 vaccine
doses for any reason including medical,
religious, or other qualified exemptions.
o This includes patients for whom vaccination
status cannot be determined.
Code 1, Yes, patient is up to date if the patient meets the
CDC’s definition of up to date.
A dash is a valid response, indicating the item was not
assessed. CMS expects dash use to be a rare occurrence.

Coding Tip
•

Current COVID-19 vaccine recommendations are available on the Centers for Disease
Control and Prevention’s (CDC’s) webpage “Stay Up to Date with COVID-19 Vaccines”
at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html.

ft
October 2024

Page O-20

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies

D
October 2024

Page O-21

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)

D
October 2024

Page O-22

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
Item Rationale
Health-related Quality of Life
Maintaining as much independence as possible in activities of daily living, mobility, and
communication is critically important to most people. Functional decline can lead to
depression, withdrawal, social isolation, breathing problems, and complications of
immobility, such as incontinence and pressure ulcers/injuries, which contribute to
diminished quality of life. The qualified therapist, in conjunction with the physician and
nursing administration, is responsible for determining the necessity for, and the frequency
and duration of, the therapy services provided to residents.

•

Rehabilitation (i.e., via Speech-Language Pathology Services and Occupational and
Physical Therapies) and respiratory, psychological, and recreational therapy can help
residents to attain or maintain their highest level of well-being and improve their quality
of life.

•

Planning for Care

Code only medically necessary therapies that occurred after admission/readmission to the
nursing home that were (1) ordered by a physician (physician’s assistant, nurse
practitioner, and/or clinical nurse specialist) based on a qualified therapist’s assessment
(i.e., one who meets Medicare requirements or, in some instances, under such a person’s
direct supervision) and treatment plan, (2) documented in the resident’s medical record,
and (3) care planned and periodically evaluated to ensure that the resident receives
needed therapies and that current treatment plans are effective. Therapy treatment may
occur either inside or outside of the facility.

•

For definitions of the types of therapies listed in this section, please refer to the
Glossary in Appendix A.

•

October 2024

Page O-23

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
Steps for Assessment
1. Review the resident’s medical record (e.g., rehabilitation therapy evaluation and treatment
records, recreation therapy notes, mental health professional progress notes), and consult
with each of the qualified care providers to collect the information required for this item.

Coding Instructions for Speech-Language Pathology and Audiology
Services and Occupational and Physical Therapies
Individual minutes—Enter the total number of minutes of therapy that were provided on
an individual basis in the last 7 days. Enter 0 if none were provided. Individual services
are provided by one therapist or assistant to one resident at a time.

•

Concurrent minutes—Enter the total number of minutes of therapy that were provided
on a concurrent basis in the last 7 days. Enter 0 if none were provided. Concurrent
therapy is defined as the treatment of 2 residents at the same time, when the residents are
not performing the same or similar activities, regardless of payer source, both of whom
must be in line-of-sight of the treating therapist or assistant for Medicare Part A. When a
Part A resident receives therapy that meets this definition, it is defined as concurrent
therapy for the Part A resident regardless of the payer source for the second resident. For
Part B, residents may not be treated concurrently: a therapist may treat one resident at a
time, and the minutes during the day when the resident is treated individually are added,
even if the therapist provides that treatment intermittently (first to one resident and then
to another). For all other payers, follow Medicare Part A instructions.

•

Group minutes—Enter the total number of minutes of therapy that were provided in a
group in the last 7 days. Enter 0 if none were provided. Group therapy is defined for Part
A as the treatment of two to six residents, regardless of payer source, who are performing
the same or similar activities, and are supervised by a therapist or an assistant who is not
supervising any other individuals. For Medicare Part B, treatment of two patients (or
more), regardless of payer source, at the same time is documented as group treatment.
For all other payers, follow Medicare Part A instructions.

•

Co-treatment minutes—Enter the total number of minutes each discipline of therapy
was administered to the resident in co-treatment sessions in the last 7 days. Skip the item
if none were provided.

•

Days—Enter the number of days therapy services were provided in the last 7 days. A day
of therapy is defined as skilled treatment for 15 minutes or more during the day. Use total
minutes of therapy provided (individual plus concurrent plus group), without any
adjustment, to determine if the day is counted. For example, if the resident received 20
minutes of concurrent therapy, the day requirement is considered met. Enter 0 if therapy
was provided but for less than 15 minutes every day for the last 7 days. If the total
number of minutes (individual plus concurrent plus group) during the last 7 days is 0,
skip this item and leave blank.

October 2024

•

Page O-24

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
•

Therapy Start Date—Record the date the most recent therapy regimen (since the most
recent entry/reentry) started. This is the date the initial therapy evaluation is conducted
regardless if treatment was rendered or not or the date of resumption, in cases where the
resident discontinued and then resumed therapy.

•

Therapy End Date—Record the date the most recent therapy regimen (since the most
recent entry) ended. This is the last date the resident received skilled therapy treatment.
Enter dashes if therapy is ongoing.

Coding Instructions for Respiratory, Psychological, and Recreational
Therapies
•

Total Minutes—Enter the actual number of minutes therapy services were provided in
the last 7 days. Enter 0 if none were provided.

•

Days—Enter the number of days therapy services were provided in the last 7 days. A day
of therapy is defined as treatment for 15 minutes or more in the day. Enter 0 if therapy
was provided but for less than 15 minutes every day for the last 7 days. If the total
number of minutes during the last 7 days is 0, skip this item and leave blank.

•

Coding Tips and Special Populations
Therapy Start Date:

1. Look at the date at A1600.
2. Determine whether the resident has had skilled rehabilitation therapy at any time from
that date to the present date.
3. If so, enter the date that the therapy regimen started; if there was more than one
therapy regimen since the A1600 date, enter the start date of the most recent therapy
regimen.
Psychological Therapy is provided by any licensed mental health professional, such as
psychiatrists, psychologists, clinical social workers, and clinical nurse specialists in
mental health as allowable under applicable state laws. Psychiatric technicians are not
considered to be licensed mental health professionals and their services may not be
counted in this item.

October 2024

•

Page O-25

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
Minutes of Therapy
Includes only therapies that were provided once the individual is actually living/being
cared for at the long-term care facility. Do NOT include therapies that occurred while the
person was an inpatient at a hospital or recuperative/rehabilitation center or other longterm care facility, or a recipient of home care or community-based services.

•

If a resident returns from a hospital stay, an initial evaluation must be performed after
entry to the facility, and only those therapies that occurred since admission/reentry to the
facility and after the initial evaluation shall be counted, except in the case of an
interrupted stay.

•

In the case of an interrupted stay, the therapy start date entered in O0400A5, O0400B5,
and/or O0400C5 must reflect a date on or after the date in A2400B. Although the therapy
start date occurred prior to the interrupted stay, the data specifications only accept a
therapy start date that is on or after the date entered in A2400B.

•

The therapist’s time spent on documentation or on initial evaluation is not included.

•

The therapist’s time spent on subsequent reevaluations, conducted as part of the treatment
process, should be counted.

•

Family education when the resident is present is counted and must be documented in the
resident’s record.

•

Only skilled therapy time (i.e., requires the skills, knowledge and judgment of a qualified
therapist and all the requirements for skilled therapy are met) shall be recorded on the
MDS. In some instances, the time during which a resident received a treatment modality
includes partly skilled and partly unskilled time; only time that is skilled may be recorded
on the MDS. Therapist time during a portion of a treatment that is non-skilled; during a
non-therapeutic rest period; or during a treatment that does not meet the therapy mode
definitions may not be included.

•

The time required to adjust equipment or otherwise prepare the treatment area for skilled
rehabilitation service is the set-up time and is to be included in the count of minutes of
therapy delivered to the resident. Set-up may be performed by the therapist, therapy
assistant, or therapy aide.

•

Respiratory therapy—only minutes that the respiratory therapist or respiratory nurse
spends with the resident shall be recorded on the MDS. This time includes resident
evaluation/assessment, treatment administration and monitoring, and setup and removal
of treatment equipment. Time that a resident self-administers a nebulizer treatment
without supervision of the respiratory therapist or respiratory nurse is not included in the
minutes recorded on the MDS. Do not include administration of metered-dose and/or dry
powder inhalers in respiratory minutes.

October 2024

•

Page O-26

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
•

•

Set-up time shall be recorded under the mode for which the resident receives initial
treatment when they receive more than one mode of therapy per visit.

•

October 2024

— Code as individual minutes when the resident receives only individual therapy or
individual therapy followed by another mode(s);
— Code as concurrent minutes when the resident receives only concurrent therapy or
concurrent therapy followed by another mode(s); and
— Code as group minutes when the resident receives only group therapy or group
therapy followed by another mode(s).
For Speech-Language Pathology Services (SLP) and Physical (PT) and Occupational
Therapies (OT) include only skilled therapy services. Skilled therapy services must meet
all of the following conditions (Refer to Medicare Benefit Policy Manual, Chapters 8 and
15, for detailed requirements and policies):
— for Part A, services must be ordered by a physician. For Part B the plan of care must
be certified by a physician following the therapy evaluation;
— the services must be directly and specifically related to an active written treatment
plan that is approved by the physician after any needed consultation with the qualified
therapist and is based on an initial evaluation performed by a qualified therapist prior
to the start of therapy services in the facility;
— the services must be of a level of complexity and sophistication, or the condition of
the resident must be of a nature that requires the judgment, knowledge, and skills of a
therapist;
— the services must be provided with the expectation, based on the assessment of the
resident’s restoration potential made by the physician, that the condition of the patient
will improve materially in a reasonable and generally predictable period of time; or,
the services must be necessary for the establishment of a safe and effective
maintenance program; or, the services must require the skills of a qualified therapist
for the performance of a safe and effective maintenance program.
— the services must be considered under accepted standards of medical practice to be
specific and effective treatment for the resident’s condition; and,
— the services must be reasonable and necessary for the treatment of the resident’s
condition; this includes the requirement that the amount, frequency, and duration of
the services must be reasonable, and they must be furnished by qualified personnel.
Include services provided by a qualified occupational/physical therapy assistant who is
employed by (or under contract with) the long-term care facility only if they are under the
direction of a qualified occupational/physical therapist. Medicare does not recognize
speech-language pathology assistants; therefore, services provided by these individuals
are not to be coded on the MDS.
For purposes of the MDS, when the payer for therapy services is not Medicare Part B,
follow the definitions and coding for Medicare Part A.

Page O-27

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
•

•

Record the actual minutes of therapy. Do not round therapy minutes (e.g., reporting)
to the nearest 5th minute. The conversion of units to minutes or minutes to units is not
appropriate. Please note that therapy logs are not an MDS requirement but reflect a
standard clinical practice expected of all therapy professionals. These therapy logs may
be used to verify the provision of therapy services in accordance with the plan of care and
to validate information reported on the MDS assessment.
When therapy is provided, staff need to document the different modes of therapy and set
up minutes that are being included on the MDS. It is important to keep records of time
included for each. When submitting a part B claim, minutes reported on the MDS may
not match the time reported on a claim. For example, therapy aide set-up time is recorded
on the MDS when it precedes skilled therapy; however, the therapy aide set-up time is
not included for billing purposes on a therapy Part B claim.
For purposes of the MDS, providers should record services for respiratory, psychological,
and recreational therapies (Item O0400D, E, and F) when the following criteria are met:
— the physician orders the therapy;
— the physician’s order includes a statement of frequency, duration, and scope of
treatment;
— the services must be directly and specifically related to an active written treatment plan
that is based on an initial evaluation performed by qualified personnel (See Glossary in
Appendix A for definitions of respiratory, psychological and recreational therapies);
— the services are required and provided by qualified personnel (See Glossary in
Appendix A for definitions of respiratory, psychological and recreational therapies);
— the services must be reasonable and necessary for treatment of the resident’s
condition.

Non-Skilled Services
•

October 2024

•

Services provided at the request of the resident or family that are not medically necessary
(sometimes referred to as family-funded services) shall not be counted in item O0400
Therapies, even when performed by a therapist or an assistant.
As noted above, therapy services can include the actual performance of a maintenance
program in those instances where the skills of a qualified therapist are needed to
accomplish this safely and effectively. However, when the performance of a maintenance
program does not require the skills of a therapist because it could be accomplished safely
and effectively by the patient or with the assistance of non-therapists (including unskilled
caregivers), such services are not considered therapy services in this context. Sometimes
a nursing home may nevertheless elect to have licensed professionals perform repetitive
exercises and other maintenance treatments or to supervise aides performing these
maintenance services even when the involvement of a qualified therapist is not medically
necessary. In these situations, the services shall not be coded as therapy in item O0400
Minutes, since the specific interventions would be considered restorative nursing care
when performed by nurses or aides. Services provided by therapists, licensed or not, that
are not specifically listed in this manual or on the MDS item set shall not be coded as
therapy in Item 0400. These services should be documented in the resident’s medical
record.

Page O-28

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
•

•
•

In situations where the ongoing performance of a safe and effective maintenance program
does not require any skilled services, once the qualified therapist has designed the
maintenance program and discharged the resident from a rehabilitation (i.e., skilled)
therapy program, the services performed by the therapist and the assistant are not to be
reported in item O0400A, B, or C Therapies. The services may be reported on the MDS
assessment in item O0500 Restorative Nursing Care, provided the requirements for
restorative nursing program are met.
Services provided by therapy aides are not skilled services (see therapy aide section
below).
When a resident refuses to participate in therapy, it is important for care planning
purposes to identify why the resident is refusing therapy. However, the time spent
investigating the refusal or trying to persuade the resident to participate in treatment is
not a skilled service and shall not be included in the therapy minutes.

Co-treatment
For Part A:

For Part B:

When two clinicians (therapists or therapy assistants), each from a different discipline, treat one
resident at the same time with different treatments, both disciplines may code the treatment
session in full. All policies regarding mode, modalities and student supervision must be followed
as well as all other federal, state, practice and facility policies. For example, if two therapists
(from different disciplines) were conducting a group treatment session, the group must be
comprised of two to six participants who were doing the same or similar activities in each
discipline. The decision to co-treat should be made on a case by case basis and the need for cotreatment should be well documented for each patient. Because co-treatment is appropriate for
specific clinical circumstances and would not be suitable for all residents, its use should be
limited.

Therapists, or therapy assistants, working together as a "team" to treat one or more patients
cannot each bill separately for the same or different service provided at the same time to the
same patient.

CPT codes are used for billing the services of one therapist or therapy assistant. The therapist
cannot bill for their services and those of another therapist or a therapy assistant, when both
provide the same or different services, at the same time, to the same patient(s). Where a physical
and occupational therapist both provide services to one patient at the same time, only one
therapist can bill for the entire service or the PT and OT can divide the service units. For
example, a PT and an OT work together for 30 minutes with one patient on transfer activities.
The PT and OT could each bill one unit of 97530. Alternatively, the 2 units of 97530 could be
billed by either the PT or the OT, but not both.

October 2024

Page O-29

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
Similarly, if two therapy assistants provide services to the same patient at the same time, only the
service of one therapy assistant can be billed by the supervising therapist or the service units can
be split between the two therapy assistants and billed by the supervising therapist(s).

Therapy Aides and Students
Therapy Aides

Therapy Aides cannot provide skilled services. Only the time a therapy aide spends on set-up
preceding skilled therapy may be coded on the MDS (e.g., set up the treatment area for wound
therapy) and should be coded under the appropriate mode for the skilled therapy (individual,
concurrent, or group) in O0400. The therapy aide must be under direct supervision of the
therapist or assistant (i.e., the therapist/assistant must be in the facility and immediately
available).

Therapy Students

Medicare Part A—Therapy students are not required to be in line-of-sight of the professional
supervising therapist/assistant (Federal Register, August 8, 2011). Within individual facilities,
supervising therapists/assistants must make the determination as to whether or not a student is
ready to treat patients without line-of-sight supervision. Additionally all state and professional
practice guidelines for student supervision must be followed.
Time may be coded on the MDS when the therapist provides skilled services and direction to a
student who is participating in the provision of therapy. All time that the student spends with
patients should be documented.
•

Medicare Part B—The following criteria must be met in order for services provided by a
student to be billed by the long-term care facility:

— The qualified professional is present and in the room for the entire session. The student
participates in the delivery of services when the qualified practitioner is directing the
service, making the skilled judgment, and is responsible for the assessment and
treatment.
— The practitioner is not engaged in treating another patient or doing other tasks at the
same time.
— The qualified professional is the person responsible for the services and, as such, signs
all documentation. (A student may, of course, also sign but it is not necessary because
the Part B payment is for the clinician’s service, not for the student’s services.)
— Physical therapy assistants and occupational therapy assistants are not precluded from
serving as clinical instructors for therapy assistant students while providing services
within their scope of work and performed under the direction and supervision of a
qualified physical or occupational therapist.

October 2024

Page O-30

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
Modes of Therapy
A resident may receive therapy via different modes during the same day or even treatment
session. When developing the plan of care, the therapist and assistant must determine which
mode(s) of therapy and the amount of time the resident receives for each mode and code the
MDS appropriately. The therapist and assistant should document the reason a specific mode of
therapy was chosen as well as anticipated goals for that mode of therapy. For any therapy that
does not meet one of the therapy mode definitions below, those minutes may not be counted on
the MDS. The therapy mode definitions must always be followed and apply regardless of when
the therapy is provided in relationship to all assessment windows (i.e., applies whether or not the
resident is in a look-back period for an MDS assessment).

Individual Therapy

The treatment of one resident at a time. The resident is receiving the therapist’s or the assistant’s
full attention. Treatment of a resident individually at intermittent times during the day is individual
treatment, and the minutes of individual treatment are added for the daily count. For example, the
speech-language pathologist treats the resident individually during breakfast for 8 minutes and
again at lunch for 13 minutes. The total of individual time for this day would be 21 minutes.

When a therapy student is involved with the treatment of a resident, the minutes may be coded as
individual therapy when only one resident is being treated by the therapy student and supervising
therapist/assistant (Medicare A and Medicare B). The supervising therapist/assistant shall not be
engaged in any other activity or treatment when the resident is receiving therapy under
Medicare B. However, for those residents whose stay is covered under Medicare A, the
supervising therapist/assistant shall not be treating or supervising other individuals and they are
able to immediately intervene/assist the student as needed.

Concurrent Therapy
Medicare Part A

Example:
• A speech therapy graduate student treats Resident A for 30 minutes. Resident A’s therapy
is covered under the Medicare Part A benefit. The supervising speech-language
pathologist is not treating any patients at this time but is not in the room with the student
or Resident A. Resident A’s therapy may be coded as 30 minutes of individual therapy on
the MDS.

The treatment of 2 residents, who are not performing the same or similar activities, at the same
time, regardless of payer source, both of whom must be in line-of-sight of the treating therapist
or assistant.

October 2024

Page O-31

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
When a therapy student is involved with the treatment, and one of the following occurs, the
minutes may be coded as concurrent therapy:
•
•
•

The therapy student is treating one resident and the supervising therapist/assistant is
treating another resident, and both residents are in line of sight of the therapist/assistant
or student providing their therapy.; or
The therapy student is treating 2 residents, regardless of payer source, both of whom are
in line-of-sight of the therapy student, and the therapist is not treating any residents and
not supervising other individuals; or
The therapy student is not treating any residents and the supervising therapist/assistant is
treating 2 residents at the same time, regardless of payer source, both of whom are in
line-of-sight.

Medicare Part B
• The treatment of two or more residents who may or may not be performing the same or
similar activity, regardless of payer source, at the same time is documented as group
treatment
Examples:
• A physical therapist provides therapies that are not the same or similar, to Resident Q and
Resident R at the same time, for 30 minutes. Resident Q’s stay is covered under the
Medicare SNF PPS Part A benefit. Resident R is paying privately for therapy. Based on
the information above, the therapist would code each individual’s MDS for this day of
treatment as follows:
— Resident Q received concurrent therapy for 30 minutes.
— Resident R received concurrent therapy for 30 minutes.
• A physical therapist provides therapies that are not the same or similar to Resident S and
Resident T at the same time, for 30 minutes. Resident S’s stay is covered under the
Medicare SNF PPS Part A benefit. Resident T’s therapy is covered under Medicare Part
B. Based on the information above, the therapist would code each individual’s MDS for
this day of treatment as follows:
— Resident S received concurrent therapy for 30 minutes.
— Resident T received group therapy (Medicare Part B definition) for 30 minutes.
(Please refer to the Medicare Benefit Policy Manual, Chapter 15, and the Medicare
Claims Processing Manual, Chapter 5, for coverage and billing requirements under
the Medicare Part B benefit.)

October 2024

Page O-32

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
•

An Occupational Therapist provides therapy to Resident K for 60 minutes. An
occupational therapy graduate student who is supervised by the occupational therapist, is
treating Resident R at the same time for the same 60 minutes but Resident K and
Resident R are not doing the same or similar activities. Both Resident K and Resident R’s
stays are covered under the Medicare Part A benefit. Based on the information above, the
therapist would code each individual’s MDS for this day of treatment as follows:
— Resident K received concurrent therapy for 60 minutes.
— Resident R received concurrent therapy for 60 minutes.

Group Therapy

Medicare Part A
The treatment of two to six residents, regardless of payer source, who are performing the same or
similar activities, and are supervised by a therapist or assistant who is not supervising any other
individuals.
When a therapy student is involved with group therapy treatment, and one of the following
occurs, the minutes may be coded as group therapy:
• The therapy student is providing the group treatment and the supervising
therapist/assistant is not treating any residents and is not supervising other individuals
(students or residents); or
• The supervising therapist/assistant is providing the group treatment and the therapy
student is not providing treatment to any resident. In this case, the student is simply
assisting the supervising therapist.
Medicare Part B
The treatment of 2 or more individuals simultaneously, regardless of payer source, who may or
may not be performing the same activity.
• When a therapy student is involved with group therapy treatment, and one of the
following occurs, the minutes may be coded as group therapy:
• The therapy student is providing group treatment and the supervising therapist/assistant is
not engaged in any other activity or treatment; or
• The supervising therapist/assistant is providing group treatment and the therapy student is
not providing treatment to any resident.

October 2024

Page O-33

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)

Examples:
• A Physical Therapist provides similar therapies to Resident W, Resident X, Resident Y
and Resident Z at the same time, for 30 minutes. Resident W and Resident X’s stays are
covered under the Medicare SNF PPS Part A benefit. Resident Y’s therapy is covered
under Medicare Part B, and Resident Z has private insurance paying for therapy. Based
on the information above, the therapist would code each individual’s MDS for this day of
treatment as follows:
— Resident W received group therapy for 30 minutes.
— Resident X received group therapy for 30 minutes.
— Resident Y received group therapy for 30 minutes. (Please refer to the Medicare
Benefit Policy Manual, Chapter 15, and the Medicare Claims Processing Manual,
Chapter 5, for coverage and billing requirements under the Medicare Part B benefit.)
— Resident Z received group therapy for 30 minutes.
• Resident V, whose stay is covered by SNF PPS Part A benefit, begins therapy in an
individual session. After 13 minutes the therapist begins working with Resident S, whose
therapy is covered by Medicare Part B, while Resident V continues with their skilled
intervention and is in line-of-sight of the treating therapist. The therapist provides
treatment during the same time period to Resident V and Resident S for 24 minutes who
are not performing the same or similar activities, at which time Resident V’s therapy
session ends. The therapist continues to treat Resident S individually for 10 minutes.
Based on the information above, the therapist would code each individual’s MDS for this
day of treatment as follows:
— Resident V received individual therapy for 13 minutes and concurrent therapy for 24.
— Resident S received group therapy (Medicare Part B definition) for 24 minutes and
individual therapy for 10 minutes. (Please refer to the Medicare Benefit Policy
Manual, Chapter 15, and the Medicare Claims Processing Manual, Chapter 5, for
coverage and billing requirements under the Medicare Part B benefit.)
• Resident A and Resident B, whose stays are covered by Medicare Part A, begin working
with a physical therapist on two different therapy interventions. After 30 minutes,
Resident A and Resident B are joined by Resident T and Resident E, whose stays are also
covered by Medicare Part A, and the therapist begins working with all of them on the
same therapy goals as part of a group session. After 15 minutes in this group session,
Resident A becomes ill and is forced to leave the group, while the therapist continues
working with the remaining group members for an additional 15 minutes. Based on the
information above, the therapist would code each individual’s MDS for this day of
treatment as follows:
—
—
—
—

Resident A received concurrent therapy for 30 minutes and group therapy for 15 minutes.
Resident B received concurrent therapy for 30 minutes and group therapy for 30 minutes.
Resident T received group therapy for 30 minutes.
Resident E received group therapy for 30 minutes.

October 2024

Page O-34

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
Therapy Modalities

Only skilled therapy time (i.e., require the skills, knowledge and judgment of a qualified therapist
and all the requirements for skilled therapy are met) shall be recorded on the MDS. In some
instances, the time a resident receives certain modalities is partly skilled and partly unskilled time;
only the time that is skilled may be recorded on the MDS. For example, a resident is receiving
TENS (transcutaneous electrical nerve stimulation) for pain management. The portion of the
treatment that is skilled, such as proper electrode placement, establishing proper pulse frequency
and duration, and determining appropriate stimulation mode, shall be recorded on the MDS. In
other instances, some modalities only meet the requirements of skilled therapy in certain situations.
For example, the application of a hot pack is often not a skilled intervention. However, when the
resident’s condition is complicated and the skills, knowledge, and judgment of the therapist are
required for treatment, then those minutes associated with skilled therapy time may be recorded on
the MDS. The use and rationale for all therapy modalities, whether skilled or unskilled should
always be documented as part of the resident’s plan of care.

Dates of Therapy

•
•
•

A resident may have more than one regimen of therapy treatment during an episode of a stay.
When this situation occurs the Therapy Start Date for the most recent episode of treatment for
the particular therapy (SLP, PT, or OT) should be coded. When a resident’s episode of treatment
for a given type of therapy extends beyond the ARD (i.e., therapy is ongoing), enter dashes in the
appropriate Therapy End Date. Therapy is considered to be ongoing if:
The resident was discharged and therapy was planned to continue had the resident
remained in the facility, or
The resident’s SNF benefit exhausted and therapy continued to be provided, or
The resident’s payer source changed and therapy continued to be provided.

•
•
•
•
•
•

For example, Resident N was admitted to the nursing home following a fall that resulted in a hip
fracture in November 2019. Occupational and Physical therapy started December 3, 2019. Their
physical therapy ended January 27, 2020 and occupational therapy ended January 29, 2020. Later
on during their stay at the nursing home, due to the progressive nature of their Parkinson’s
disease, they were referred to SLP and OT February 10, 2020 (they remained in the facility the
entire time). The speech-language pathologist evaluated them on that day and the occupational
therapist evaluated them the next day. The ARD for Resident N’s MDS assessment is February
28, 2020. Coding values for their MDS are:
O0400A5 (SLP start date) is 02102020,
O0400A6 (SLP end date) is dash filled,
O0400B5 (OT start date) is 02112020,
O0400B6 (OT end date) is dash filled,
O0400C5 (PT start date) is 12032019, and
O0400C6 (PT end date) is 01272020.

October 2024

Page O-35

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
General Coding Example:
Following a stroke, Resident F was admitted to the skilled nursing facility in stable condition for
rehabilitation therapy on 10/06/19 under Part A skilled nursing facility coverage. They had
slurred speech, difficulty swallowing, severe weakness in both their right upper and lower
extremities, and a Stage 3 pressure ulcer on their left lateral malleolus. They were referred to
SLP, OT, and PT with the long-term goal of returning home with their child and child’s spouse.
Their initial SLP evaluation was performed on 10/06/19, the PT initial evaluation on 10/07/19,
and the OT initial evaluation on 10/09/19. They were also referred to recreational therapy and
respiratory therapy. The interdisciplinary team determined that 10/13/19 was an appropriate
ARD for their 5-Day assessment. During the look-back period they received the following:
Speech-language pathology services that were provided over the 7-day look-back period:

D
•
•
•

Individual dysphagia treatments; Monday-Friday for 30 minute sessions each day.
Cognitive training; Monday and Thursday for 35 minute concurrent therapy sessions and
Tuesday, Wednesday and Friday 25 minute group sessions.
Individual speech techniques; Tuesday and Thursday for 20-minute sessions each day.
Coding:

O0400A1 would be coded 190; O0400A2 would be coded 70; O0400A3 would be
coded 75; O0400A4 would be coded 5; O0400A5 would be coded 10062019;
and O0400A6 would be coded with dashes.
Rationale:

Individual minutes totaled 190 over the 7-day look-back period
[(30 × 5) + (20 × 2) = 190]; concurrent minutes totaled 70 over the 7-day look-back
period (35 × 2 = 70); and group minutes totaled 75 over the 7-day look-back period
(25 × 3 = 75). Therapy was provided 5 out of the 7 days of the look-back period. Date
speech-language pathology services began was 10-06-2019, and dashes were used as the
therapy end date value because the therapy was ongoing.
•
•
•

Occupational therapy services that were provided over the 7-day look-back period:

Individual sitting balance activities; Monday and Wednesday for 30-minute co-treatment
sessions with PT each day (OT and PT each code the session as 30 minutes for each
discipline).
Individual wheelchair seating and positioning; Monday, Wednesday, and Friday for the
following times: 23 minutes, 18 minutes, and 12 minutes.
Balance/coordination activities; Tuesday-Friday for 20 minutes each day in group
sessions.
Coding:

O0400B1 would be coded 113, O0400B2 would be coded 0, O0400B3 would be
coded 80, O0400B3A would be coded 60, O0400B4 would be coded 5, O0400B5
would be coded 10092019, and O0400B6 would be coded with dashes.

October 2024

Page O-36

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
Rationale:

Individual minutes (including 60 co-treatment minutes) totaled 113 over the 7-day lookback period [(30 × 2) + 23 + 18 + 12 = 113]; concurrent minutes totaled 0 over the 7-day
look-back period (0 × 0 = 0); and group minutes totaled 80 over the 7-day look-back
period (20 × 4 = 80). Therapy was provided 5 out of the 7 days of the look-back period.
Date occupational therapy services began was 10-09-2019 and dashes were used as the
therapy end date value because the therapy was ongoing.
Physical therapy services that were provided over the 7-day look-back period:
•

•
•
•

Individual wound debridement followed by application of routine wound dressing;
Monday the session lasted 22 minutes, 5 minutes of which were for the application of the
dressing. On Thursday the session lasted 27 minutes, 6 minutes of which were for the
application of the dressing. For each session the therapy aide spent 7 minutes preparing
the debridement area (set-up time) for needed therapy supplies and equipment for the
therapist to conduct wound debridement.
Individual sitting balance activities; on Monday and Wednesday for 30-minute cotreatment sessions with OT (OT and PT each code the session as 30 minutes for each
discipline).
Individual bed positioning and bed mobility training; Monday-Friday for 35 minutes each
day.
Concurrent therapeutic exercises; Monday-Friday for 20 minutes each day.

Coding:

O0400C1 would be coded 287, O0400C2 would be coded 100, O0400C3 would be
coded 0, O0400C3A would be coded 60, O0400C4 would be coded 5, O0400C5
would be coded 10072019, and O0400C6 would be coded with dashes.
Rationale:

Individual minutes (including 60 co-treatment minutes) totaled 287 over the 7-day lookback period [(30 × 2) + (35 × 5) + (22 - 5) + 7 + (27 - 6) + 7 = 287]; concurrent minutes
totaled 100 over the 7-day look-back period (20 × 5 = 100); and group minutes totaled 0
over the 7-day look-back period (0 × 0 = 0). Therapy was provided 5 out of the 7 days of
the look-back period. Date physical therapy services began was 10-07-2019, and dashes
were used as the therapy end date value because the therapy was ongoing.
Respiratory therapy services that were provided over the 7-day look-back period:
•

Respiratory therapy services; Sunday-Thursday for 10 minutes each day.
Coding:

O0400D1 would be coded 50, O0400D2 would be coded 0.
Rationale:

Total minutes were 50 over the 7-day look-back period (10 × 5 = 50). Although a total of
50 minutes of respiratory therapy services were provided over the 7-day look-back
period, there were not any days that respiratory therapy was provided for 15 minutes or
more. Therefore, O0400D equals zero days.

October 2024

Page O-37

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)
Psychological therapy services that were provided over the 7-day look-back period:
•

Psychological therapy services were not provided at all over the 7-day look-back period.
Coding:

O0400E1 would be coded 0, O0400E2 would be left blank.
Rationale:

There were no minutes or days of psychological therapy services provided over the 7-day
look-back period.
Recreational therapy services that were provided over the 7-day look-back period:
•

Recreational therapy services; Tuesday, Wednesday, and Friday for 30-minute sessions
each day.

Coding:

O0400F1 would be coded 90, O0400F2 would be coded 3.
Rationale:

Total minutes were 90 over the 7-day look-back period (30 × 3 = 90). Sessions provided
were longer than 15 minutes each day, therefore each day recreational therapy was
performed can be counted.

ra
October 2024

Page O-38

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)

D
October 2024

Page O-39

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0400: Therapies (cont.)

D
October 2024

Page O-40

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0420: Distinct Calendar Days of Therapy

Item Rationale
To record the number of calendar days that the resident received Speech-Language Pathology
and Audiology Services, Occupational Therapy, or Physical Therapy for at least 15 minutes in
the past 7 days.

Coding Instructions
Enter the number of calendar days that the resident received Speech-Language Pathology and
Audiology Services, Occupational Therapy, or Physical Therapy for at least 15 minutes in the past
7 days. If a resident receives more than one therapy discipline on a given calendar day, this may
only count for one calendar day for purposes of coding Item O0420. Consider the following
examples:
•

•

Example 1: Resident T received 60 minutes of physical therapy on Monday, Wednesday
and Friday within the 7-day look-back period. Resident T also received 45 minutes of
occupational therapy on Monday, Tuesday and Friday during the last 7 days. Given the
therapy services received by Resident T during the 7-day look-back period, item O0420
would be coded as 4 because therapy services were provided for at least 15 minutes on
4 distinct calendar days during the 7-day look-back period (i.e., Monday, Tuesday,
Wednesday, and Friday).
Example 2: Resident F received 120 minutes of physical therapy on Monday, Wednesday
and Friday within the 7-day look-back period. Resident F also received 90 minutes of
occupational therapy on Monday, Wednesday and Friday during the last 7 days. Finally,
Resident F received 60 minutes of speech-language pathology services on Monday and
Friday during the 7-day look-back period. Given the therapy services received by
Resident F during the 7-day look-back period, item O0420 would be coded as 3
because therapy services were provided for at least 15 minutes on 3 distinct calendar days
during the 7-day look-back period (i.e., Monday, Wednesday, and Friday).

October 2024

Page O-41

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0425: Part A Therapies

D
October 2024

Page O-42

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0425: Part A Therapies (cont.)
Item Rationale
Health-related Quality of Life
Maintaining as much independence as possible in activities of daily living, mobility, and
communication is critically important to most people. Functional decline can lead to
depression, withdrawal, social isolation, breathing problems, and complications of
immobility, such as incontinence and pressure ulcers/injuries, which contribute to
diminished quality of life. The qualified therapist, in conjunction with the physician and
nursing administration, is responsible for determining the necessity for, and the frequency
and duration of, the therapy services provided to residents.

•

Planning for Care

Except in the case of an interrupted stay, code only medically necessary therapies that
occurred after admission/readmission to the nursing home that were (1) ordered by a
physician (physician’s assistant, nurse practitioner, and/or clinical nurse specialist as
allowable under state licensure laws) based on a qualified therapist’s assessment (i.e., one
who meets Medicare requirements or, in some instances, under such a person’s direct
supervision) and treatment plan, (2) documented in the resident’s medical record, and (3)
care planned and periodically evaluated to ensure that the resident receives needed
therapies and that current treatment plans are effective. Therapy treatment may occur
either inside or outside of the facility.

•

In the case of an interrupted stay, code medically necessary therapies that occurred during
the entire current Medicare Part A PPS stay that meet the above-noted criteria.

•

For definitions of the types of therapies listed in this section, please refer to the
Glossary in Appendix A.

October 2024

•

Page O-43

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0425: Part A Therapies (cont.)
Steps for Assessment
1. Complete only if A0310H (Is this a SNF Part A PPS Discharge Assessment?) = 1, Yes.
2. Review the resident’s medical record (e.g., rehabilitation therapy evaluation and treatment
records, recreation therapy notes, mental health professional progress notes), and consult
with each of the qualified care providers to collect the information required for this item.

NOTE: The look-back period for these items is the entire SNF Part A stay, starting at Day 1
of the Part A stay and finishing on the last day of the Part A stay. Once reported on the
MDS, CMS grouping software will calculate the percentage of group and concurrent
therapy, combined, provided to each resident as a percentage of all therapies provided to
that resident, by discipline. If the combined amount of group and concurrent therapy
provided, by discipline, exceeds 25 percent, then this would be deemed as non-compliance
and a warning message would be received on the Final Validation Report.

Providers should follow the steps outlined below for calculating compliance with the
concurrent/group therapy limit:
•
•

•
•

Step 1: Total Therapy Minutes, by discipline (O0425X1 + O0425X2 + O0425X3)
Step 2: Total Concurrent and Group Therapy Minutes, by discipline
(O0425X2+O0425X3)
Step 3: Concurrent/Group Ratio (Step 2 result/Step 1 result)
Step 4: If Step 3 result is greater than 0.25, then the provider is non-compliant.

October 2024

Page O-44

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0425: Part A Therapies (cont.)
Coding Instructions for Speech-Language Pathology and Audiology
Services and Occupational and Physical Therapies
Individual minutes—Enter the total number of minutes of therapy that were provided on
an individual basis during the entire Part A stay (i.e., from the date in A2400B through
the date in A2400C). Enter 0 if none were provided. Individual services are provided by
one therapist or assistant to one resident at a time. (For detailed definitions and examples
of individual therapy, refer to O0400 above.)

•

Concurrent minutes—Enter the total number of minutes of therapy that were provided
on a concurrent basis during the entire Part A stay (i.e., from the date in A2400B through
the date in A2400C). Enter 0 if none were provided. Concurrent therapy is defined as the
treatment of 2 residents at the same time, when the residents are not performing the same
or similar activities, regardless of payer source, both of whom must be in line-of-sight of
the treating therapist or assistant for Medicare Part A. When a Part A resident receives
therapy that meets this definition, it is defined as concurrent therapy for the Part A
resident regardless of the payer source for the second resident. (For detailed definitions
and examples of concurrent therapy, refer to item O0400 above.)

•

Group minutes—Enter the total number of minutes of therapy that were provided in a
group during the entire Part A stay (i.e., from the date in A2400B through the date in
A2400C). Enter 0 if none were provided. Group therapy is defined for Part A as the
treatment of two to six residents, regardless of payer source, who are performing the
same or similar activities, and are supervised by a therapist or an assistant who is not
supervising any other individuals. (For detailed definitions and examples of group
therapy, refer to item O0400 above.)

•

Co-treatment minutes—Enter the total number of minutes each discipline of therapy
was administered to the resident in co-treatment sessions during the entire Part A stay
(i.e., from the date in A2400B through the date in A2400C). Skip the item if none were
provided. (For detailed definitions and examples of co-treatment, refer to item O0400
above.)

•

Speech-Language Pathology Days—Enter the number of days speech-language
pathology therapy services were provided over the entire Part A stay (i.e., from the date
in A2400B through the date in A2400C). A day of therapy is defined as skilled treatment
for 15 minutes or more during the day. Use total minutes of therapy provided (individual
plus concurrent plus group), without any adjustment, to determine if the day is counted.
For example, if the resident received 20 minutes of concurrent therapy, the day
requirement is considered met. Enter 0 if therapy was provided but for less than 15
minutes every day during the stay. If the total number of minutes (individual plus
concurrent plus group) during the stay is 0, skip this item and leave blank.

October 2024

•

Page O-45

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0425: Part A Therapies (cont.)
Occupational Therapy Days—Enter the number of days occupational therapy services
were provided over the entire Part A stay (i.e., from the date in A2400B through the date
in A2400C). A day of therapy is defined as skilled treatment for 15 minutes or more
during the day. Use total minutes of therapy provided (individual plus concurrent plus
group), without any adjustment, to determine if the day is counted. For example, if the
resident received 20 minutes of concurrent therapy, the day requirement is considered
met. Enter 0 if therapy was provided but for less than 15 minutes every day during the
stay. If the total number of minutes (individual plus concurrent plus group) during the
stay is 0, skip this item and leave blank.

•

Physical Therapy Days—Enter the number of days physical therapy services were
provided over the entire Part A stay (i.e., from the date in A2400B through the date in
A2400C). A day of therapy is defined as skilled treatment for 15 minutes or more during
the day. Use total minutes of therapy provided (individual plus concurrent plus group),
without any adjustment, to determine if the day is counted. For example, if the resident
received 20 minutes of concurrent therapy, the day requirement is considered met. Enter
0 if therapy was provided but for less than 15 minutes every day during the stay. If the
total number of minutes (individual plus concurrent plus group) during the stay is 0, skip
this item and leave blank.

•

Coding Tips and Special Populations
•

For detailed descriptions of how to code minutes of therapy and explanation of skilled
versus nonskilled therapy services, co-treatment, therapy aides and students, please refer
to these topic headings in the discussion of item O0400 above.

Modes of Therapy

A resident may receive therapy via different modes during the same day or even treatment
session. These modes are individual, concurrent and group therapy. When developing the plan of
care, the therapist and assistant must determine which mode(s) of therapy and the amount of time
the resident receives for each mode and code the MDS appropriately. The therapist and assistant
should document the reason a specific mode of therapy was chosen as well as anticipated goals
for that mode of therapy. For any therapy that does not meet one of the therapy mode definitions
below, those minutes may not be counted on the MDS. The therapy mode definitions must
always be followed and apply regardless of when the therapy is provided in relationship to all
assessment windows (i.e., applies whether or not the resident is in a look-back period for an
MDS assessment).

Individual Therapy
For a detailed definition and example of individual therapy, please refer to the discussion of item
O0400 above.

October 2024

Page O-46

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0425: Part A Therapies (cont.)
Concurrent Therapy
For a detailed definition and example of concurrent therapy, please refer to the discussion of item
O0400 above.

Group Therapy
For a detailed definition and example of group therapy, please refer to the discussion of item
O0400 above.

Therapy Modalities

For a detailed definition and explanation of therapy modalities, please refer to the discussion of
item O0400 above.

General Coding Example:

Following a bilateral knee replacement, Resident G was admitted to the skilled nursing facility in
stable condition for rehabilitation therapy on Sunday 10/06/19 under Part A skilled nursing
facility coverage. While in the hospital, they exhibited some short-term memory difficulties
specifically affecting orientation. They were non-weight bearing, had reduced range of motion,
and had difficulty with ADLs. They were referred to SLP, OT, and PT with the long-term goal of
returning home with their spouse. Their initial SLP evaluation was performed on 10/06/19, and
the OT and PT initial evaluations were done on 10/07/19. They were also referred to recreational
therapy. They were in the SNF for 14 days and were discharged home on 10/19/2019. Resident
G received the following rehabilitation services during their stay in the SNF.
Speech-language pathology services that were provided over the SNF stay:
•
•

Individual cognitive training; six sessions for 45 minutes each day.
Discharged from SLP services on 10/14/2019.

Coding:

O0425A1 would be coded 270; O0425A2 would be coded 0; O0425A3 would be
coded 0; O0425A4 would be coded 0; O0425A5 would be coded 6.
Rationale:

Individual minutes totaled 270 over the stay (45 minutes × 6 days); concurrent minutes
totaled 0 over the stay (0 × 0 = 0); and group minutes totaled 0 over the stay (0 × 0 = 0).
Therapy was provided 6 days of the stay.
Occupational therapy services that were provided over the SNF stay:
•
•
•

Individual ADL activities daily for 30 minutes each starting 10/08/19.
Co-treatment: seating and transferring with PT; three sessions for the following times: 23
minutes, 18 minutes, and 12 minutes.
Balance/coordination activities: 10 sessions for 20 minutes each session in a group.

October 2024

Page O-47

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0425: Part A Therapies (cont.)
•

Discharged from OT services on 10/19/19.
Coding:

O0425B1 would be coded 413, O0425B2 would be coded 0, O0425B3 would be
coded 200, O0425B4 would be coded 53, O0425B5 would be coded 12.
Rationale:

Individual minutes (including 53 co-treatment minutes) totaled 413 over the stay [(30 ×
12) + 53 = 413]; concurrent minutes totaled 0 over the stay (0 × 0 = 0); and group
minutes totaled 200 over the stay (20 × 10 = 200). Therapy was provided 12 days of the
stay.
Physical therapy services that were provided over the stay:
Individual mobility training daily for 45 minutes per session starting 10/07/19.
Group mobility training for 30 minutes Tuesdays, Wednesdays, and Fridays.
Co-treatment seating and transferring for three sessions with OT for 7 minutes, 22
minutes, and 18 minutes.
Concurrent therapeutic exercises Monday-Friday for 20 minutes each day.
Discharged from PT services on 10/19/19.

•
•
•

•
•

Coding:

O0425C1 would be coded 632, O0425C2 would be coded 200, O0425C3 would be
coded 180, O0425C4 would be coded 47, O0425C5 would be coded 13.
Rationale:

Individual minutes (including 47 co-treatment minutes) totaled 632 over stay [(45 × 13) +
(7 + 22 + 18) = 632]; concurrent minutes totaled 200 over the stay (20 × 10 = 200); and
group minutes totaled 180 over the stay (30 × 6 = 180). Therapy was provided 13 days of
the stay.

ft
October 2024

Page O-48

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0430: Distinct Calendar Days of Part A Therapy

Coding Instructions
Enter the number of calendar days that the resident received Speech-Language Pathology and
Audiology Services, Occupational Therapy, or Physical Therapy for at least 15 minutes during the
SNF Part A stay (i.e., from the date in A2400B through the date in A2400C). If a resident receives
more than one therapy discipline on a given calendar day, this may only count for one calendar day
for purposes of coding item O0430. Consider the following example:
Example: Resident T was admitted to the SNF on Sunday 10/06/18 and discharged on Saturday
10/26/18. They received 60 minutes of physical therapy every Monday, Wednesday, and Friday
during the SNF stay. Resident T also received 45 minutes of occupational therapy every
Monday, Tuesday, and Friday during the stay. Given the therapy services received by Resident T
during the stay, item O0430 would be coded as 12 because therapy services were provided for
at least 15 minutes on 12 distinct calendar days during the stay (i.e., every Monday, Tuesday,
Wednesday, and Friday).

October 2024

Page O-49

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0500: Restorative Nursing Programs

D
Item Rationale
•

•

Maintaining independence in activities of daily living and mobility is critically important
to most people.
Functional decline can lead to depression, withdrawal, social isolation, and complications
of immobility, such as incontinence and pressure ulcers/injuries.

Planning for Care

•

Health-related Quality of Life

Restorative nursing program refers to nursing interventions that promote the resident’s
ability to adapt and adjust to living as independently and safely as possible. This concept
actively focuses on achieving and maintaining optimal physical, mental, and psychosocial
functioning.
A resident may be started on a restorative nursing program when they are admitted to the
facility with restorative needs, but are not a candidate for formalized rehabilitation
therapy, or when restorative needs arise during the course of a longer-term stay, or in
conjunction with formalized rehabilitation therapy. Generally, restorative nursing
programs are initiated when a resident is discharged from formalized physical,
occupational, or speech rehabilitation therapy.

October 2024

Page O-50

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0500: Restorative Nursing Programs (cont.)
Steps for Assessment
1. Review the restorative nursing program notes and/or flow sheets in the medical record.
2. For the 7-day look-back period, enter the number of days on which the technique, training or
skill practice was performed for a total of at least 15 minutes during the 24-hour period.

3. The following criteria for restorative nursing programs must be met in order to code O0500:
• Measurable objective and interventions must be documented in the care plan and in the
medical record. If a restorative nursing program is in place when a care plan is being
revised, it is appropriate to reassess progress, goals, and duration/frequency as part of the
care planning process. Good clinical practice would indicate that the results of this
reassessment should be documented in the resident’s medical record.
• Evidence of periodic evaluation by the licensed nurse must be present in the resident’s
medical record. When not contraindicated by state practice act provisions, a progress note
written by the restorative aide and countersigned by a licensed nurse is sufficient to
document the restorative nursing program once the purpose and objectives of treatment
have been established.
• Nursing assistants/aides must be trained in the techniques that promote resident
involvement in the activity.
• A registered nurse or a licensed practical (vocational) nurse must supervise the activities
in a restorative nursing program. Sometimes, under licensed nurse supervision, other staff
and volunteers will be assigned to work with specific residents. Restorative nursing does
not require a physician’s order. Nursing homes may elect to have licensed rehabilitation
professionals perform repetitive exercises and other maintenance treatments or to
supervise aides performing these maintenance services. In situations where such services
do not actually require the involvement of a qualified therapist, the services may not be
coded as therapy in item O0400, Therapies or O0425, Part A Therapies, because the
specific interventions are considered restorative nursing services (see item O0400,
Therapies and O0425, Part A Therapies). The therapist’s time actually providing the
maintenance service can be included when counting restorative nursing minutes.
Although therapists may participate, members of the nursing staff are still responsible for
overall coordination and supervision of restorative nursing programs.
• This category does not include groups with more than four residents per supervising
helper or caregiver.

October 2024

Page O-51

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0500: Restorative Nursing Programs (cont.)
Coding Instructions
•

•

This item does not include procedures or techniques carried out by or under the direction
of qualified therapists, as identified in Speech-Language Pathology and Audiology
Services item O0400A or O0425A, Occupational Therapy item O0400B or O0425B,
and Physical Therapy item O0400C or O0425C.
The time provided for items O0500A-J must be coded separately, in time blocks of 15
minutes or more. For example, to check Technique—Range of Motion [Passive] item
O0500A, 15 or more minutes of passive range of motion (PROM) must have been
provided during a 24-hour period in the last 7 days. The 15 minutes of time in a day may
be totaled across 24 hours (e.g., 10 minutes on the day shift plus 5 minutes on the evening
shift). However, 15-minute time increments cannot be obtained by combining 5 minutes
of Technique—Range of Motion [Passive] item O0500A, 5 minutes of Technique—
Range of Motion [Active] item O0500B, and 5 minutes of Splint or Brace Assistance
item O0500C, over 2 days in the last 7 days.
Review for each activity throughout the 24-hour period. Enter 0, if none.

•

Technique
•

Activities provided by restorative nursing staff.

O0500A, Range of Motion (Passive)

Code provision of passive movements in order to maintain flexibility and useful motion
in the joints of the body. These exercises must be individualized to the resident’s needs,
planned, monitored, evaluated and documented in the resident’s medical record.
•

O0500B, Range of Motion (Active)

•

Code exercises performed by the resident, with cueing, supervision, or physical assist by
staff that are individualized to the resident’s needs, planned, monitored, evaluated, and
documented in the resident’s medical record. Include active ROM and active-assisted
ROM.
O0500C, Splint or Brace Assistance

Code provision of (1) verbal and physical guidance and direction that teaches the resident
how to apply, manipulate, and care for a brace or splint; or (2) a scheduled program of
applying and removing a splint or brace. These sessions are individualized to the
resident’s needs, planned, monitored, evaluated, and documented in the resident’s
medical record.

October 2024

Page O-52

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0500: Restorative Nursing Programs (cont.)
Training and Skill Practice
Activities including repetition, physical or verbal cueing, and/or task segmentation provided by
any staff member under the supervision of a licensed nurse.
•

O0500D, Bed Mobility

Code activities provided to improve or maintain the resident’s self-performance in
moving to and from a lying position, turning side to side and positioning themself in bed.
These activities are individualized to the resident’s needs, planned, monitored, evaluated,
and documented in the resident’s medical record.
•

O0500E, Transfer

Code activities provided to improve or maintain the resident’s self-performance in
moving between surfaces or planes either with or without assistive devices. These
activities are individualized to the resident’s needs, planned, monitored, evaluated, and
documented in the resident’s medical record.

•

O0500F, Walking

•

Code activities provided to improve or maintain the resident’s self-performance in
walking, with or without assistive devices. These activities are individualized to the
resident’s needs, planned, monitored, evaluated, and documented in the resident’s
medical record.
O0500G, Dressing and/or Grooming

Code activities provided to improve or maintain the resident’s self-performance in
dressing and undressing, bathing and washing, and performing other personal hygiene
tasks. These activities are individualized to the resident’s needs, planned, monitored,
evaluated, and documented in the resident’s medical record.
O0500H, Eating and/or Swallowing

•

Code activities provided to improve or maintain the resident’s self-performance in
feeding oneself food and fluids, or activities used to improve or maintain the resident’s
ability to ingest nutrition and hydration by mouth. These activities are individualized to
the resident’s needs, planned, monitored, evaluated, and documented in the resident’s
medical record.
•

O0500I, Amputation/ Prosthesis Care

Code activities provided to improve or maintain the resident’s self-performance in
putting on and removing a prosthesis, caring for the prosthesis, and providing appropriate
hygiene at the site where the prosthesis attaches to the body (e.g., leg stump or eye
socket). Dentures are not considered to be prostheses for coding this item. These
activities are individualized to the resident’s needs, planned, monitored, evaluated, and
documented in the resident’s medical record.

October 2024

Page O-53

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0500: Restorative Nursing Programs (cont.)
•

O0500J, Communication

Code activities provided to improve or maintain the resident’s self-performance in
functional communication skills or assisting the resident in using residual communication
skills and adaptive devices. These activities are individualized to the resident’s needs,
planned, monitored, evaluated, and documented in the resident’s medical record.

Coding Tips and Special Populations
•
•
•

•
•

•

For range of motion (passive): the caregiver moves the body part around a fixed point or
joint through the resident’s available range of motion. The resident provides no
assistance.
For range of motion (active): any participation by the resident in the ROM activity should
be coded here.
For both active and passive range of motion: movement by a resident that is incidental to
dressing, bathing, etc., does not count as part of a formal restorative nursing program. For
inclusion in this section, active or passive range of motion must be a component of an
individualized program that is planned, monitored evaluated, and documented in the
resident’s medical record. Range of motion should be delivered by staff who are trained
in the procedures.
For splint or brace assistance: assess the resident’s skin and circulation under the device,
and reposition the limb in correct alignment.
The use of continuous passive motion (CPM) devices in a restorative nursing program is
coded when the following criteria are met: (1) ordered by a physician, (2) nursing staff
have been trained in technique (e.g., properly aligning resident’s limb in device, adjusting
available range of motion), and (3) monitoring of the device. Nursing staff should
document the application of the device and the effects on the resident. Do not include the
time the resident is receiving treatment in the device. Include only the actual time staff
were engaged in applying and monitoring the device.
Remember that persons with dementia learn skills best through repetition that occurs
multiple times per day.
Grooming programs, including programs to help residents learn to apply make-up, may
be considered restorative nursing programs when conducted by a member of the activity
staff. These grooming programs would need to be individualized to the resident’s needs,
planned, monitored, evaluated, and documented in the resident’s medical record.

October 2024

Page O-54

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0500: Restorative Nursing Programs (cont.)
Examples

1. Resident V has lost range of motion in their right arm, wrist, and hand due to a
cerebrovascular accident (CVA) experienced several years ago. They have moderate to
severe loss of cognitive decision-making skills and memory. To avoid further ROM loss and
contractures to their right arm, the occupational therapist fabricated a right resting hand splint
and instructions for its application and removal. The nursing coordinator developed
instructions for providing passive range of motion exercises to their right arm, wrist, and
hand three times per day. The nurse’s aides and Resident V’s spouse have been instructed in
how and when to apply and remove the hand splint and how to do the passive ROM
exercises. These plans are documented in Resident V’s care plan. The total amount of time
involved each day in removing and applying the hand splint and completing the ROM
exercises is 30 minutes (15 minutes to perform ROM exercises and 15 minutes to
apply/remove the splint). The nurse’s aides report that there is less resistance in Resident V’s
affected extremity when bathing and dressing them.
Coding: Both Splint or Brace Assistance item (O0500C), and Range of Motion
(Passive) item (O0500A), would be coded 7.
Rationale: Because this was the number of days these restorative nursing techniques

were provided.

2. Resident R’s right shoulder ROM has decreased slightly over the past week. Upon
examination and X-ray, their physician diagnosed them with right shoulder impingement
syndrome. Resident R was given exercises to perform on a daily basis to help improve their
right shoulder ROM. After initial training in these exercises by the physical therapist,
Resident R and the nursing staff were provided with instructions on how to cue and
sometimes actively assist Resident R when they cannot make the full ROM required by the
exercises on their own. Their exercises are to be performed for 15 minutes, two times per day
at change of shift in the morning and afternoon. This information is documented in
Resident R’s medical record. The nursing staff cued and sometimes actively assisted
Resident R two times daily over the past 7 days.
Coding: Range of motion (active) item (O0500B), would be coded 7.
Rationale: Because this was the number of days restorative nursing training and skill

practice for active ROM were provided.

October 2024

Page O-55

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0500: Restorative Nursing Programs (cont.)

3. Resident K was admitted to the nursing facility 7 days ago following repair to a fractured hip.
Physical therapy was delayed due to complications and a weakened condition. Upon
admission, they had difficulty moving themself in bed and were dependent for transfers. To
prevent further deterioration and increase their independence, the nursing staff implemented
a plan on the second day following admission to teach them how to move themself in bed
and transfer from bed to chair using a trapeze, the bed rails, and a transfer board. The plan
was documented in Resident K’s medical record and communicated to all staff at the change
of shift. The charge nurse documented in the nurse’s notes that in the 5 days Resident K has
been receiving training and skill practice for bed mobility for 20 minutes a day and
transferring for 25 minutes a day, their endurance and strength have improved, and they
require only substantial/maximal assistance for transferring. Each day the amount of time to
provide this nursing restorative intervention has been decreasing, so that for the past 5 days,
the average time is 45 minutes.
Coding: Both Bed Mobility item (O0500D), Transfer item (O0500E), would be
coded 5.
Rationale: Because this was the number of days that restorative nursing training and

skill practice for bed mobility and transfer were provided.

4. Resident D is receiving training and skill practice in walking using a quad cane. Together,
Resident D and the nursing staff have set progressive walking distance goals. The nursing
staff has received instruction on how to provide Resident D with the instruction and guidance
they need to achieve the goals. They have three scheduled times each day where they learn
how to walk with their quad cane. Each teaching and practice episode for walking,
supervised by a nursing assistant, takes approximately 15 minutes.
Coding: Walking item (O0500F), would be coded 7.
Rationale: Because this was the number of days that restorative nursing skill and

practice training for walking was provided.

5. Resident J had a CVA less than a year ago resulting in left-sided hemiplegia. Resident J has a
strong desire to participate in their own care. Although they cannot dress themself
independently, they are capable of participating in this activity of daily living. Resident J’s
overall care plan goal is to maximize their independence in ADLs. A plan, documented on the
care plan, has been developed to assist Resident J in how to maintain the ability to put on and
take off their shirt with no physical assistance from the staff. All of their shirts have been
adapted for front closure with hook and loop fasteners. The nursing assistants have been
instructed in how to verbally guide Resident J as they put on and takes off their shirt to
enhance their efficiency and maintain their level of function. It takes approximately 20
minutes per day for Resident J to complete this task (dressing and undressing).
Coding: Dressing or Grooming item (O0500G), would be coded 7.
Rationale: Because this was the number of days that restorative nursing training and

skill practice for dressing and grooming were provided.

October 2024

Page O-56

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [O]

O0500: Restorative Nursing Programs (cont.)
6. Resident W’s cognitive status has been deteriorating progressively over the past several
months. Despite deliberate nursing restoration attempts to promote their independence in
feeding themself, they will not eat unless they are fed.
Coding: Eating and/or Swallowing item (O0500H), would be coded 0.
Rationale: Because restorative nursing skill and practice training for eating and/or

swallowing were not provided over the last 7 days.

7. Resident E has Amyotrophic Lateral Sclerosis. They no longer have the ability to speak or
even to nod their head “yes” or “no.” Their cognitive skills remain intact, they can spell, and
they can move their eyes in all directions. The speech-language pathologist taught both
Resident E and the nursing staff to use a communication board so that Resident E could
communicate with staff. The communication board has been in use over the past 2 weeks and
has proven very successful. The nursing staff, volunteers, and family members are reminded
by a sign over Resident E’s bed that they are to provide them with the board to enable
Resident E to communicate with them. This is also documented in Resident E’s care plan.
Because the teaching and practice using the communication board had been completed 2
weeks ago and Resident E is able to use the board to communicate successfully, they no
longer receive skill and practice training in communication.

Coding: Communication item (O0500J), would be coded 0.
Rationale: Because the resident has mastered the skill of communication, restorative

nursing skill and practice training for communication was no longer needed or provided
over the last 7 days.

ft
October 2024

Page O-57

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

SECTION P: RESTRAINTS AND ALARMS
Intent: The intent of this section is to record the frequency that the resident was restrained by
any of the listed devices or an alarm was used, at any time during the day or night, during the 7day look-back period. Assessors will evaluate whether or not a device meets the definition of a
physical restraint or an alarm and code only the devices that meet the definitions in the
appropriate categories.

Are Restraints Prohibited by CMS?

CMS is committed to reducing unnecessary physical restraints in nursing homes and ensuring
that residents are free of physical restraints unless deemed necessary and appropriate as
permitted by regulation. Proper interpretation of the physical restraint definition is necessary to
understand if nursing homes are accurately assessing manual methods or physical or mechanical
devices, materials or equipment as physical restraints and meeting the federal requirements for
restraint use. These requirements, as well as those related to alarms and their relevant definitions,
are available in Appendix PP of the State Operations Manual Appendix PP - Guidance to
Surveyors for Long Term Care Facilities available at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.
DEFINITION

Federal regulations and CMS guidelines do not prohibit use of
physical restraints in nursing homes, except when they are
imposed for discipline or convenience and are not required to
treat the resident’s medical symptoms. The regulation
specifically states, “The resident has the right to be free from
any physical or chemical restraints imposed for the purposes of
discipline or convenience and not required to treat the
resident’s medical symptoms” (42 CFR 483.10(e)(1) and
483.12). Research and standards of practice show that physical
restraints have many negative side effects and risks that far
outweigh any benefit from their use.

PHYSICAL
RESTRAINTS
Any manual method or
physical or mechanical
device, material or equipment
attached or adjacent to the
resident’s body that the
individual cannot remove
easily, which restricts
freedom of movement or
normal access to one’s body
(State Operations Manual,
Appendix PP).

Prior to using any physical restraint, the nursing home must
assess the resident to properly identify the resident’s needs and
the medical symptom(s) that the restraint is being employed to
address. If a physical restraint is needed to treat the resident’s
medical symptom(s), the nursing home is responsible for assessing the appropriateness of that
restraint. When the decision is made to use a physical restraint, CMS encourages, to the extent
possible, gradual restraint reduction because there are many negative outcomes associated with
restraint use.
While a restraint-free environment is not a federal requirement, the use of physical restraints
should be the exception, not the rule.

October 2024

Page P-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

P0100: Physical Restraints

D
Item Rationale

Health-related Quality of Life

Although the requirements describe the narrow instances when physical restraints may be
used, growing evidence supports that physical restraints have a limited role in medical
care. Physical restraints limit mobility and increase the risk for a number of adverse
outcomes, such as functional decline, agitation, diminished sense of dignity, depression,
and pressure ulcers.

•

Residents who are cognitively impaired are at a higher risk of entrapment and injury or
death caused by physical restraints. It is vital that physical restraints used on this
population be carefully considered and monitored. In many cases, the risk of using the
physical restraint may be greater than the risk of it not being used.

•

The risk of restraint-related injury and death is significant when physical restraints are
used.

Planning for Care
•

•

When the use of physical restraints is considered, thorough assessment of problems to be
addressed by restraint use is necessary to determine reversible causes and contributing
factors and to identify alternative methods of treating non-reversible issues.

October 2024

Page P-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

P0100: Physical Restraints (cont.)
•

When the interdisciplinary team determines that the use of physical restraints is the
appropriate course of action, and there is a signed physician order that gives the medical
symptom supporting the use of the restraint, the least restrictive manual method or
physical or mechanical device, material or equipment that will meet the resident’s needs
must be selected.

•

Care planning must focus on preventing the adverse effects of physical restraint use.

Steps for Assessment

1. Review the resident’s medical record (e.g., physician orders, nurses’ notes, nursing assistant
documentation) to determine if physical restraints were used during the 7-day look-back
period.
2. Consult the nursing staff to determine the resident’s cognitive and physical status/limitations.
3. Considering the physical restraint definition as well as the clarifications listed below, observe
the resident to determine the effect the restraint has on the resident’s normal function. Do not
focus on the type, intent, or reason behind its use.
4. Evaluate whether the resident can easily and voluntarily remove any manual method or
physical or mechanical device, material, or equipment attached or adjacent to their body. If
the resident cannot easily and voluntarily do this, continue with the assessment to determine
whether or not the manual method or physical or mechanical device, material or equipment
restrict freedom of movement or restrict the resident’s access to their own body.
5. Any manual method or physical or mechanical device, material or equipment should be
classified as a restraint only when it meets the criteria of the physical restraint definition.
This can only be determined on a case-by-case basis by individually assessing each and every
manual method or physical or mechanical device, material or equipment (whether or not it is
listed specifically on the MDS) attached or adjacent to the resident’s body, and the effect it
has on the resident.
6. Determine if the manual method or physical or mechanical device, material, or equipment
meets the definition of a physical restraint as clarified below. Remember, the decision about
coding any manual method or physical or mechanical device, material, equipment as a
restraint depends on the effect it has on the resident.
7. Any manual method or physical or mechanical device, material, or equipment that meets the
definition of a physical restraint must have:
•

physician documentation of a medical symptom that supports the use of the restraint,

•

a physician’s order for the type of restraint and parameters of use, and

•

a care plan and a process in place for systematic and gradual restraint reduction (and/or
elimination, if possible), as appropriate.

October 2024

Page P-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

P0100: Physical Restraints (cont.)
Clarifications
“Remove easily” means that the manual method or physical or mechanical device,
material, or equipment can be removed intentionally by the resident in the same manner
as it was applied by the staff (e.g., side rails are put down or not climbed over, buckles
are intentionally unbuckled, ties or knots are intentionally untied), considering the
resident’s physical condition and ability to accomplish their objective (e.g., transfer to a
chair, get to the bathroom in time).

•

“Freedom of movement” means any change in place or position for the body or any part
of the body that the person is physically able to control or access.

•

“Medical symptoms/diagnoses” are defined as an indication or characteristic of a
physical or psychological condition. Objective findings derived from clinical evaluation
of the resident’s subjective symptoms and medical diagnoses should be considered when
determining the presence of medical symptom(s) that might support restraint use. The
resident’s subjective symptoms may not be used as the sole basis for using a
restraint. In addition, the resident’s medical symptoms/diagnoses should not be
viewed in isolation; rather, the medical symptoms identified should become the
context in which to determine the most appropriate method of treatment related to
the resident’s condition, circumstances, and environment, and not a way to justify
restraint use.

•

The identification of medical symptoms should assist the nursing home in determining if
the specific medical symptom can be improved or addressed by using other, less
restrictive interventions. The nursing home should perform all due diligence and
document this process to ensure that they have exhausted alternative treatments and less
restrictive measures before a physical restraint is employed to treat the medical symptom,
protect the resident’s safety, help the resident attain or maintain their highest level of
physical or psychological well-being and support the resident’s goals, wishes,
independence, and self-direction.

•

Physical restraints as an intervention do not treat the underlying causes of medical
symptoms. Therefore, as with other interventions, physical restraints should not be
used without also seeking to identify and address the physical or psychological
condition causing the medical symptom.

•

Physical restraints may be used, if warranted, as a temporary symptomatic intervention
while the actual cause of the medical symptom is being evaluated and managed.
Additionally, physical restraints may be used as a symptomatic intervention when they
are immediately necessary to prevent a resident from injuring themself or others and/or to
prevent the resident from interfering with life-sustaining treatment when no other less
restrictive or less risky interventions exist.

October 2024

•

Page P-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

P0100: Physical Restraints (cont.)
•

Therefore, a clear link must exist between physical restraint use and how it benefits the
resident by addressing the specific medical symptom. If it is determined, after thorough
evaluation and attempts at using alternative treatments and less restrictive methods, that a
physical restraint must still be employed, the medical symptoms that support the use of
the restraint must be documented in the resident’s medical record, ongoing assessments,
and care plans. There also must be a physician’s order reflecting the use of the physical
restraint and the specific medical symptom being treated by its use. The physician’s order
alone is not sufficient to employ the use of a physical restraint. CMS will hold the
nursing home ultimately accountable for the appropriateness of that determination.

Coding Instructions

Identify all physical restraints that were used at any time (day or night) during the 7-day lookback period.
After determining whether or not an item listed in (P0100) is a physical restraint and was used
during the 7-day look-back period, code the frequency of use:
• Code 0, not used: if the item was not used during the 7-day look-back period or it
was used but did not meet the definition.
• Code 1, used less than daily: if the item met the definition and was used less than
daily during the observation period.
• Code 2, used daily: if the item met the definition and was used on a daily basis
during the look-back period.

Coding Tips and Special Populations
•

•

October 2024

•

Any manual method or physical or mechanical device, material or equipment, that does
not fit into the listed categories but that meets the definition of a physical restraint, and
has not been excluded from this section, should be coded in items P0100D or P0100H,
Other. These devices, although not coded on the MDS, must be assessed, care-planned,
monitored, and evaluated.
In classifying any manual method or physical or mechanical device, material or
equipment as a physical restraint, the assessor must consider the effect it has on the
resident, not the purpose or intent of its use. It is possible that a manual method or
physical or mechanical device, material or equipment may improve a resident’s mobility
but also have the effect of physically restraining them.
Exclude from this section items that are typically used in the provision of medical care,
such as catheters, drainage tubes, casts, traction, leg, arm, neck, or back braces,
abdominal binders, and bandages that are serving in their usual capacity to meet medical
need(s).
When coding this section, do not consider as a restraint a locked/secured unit or building
in which the resident has the freedom to move about the locked/secured unit or building.
Additional guidance regarding locked/secured units is provided in the section
“Considerations Involving Secured/Locked Areas” of F603 in Appendix PP of the State
Operations Manual.

Page P-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

P0100: Physical Restraints (cont.)
•

•

October 2024

•

Bed rails include any combination of partial or full rails (e.g., one-side half-rail, one-side
full rail, two-sided half-rails or quarter-rails, rails along the side of the bed that block
three-quarters to the whole length of the mattress from top to bottom, etc.). Include in this
category enclosed bed systems.
— Bed rails used as positioning devices. If the use of bed rails (quarter-, half- or threequarter, one or both, etc.) meet the definition of a physical restraint even though they
may improve the resident’s mobility in bed, the nursing home must code their use as a
restraint at P0100A.
— Bed rails used with residents who are immobile. If the resident is immobile and
cannot voluntarily get out of bed because of a physical limitation or because proper
assistive devices were not present, the bed rails do not meet the definition of a
physical restraint.
For residents who have no voluntary movement, the staff need to determine if there is
an appropriate use of bed rails. Bed rails may create a visual barrier and deter
physical contact from others. Some residents have no ability to carry out voluntary
movements, yet they exhibit involuntary movements. Involuntary movements,
resident weight, and gravity’s effects may lead to the resident’s body shifting toward
the edge of the bed. When bed rails are used in these cases, the resident could be at
risk for entrapment. For this type of resident, clinical evaluation of alternatives (e.g., a
concave mattress to keep the resident from going over the edge of the bed), coupled
with frequent monitoring of the resident’s position, should be considered. While the
bed rails may not constitute a physical restraint, they may affect the resident’s quality
of life and create an accident hazard.
Trunk restraints include any manual method or physical or mechanical device, material
or equipment attached or adjacent to the resident’s body that the resident cannot easily
remove such as, but not limited to, vest or waist restraints or belts used in a wheelchair
that either restricts freedom of movement or access to their body.
Limb restraints include any manual method or physical or mechanical device, material
or equipment that the resident cannot easily remove, that restricts movement of any part
of an upper extremity (i.e., hand, arm, wrist) or lower extremity (i.e., foot, leg) that either
restricts freedom of movement or access to their own body. Hand mitts/mittens are
included in this category.
Trunk or limb restraints, if used in both bed and chair, should be marked in both
sections.

Page P-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

P0100: Physical Restraints (cont.)
•

•

Additional Information
•

Chairs that prevent rising include any type of chair with a locked lap board, that places
the resident in a recumbent position that restricts rising, chairs that are soft and low to the
floor, chairs that have a cushion placed in the seat that prohibit the resident from rising,
geriatric chairs, and enclosed-frame wheeled walkers.
— For residents who have the ability to transfer from other chairs, but cannot transfer
from a geriatric chair, the geriatric chair would be considered a restraint to that
individual, and should be coded as P0100G–Chair Prevents Rising.
— For residents who have no ability to transfer independently, the geriatric chair does
not meet the definition of a restraint, and should not be coded at P0100G–Chair
Prevents Rising.
— Geriatric chairs used for residents who are immobile. For residents who have no
voluntary or involuntary movement, the geriatric chair does not meet the definition of
a restraint.
Enclosed-frame wheeled walkers, with or without a posterior seat, and other devices
like it should not automatically be classified as a physical restraint. These types of
walkers are only classified as a physical restraint if the resident cannot exit the walker
via opening a gate, bar, strap, latch, removing a tray, etc. When deemed a physical
restraint, these walkers should be coded at P0100G–Chair Prevents Rising.
Restraints used in emergency situations. If the resident needs emergency care, physical
restraints may be used for brief periods to permit medical treatment to proceed, unless the
resident or legal representative has previously made a valid refusal of the treatment in
question. The resident's right to participate in care planning and the right to refuse
treatment are addressed at 42 CFR 483.10(c)(6) and 483.21(b)(ii)(A)–(F) respectively.
The use of physical restraints in this instance should be limited to preventing the resident
from interfering with life-sustaining procedures only and not for routine care.
— A resident who is injuring themself or is threatening physical harm to others may be
physically restrained in an emergency to safeguard the resident and others. A resident
whose unanticipated violent or aggressive behavior places them or others in imminent
danger does not have the right to refuse the use of physical restraints, as long as those
restraints are used as a last resort to protect the safety of the resident or others and use
is limited to the immediate episode.
Restraint reduction/elimination. It is further expected, for residents whose care plan
indicates the need for physical restraints, that the nursing home engages in a systematic
and gradual process towards reducing (or eliminating, if possible) the restraints (e.g.,
gradually increasing the time for ambulation and strengthening activities). This
systematic process also applies to recently-admitted residents for whom physical
restraints were used in the previous setting.

October 2024

Page P-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

P0100: Physical Restraints (cont.)
•

•

Restraints as a fall prevention approach. Although physical restraints have been
traditionally used as a fall prevention approach, they have major drawbacks and can
contribute to serious injuries. Falls do not constitute self-injurious behavior nor a medical
symptom supporting the use of physical restraints. There is no evidence that the use of
physical restraints, including but not limited to side rails, will prevent, reduce, or
eliminate falls. In fact, in some instances, reducing the use of physical restraints may
actually decrease the risk of falling. Additionally, falls that occur while a person is
physically restrained often result in more severe injuries.
Request for restraints. While a resident, family member, legal representative, or
surrogate may request use of a physical restraint, the nursing home is responsible for
evaluating the appropriateness of that request, just as they would for any medical
treatment. As with other medical treatments, such as the use of prescription drugs, a
resident, family member, legal representative, or surrogate has the right to refuse
treatment, but not to demand its use when it is not deemed medically necessary.
According to 42 CFR 483.10(e)(1) and 483.12, “The resident has the right to be free from
any physical or chemical restraints imposed for the purposes of discipline or convenience
and not required to treat the resident’s medical symptoms.” CMS expects that no resident
will be physically restrained for discipline or convenience. Prior to employing any
physical restraint, the nursing home must perform a prescribed resident assessment to
properly identify the resident’s needs and the medical symptom(s) the physical restraint is
being employed to address. The guidelines in the State Operations Manual (SOM) state,
“...the legal surrogate or representative cannot give permission to use restraints for the
sake of discipline or staff convenience or when the restraint is not necessary to treat the
resident’s medical symptoms. That is, the facility may not use restraints in violation of
regulation solely based on a resident, legal surrogate or representative’s request or
approval.” The SOM goes on to state, “While Federal regulations affirm the resident’s
right to participate in care planning and to refuse treatment, the regulations do not create
the right for a resident, legal surrogate or representative to demand that the facility use
specific medical interventions or treatment that the facility deems inappropriate. Statutory
requirements hold the facility ultimately accountable for the resident’s care and safety,
including clinical decisions.”

October 2024

Page P-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

P0200: Alarms

D
Item Rationale

Health-related Quality of Life
An alarm is any physical or electronic device that monitors resident movement and alerts
the staff, by either audible or inaudible means, when movement is detected, and may
include bed, chair and floor sensor pads, cords that clip to the resident’s clothing, motion
sensors, door alarms, or elopement/wandering devices.

•

While often used as an intervention in a resident’s fall prevention strategy, the efficacy of
alarms to prevent falls has not been proven; therefore, alarm use must not be the primary
or sole intervention in the plan.

•

The use of an alarm as part of the resident’s plan of care does not eliminate the need for
adequate supervision, nor does the alarm replace individualized, person-centered care
planning.

•

Adverse consequences of alarm use include, but are not limited to, fear, anxiety, or
agitation related to the alarm sound; decreased mobility; sleep disturbances; and
infringement on freedom of movement, dignity, and privacy.

October 2024

•

Page P-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

P0200: Alarms (cont.)
Planning for Care
Individualized, person-centered care planning surrounding the resident’s use of an alarm
is important to the resident’s overall well-being.

•

When the use of an alarm is considered as an intervention in the resident’s safety
strategy, use must be based on the assessment of the resident and monitored for efficacy
on an ongoing basis, including the assessment of unintended consequences of the alarm
use and alternative interventions.

•

There are times when the use of an alarm may meet the definition of a restraint, as the
alarm may restrict the resident’s freedom of movement and may not be easily removed by
the resident.

•

When an alarm is used as an intervention in the resident’s safety strategy, the effect the
alarm has on the resident must be evaluated individually for that resident.

•

Steps for Assessment

1. Review the resident’s medical record (e.g., physician orders, nurses’ notes, nursing assistant
documentation) to determine if alarms were used during the 7-day look-back period.
2. Consult the nursing staff to determine the resident’s cognitive and physical status/limitations.
3. Evaluate whether the alarm affects the resident’s freedom of movement when the
alarm/device is in place. For example, does the resident avoid standing up or repositioning
themself due to fear of setting off the alarm?

Coding Instructions

Identify all alarms that were used at any time (day or night) during the 7-day look-back period.
After determining whether or not an item listed in P0200 was used during the 7-day look-back
period, code the frequency of use:
• Code 0, not used: if the device was not used during the 7-day look-back period.
•

Code 1, used less than daily: if the device was used less than daily.

•

Code 2, used daily: if the device was used on a daily basis during the look-back

period.

Coding Tips
•
•
•
•

Bed alarm includes devices such as a sensor pad placed on the bed or a device that clips
to the resident’s clothing.
Chair alarm includes devices such as a sensor pad placed on the chair or wheelchair or a
device that clips to the resident’s clothing.
Floor mat alarm includes devices such as a sensor pad placed on the floor beside the
bed.
Motion sensor alarm includes infrared beam motion detectors.

October 2024

Page P-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [P]

P0200: Alarms (cont.)
•

•
•
•

•

•
•
•

October 2024

•

Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the
resident’s clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the
resident that activate an alarm and/or alert the staff when the resident nears or exits a
specific area or the building. This includes devices that are attached to the resident’s
assistive device (e.g., walker, wheelchair, cane) or other belongings.
Other alarm includes devices such as alarms on the resident’s bathroom and/or bedroom
door, toilet seat alarms, or seatbelt alarms.
Code any type of alarm, audible or inaudible, used during the look-back period in this
section.
If an alarm meets the criteria as a restraint, code the alarm use in both P0100, Physical
Restraints, and P0200, Alarms.
Motion sensors and wrist sensors worn by the resident to track the resident’s sleep
patterns should not be coded in this section.
Wandering is random or repetitive locomotion. This movement may be goal-directed
(e.g., the resident appears to be searching for something such as an exit) or may be nongoal directed or aimless. Non-goal directed wandering requires a response in a manner
that addresses both safety issues and an evaluation to identify root causes to the degree
possible.
While wander, door, or building alarms can help monitor a resident’s activities, staff must
be vigilant in order to respond to them in a timely manner. Alarms do not replace
necessary supervision.
Bracelets or devices worn by or attached to the resident and/or their belongings that
signal a door to lock when the resident approaches should be coded in P0200E
Wander/elopement alarm, whether or not the device activates a sound or alerts the staff.
Do not code a universal building exit alarm applied to an exit door that is intended to
alert staff when anyone (including visitors or staff members) exits the door.
When determining whether the use of an alarm also meets the criteria of a restraint, refer
to the section “Determination of the Use of Position Change Alarms as Restraints” of
F604 in Appendix PP of the State Operations Manual available at
https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf.

Page P-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

SECTION Q: PARTICIPATION IN ASSESSMENT AND GOAL
SETTING
Intent: Interviewing the resident or designated individuals places the resident or their family at
the center of decision-making. The items in this section are intended to record the participation
and expectations of the resident, family members, or significant other(s) in the assessment, and to
understand the resident’s overall goals. Discharge planning follow-up is already a regulatory
requirement (CFR 483.21(c)(1)). Section Q of the MDS uses a person-centered approach to
ensure that all individuals have the opportunity to learn about home- and community-based
services and to receive long term care in the least restrictive setting possible. This may not be a
nursing home. This is also a civil right for all residents.

Q0110: Participation in Assessment and Goal Setting

Item Rationale

Health-related Quality of Life

Residents who actively participate in the assessment
process and in development of their care plan through
interview and conversation often experience improved
quality of life and higher quality care based on their
needs, goals, and priorities.

Planning for Care
•

RESIDENT’S
PARTICIPATION IN
ASSESSMENT
The resident actively
engages in interviews and
conversations to
meaningfully contribute to the
completion of the MDS 3.0.
Interdisciplinary team
members should engage the
resident during assessment
in order to determine the
resident’s expectations and
perspectives during
assessment.

•

DEFINITION

Each care plan should be individualized and residentdriven. Whenever possible, the resident should be
actively involved—except in unusual circumstances
such as if the individual is unable to understand the
proceedings or is comatose. Involving the resident in all
assessment interviews and care planning meetings is
also important to address dignity and self-determination
survey and certification requirements (CFR §483.24 Quality of Life).

October 2024

Page Q-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0110: Participation in Assessment and Goal Setting (cont.)
•
•

•

During the care planning meetings, the resident should
be made comfortable and verbal communication should
be directly with them.
Residents should be asked about inviting family
members, significant others, and/or guardian/legally
authorized representatives to participate, and if they
desire that they be involved in the assessment process.
If the individual resident is unable to understand the
process, their family member, significant other, and/or
guardian/legally authorized representative, who
represents the individual, should be invited to attend the
assessment process whenever possible.
When the resident is unable to participate in the
assessment process, a family member or significant
other, and/or guardian or legally authorized
representatives can provide information about the
resident’s needs, goals, and priorities on the resident’s
behalf.

•

DEFINITIONS
FAMILY OR
SIGNIFICANT OTHER
A spousal, kinship (e.g.,
sibling, child, parent,
nephew), or in-law
relationship; a partner,
housemate, primary
community caregiver or
close friend. Significant other
does not include staff at the
nursing home.

GUARDIAN/LEGALLY
AUTHORIZED
REPRESENTATIVE
A person who is authorized,
under applicable law, to
make decisions for the
resident, including giving
and withholding consent for
medical treatment.

Steps for Assessment

1. Review the clinical record for documentation that the
resident, family member and/or significant other, and guardian or legally authorized
representative participated in the assessment process.
2. Ask the resident, the family member or significant other (when applicable), and the guardian
or legally authorized representative (when applicable) if they actively participated in the
assessment process.
3. Ask staff members who completed the assessment whether or not the resident, family or
significant other, or guardian or legally authorized representative participated in the
assessment process.

Coding Instructions for Q0110, Participation in Assessment and Goal
Setting

Record the participation of all those who participated in the assessment process. Check all that
apply.
•

Code A, Resident: if the resident actively participated in the assessment process.

•

Code B, Family: if a member of the resident’s family actively participated in the

•

Code C, Significant other: if a significant other of the resident actively participated

•

Code D, Legal guardian: if a legal guardian actively participated in the assessment

assessment process.

in the assessment process.
process.

October 2024

Page Q-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0110: Participation in Assessment and Goal Setting (cont.)
•
•

Code E, Other legally authorized representative: if a legally authorized

representative actively participated in the assessment process.
Code Z, None of the above: if none of the above actively participated in the
assessment process.

Coding Tips
•

•

While family, significant others, or, if necessary, the guardian or legally authorized
representative can be involved, the response selected must reflect the resident’s
perspective if they are able to express it, even if the opinion of family member/significant
other or guardian/legally authorized representative differs.
Significant other does not include nursing home staff.

Q0310: Resident’s Overall Goal

Item Rationale

This item identifies the resident’s general expectations and goals for nursing home stay. The
resident should be asked about their own expectations regarding return to the community and
goals for care. The resident may not be aware of the option of returning to the community and
that services and supports may be available in the community to meet their individual long-term
care needs. Additional assessment information may be needed to determine whether the resident
requires additional community services and supports.
Some residents have very clear and directed expectations that will change little prior to
discharge. Other residents may be unsure or may be experiencing an evolution in their thinking
as their clinical condition changes or stabilizes.

October 2024

Page Q-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0310: Resident’s Overall Goal (cont.)
Health-related Quality of Life
•

Unless the residents’ goals for care are understood, their
needs, goals, and priorities are not likely to be met.

Planning for Care

DEFINITION
DISCHARGE
To release from nursing
home care. Can be to home,
another community setting,
or a healthcare setting.

The resident’s goals should be the basis for care
planning.

•

Great progress has been made in this area. This progress allows individuals more choices
when it comes to care options and available support options to meet care preferences and
needs in the least restrictive setting possible. This progress resulted from the 1999 U.S.
Supreme Court decision in Olmstead v. L.C., which states that residents needing long
term services and supports have a civil right to receive services in the least restrictive and
most integrated setting appropriate to their needs.

•

Steps for Assessment

1. Ask the resident about their overall expectations and goals to be sure that they have
participated in the assessment process and have an understanding of their current situation
and the implications of choices such as returning home or moving to another appropriate
community setting such as an assisted living facility or an alternative healthcare setting.
2. Ask the resident to consider their current health status, expectations regarding improvement
or worsening, social supports and opportunities to obtain services and supports in the
community.
3. If goals have not already been stated directly by the resident and documented since
admission, ask the resident directly about what their expectation is regarding the outcome of
this nursing home admission and expectations about returning to the community.
4. The resident’s stated goals should be recorded here. The goals for the resident, as described
by the family, significant other, guardian, or legally authorized representative, may also be
recorded in the clinical record.
5. Because of a temporary (e.g., delirium) or permanent (e.g., profound dementia) condition,
some residents may be unable to provide a clear response. If the resident is unable to
communicate their preference either verbally or nonverbally, the information can be obtained
from the family or significant other, as designated by the individual. If family or the
significant other is not available, the information should be obtained from the guardian or
legally authorized representative.
6. Encourage the involvement of family or significant others in the discussion, if the resident
consents. While family, significant others, or the guardian or legally authorized
representative can be involved if the resident is uncertain about their goals, the response
selected must reflect the resident’s perspective if they are able to express it.
7. In some guardianship situations, the decision-making authority regarding the individual’s
care is vested in the guardian. But this should not create a presumption that the individual
resident is not able to comprehend and communicate their wishes.

October 2024

Page Q-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0310: Resident’s Overall Goal (cont.)
Coding Instructions for Q0310A, Resident’s overall goal for discharge
established during the assessment process
Record the resident’s expectations as expressed by them. It is important to document their
expectations.
•
•
•

Code 1, Discharge to the community: if the resident indicates an expectation to

return home, to assisted living, or to another community setting.
Code 2, Remain in this facility: if the resident indicates that they expect to remain
in the nursing home.
Code 3, Discharge to another facility/institution: if the resident expects to be
discharged to another nursing home, rehabilitation facility, or another institution.
Code 9, Unknown or uncertain: if the resident is uncertain or if the resident is not
able to participate in the discussion or indicate a goal, and family, significant other, or
guardian or legally authorized representative do not exist or are not available to
participate in the discussion.

•

DEFINITION

Coding Tips

The response to this item should be individualized and
DESIGNATED LOCAL
resident-driven rather than what the nursing home staff
CONTACT AGENCY
judge to be in the best interest of the resident. This item
(LCA)
focuses on exploring the resident’s expectations, not
Each state has community
whether or not the staff considers them to be realistic.
contact agencies that can
Coding other than the resident’s stated expectation is a
provide individuals with
violation of the resident’s civil rights.
information about community
living options and available
Q0310A, Code 1 “Discharge to the community” may
community-based supports
include newly admitted residents with a facilityand services. These local
arranged discharge plan or those residents with
contact agencies may be a
adequate supports already in place that would not
single entry point agency, an
require referral to a local contact agency (LCA). It may
Aging and Disability
also include residents who ask to talk to someone about Resource Center (ADRC), an
the possibility of leaving this facility and returning to
Area Agency on Aging (AAA),
live and receive services in the community (Q0500B,
a Center for Independent
Code 1, Yes).
Living (CIL), or other state
designated entities.
Avoid trying to guess what the resident might identify
as a goal or to judge the resident’s goal. Do not infer a
response based on a specific advance directive, e.g., “do not resuscitate” (DNR).
The resident should be provided options, as well as access to information that allows
them to make the decision and to be supported in directing their care planning.

•
•

October 2024

Page Q-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0310: Resident’s Overall Goal (cont.)
•

If the resident is unable to communicate their preference either verbally or nonverbally,
or has been legally determined incompetent, the information can be obtained from the
family or significant other, as designated by the individual. Families, significant others or
legal guardians should be consulted as part of the assessment.

Coding Instructions for Q0310B, Indicate information source for
Q0310A
•

Code 1, Resident: if the resident is the source for completing this item.

•

Code 2, Family: if a family member is the source for completing this item because the
Code 3, Significant other: if a significant other of the resident is the source for

•

resident is unable to respond.

•
•

Examples

•

completing this item because the resident is unable to respond.
Code 4, Legal guardian: if a legal guardian of the resident is the source for
completing this item because the resident is unable to respond.
Code 5, Other legally authorized representative: if a legally authorized
representative of the resident is the source for completing this item because the resident is
unable to respond.
Code 9, None of the above: if the resident cannot respond and the family or
significant other, or guardian or legally authorized representative does not exist or cannot
be contacted or is unable to respond (Q0310A = 9).

1. Resident F is a 55-year-old married individual who had a cerebrovascular accident (CVA,
also known as stroke) 2 weeks ago. They were admitted to the nursing home 1 week ago for
rehabilitation, specifically for transfer, gait, and wheelchair mobility training. Resident F is
extremely motivated to return home. Their spouse is supportive and has been busy adapting
their home to promote their independence. Resident F’s goal is to return home once they have
completed rehabilitation.
Coding: Q0310A would be coded 1, Discharge to the community.
Q0310B would be coded 1, Resident.
Rationale: Resident F has clear expectations and a goal to return home.

2. Resident W is a 73-year-old individual who has severe heart failure and renal dysfunction.
They also have a new diagnosis of metastatic colorectal cancer and were readmitted to the
nursing home after a prolonged hospitalization for lower gastrointestinal (GI) bleeding. They
rely on nursing staff for all activities of daily living (ADLs). They indicate that they are
“strongly optimistic” about their future and only want to think “positive thoughts” about what
is going to happen and need to believe that they will return home.
Coding: Q0310A would be coded 1, Discharge to the community.
Q0310B would be coded 1, Resident.

October 2024

Page Q-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0310: Resident’s Overall Goal (cont.)
Rationale: Resident W has a clear goal to return home. Even if the staff believe this is

unlikely based on available social supports and past nursing home residence, this item
should be coded based on the resident’s expressed goals.

3. Resident T is a 93-year-old individual with chronic renal failure, oxygen dependent chronic
obstructive pulmonary disease (COPD), severe osteoporosis, and moderate dementia. When
queried about their care preferences, they are unable to voice consistent preferences for their
own care, simply stating that “It’s such a nice day.” When their adult child is asked about
goals for their parent’s care, they state that “We know her time is coming. The most
important thing now is for her to be comfortable. Because of monetary constraints, the level
of care that she needs, and other work and family responsibilities we cannot adequately meet
her needs at home. Other than treating simple things, what we really want most is for her to
live out whatever time she has in comfort and for us to spend as much time as we can with
her.” The assessor confirms that the adult child wants care oriented toward making their
parent comfortable in their final days, in the nursing home, and that the family does not have
the capacity to provide all the care the resident needs.
Coding: Q0310A would be coded 2, Remain in this facility.
Q0310B would be coded 2, Family.
Rationale: Resident T does not respond appropriately to the question of their care
preferences, but their adult child has clear expectations that their parent will remain in
the nursing home where they will be made comfortable for their remaining days.

4. Resident G, an 84-year-old individual with severe dementia, is admitted by their adult child
for a 7-day period. Their adult child stated that they “just need to have a break.” Their parent
has been wandering at times and has little interactive capacity. The adult child is planning to
take their parent back home at the end of the week.
Coding: Q0310A would be coded 1, Discharge to the community.
Q0310B would be coded 2, Family.
Rationale: Resident G is not able to respond but their adult child has clear
expectations that their parent will return home at the end of the 7-day respite visit.

5. Resident C is a 72-year-old individual who had been living alone and was admitted to the
nursing home for rehabilitation after a severe fall. Upon admission, they were diagnosed with
moderate dementia and were unable to voice consistent preferences for their own care. They
have no living relatives and no significant other who is willing to participate in their care
decisions. The court appointed a legal guardian to oversee their care. Community-based
services, including assisted living and other residential care situations, were discussed with
the guardian. The guardian decided that it is in Resident C’s best interest that they be
discharged to a nursing home that has a specialized dementia care unit once rehabilitation
was complete.
Coding: Q0310A would be coded 3, Discharge to another
facility/institution.
Q0310B would be coded 4, Legal guardian.

October 2024

Page Q-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0310: Resident’s Overall Goal (cont.)
Rationale: Resident C is not able to respond and has no family or significant other

available to participate in their care decisions. A court-appointed legal guardian
determined that it is in Resident C’s best interest to be discharged to a nursing home
that could provide dementia care once rehabilitation was complete.

6. Resident K is a 40-year-old with cerebral palsy and a learning disability. They lived in a
group home 5 years ago, but after a hospitalization for pneumonia they were admitted to the
nursing home for respiratory therapy. Although their group home bed is no longer available,
they are now medically stable and there is no medical reason why they could not transition
back to the community. Resident K states they want to return to the group home. Their legal
guardian agrees that they should return to the community to a small group home.
Coding: Q0310A would be coded 1, Discharge to the community
Q0310B would be coded 1, Resident
Rationale: Resident K understands and is able to respond and says they would like to
go back to the group home. Their expression of choice should be recorded. When the
legal guardian, with legal decision-making authority under state law, was told that
Resident K is medically stable and would like to go back to the community, the legal
guardian confirmed that it is in Resident K’s best interest to be transferred to a group
home. Small group homes are considered community settings. This information should
also be recorded in the individual’s clinical record.

Q0400: Discharge Plan

Item Rationale

Health-related Quality of Life
•
•

•

Returning home or to a non-institutional setting can be very important to a resident’s
health and quality of life.
For residents who have been in the facility for a long time, it is important to discuss with
them their interest in talking with LCA experts about returning to the community.
Community resources and supports exist that may benefit these residents and allow them
to return to a community setting.
Being discharged from the nursing home without adequate discharge planning occurring
(planning and implementation of a plan before discharge) could result in the resident’s
decline and increase the chances for re-hospitalization and aftercare, so a thorough
examination of the options with the resident and local community experts is imperative.

October 2024

Page Q-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0400: Discharge Plan (cont.)
Planning for Care
•
•

•

Many nursing home residents may be able to return to the community if they are provided
appropriate assistance and referral to community resources.
The care plan should include the name and contact information of a primary care provider
chosen by the resident, family, significant other, guardian or legally authorized
representative, arrangements for durable medical equipment (if needed), formal and
informal supports that will be available, the person(s) and provider(s) in the community
who will meet the resident’s needs, and the place the resident is going to be living.
Each situation is unique to the resident, their family, and/or guardian/legally authorized
representative. A referral to the LCA may be appropriate for many individuals, who
could be maintained in the community homes of their choice for long periods of time,
depending on the residential setting and support services available. For example, a
referral to the LCA may be appropriate for some individuals with Alzheimer’s disease.
There are many individuals with this condition being maintained in their own homes for
long periods of time, depending on the residential setting and support services available.
The interdisciplinary team should not assume that any particular resident is unable to be
discharged. A successful transition will depend on the services, settings, and sometimes
family support services that are available.
Discharge instructions should include at a minimum:
— the individuals preferences and needs for care and supports;
○ personal identification and contact information, including Advance Directives;
○ contact information of primary care physician, pharmacy, and community care
agency including personal care services (if applicable) etc.;
○ brief medical history;
○ current medications, treatments, therapies, and allergies;
○ arrangements for durable medical equipment;
○ arrangements for housing;
○ arrangements for transportation to follow-up appointments; and
○ contact information at the nursing home if a problem arises during discharge
— A follow-up appointment with the designated primary care provider in the community
and other specialists (as appropriate).
— Medication education.
— Prevention and disease management education, focusing especially on warning
symptoms for when to call the doctor.
— Who to call in case of an emergency or if symptoms of decline occur.
— Nursing home (NH) procedures and discharge planning for sub-acute and
rehabilitation community discharges are most often well-defined and efficient.

October 2024

Page Q-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0400: Discharge Plan (cont.)

— Section Q has broadened the scope of the traditional boundary of discharge planning
for sub-acute residents to encompass long stay residents. In addition to home health
and other medical services, discharge planning may include expanded resources such
as assistance with locating housing, transportation, employment if desired, and social
engagement opportunities.
○ Asking the resident and family about whether they want to talk to someone about
a return to the community gives the resident voice and respects their wishes. This
step in no way guarantees discharge but provides an opportunity for the resident
to interact with LCA experts.
○ The NH is responsible for making referrals to the LCAs under the process that the
State has set up. The LCA is responsible for contacting referred residents and
assisting with providing information regarding community-based services and,
when appropriate, transition services planning. The nursing facility
interdisciplinary team and the LCA should work closely together. The LCA is the
entity that does the community support planning, (e.g., housing, home
modification, setting up a household, transportation, community inclusion
planning, etc.). A referral to the LCA may come from the nursing facility by
phone, by e-mails or by a state’s on-line/website or by other state-approved
processes. Each state has a process for referral to an LCA, and it is vital to know
the process in your state and for your facility. In most cases, further screening and
consultation with the resident, their family and the interdisciplinary team by the
nursing home social worker or staff member would likely be an important step in
the referral determination process.
○ Each NH needs to develop relationships with their LCAs to work with them to
contact the resident and their family, guardian or significant others concerning a
potential return to the community. A thorough review of medical, psychological,
functional, and financial information is necessary in order to assess what each
individual resident needs and whether or not there are sufficient community
resources and finances to support a transition to the community.
○ Enriched transition resources including housing, in-home caretaking services and
meals, home modifications, etc. are more readily available than in the recent past.
Resource availability and eligibility coverage varies across States and local
communities.
○ Should a planned relocation not occur, it might create stress and disappointment
for the resident and family that will require support and nursing home care
planning interventions. However, a referral should not be avoided based upon
facility staff judgment of potential discharge success or failure. It is the resident’s
right to be provided information if requested and to receive care in the most
integrated setting.

October 2024

Page Q-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0400: Discharge Plan (cont.)
•
•
•

Involve community mental health resources (as appropriate) to ensure that the resident
has support and active coping skills that will help them to readjust to community living.
Use teach-back methods to ensure that the resident understands all of the factors
associated with their discharge.
For additional guidance, see CMS’ Your Discharge Planning Checklist: For patients
and their caregivers preparing to leave a hospital, nursing home, or other care
setting. Available at https://www.medicare.gov/pubs/pdf/11376-discharge-planningchecklist.pdf.

Steps for Assessment
DEFINITION
ACTIVE DISCHARGE
PLANNING
An active discharge plan
means a plan that is being
currently implemented. In
other words, the resident’s
care plan has current goals
to make specific
arrangements for discharge,
staff are taking active steps
to accomplish discharge, and
there is a target discharge
date for the near future.

1. A review should be conducted of the care plan, the clinical
record, and clinician progress notes, including but not
limited to nursing, physician, social services, and therapy to
consider the resident’s discharge planning needs.
2. If the resident is unable to communicate their preference
either verbally or nonverbally, or has been legally
determined incompetent, the information can be obtained
from the family or significant other or guardian, as
designated by the individual.
3. Record the resident’s expectations as
expressed/communicated, whether NH staff believe that
they are realistic or not realistic.
4. The resident, their interdisciplinary team, and LCA (when a
referral has been made) should determine the services and
assistance that the resident will need post discharge (e.g.,
homemaker, meal preparation, ADL assistance,
transportation, prescription assistance).
5. Eligibility for financial assistance through various funding
sources (e.g., private funds, family assistance, Medicaid,
long-term care insurance) should be considered prior to
discharge to identify the options available to the individual
(e.g., home, assisted living, board and care, or group
homes).
6. A determination of family involvement, capability and
support after discharge should also be made. However,
support from the family is not always necessary for a
discharge to take place.

If there is not an active
discharge plan, residents
should be asked if they want
to talk to someone about
community living (Q0500B)
and then referred to the LCA
accordingly. Furthermore,
referrals to the LCA are
recommended as part of
many residents’ discharge
plans. Such referrals are a
helpful source of information
for residents and facilities in
informing the discharge
planning process.

October 2024

Page Q-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0400: Discharge Plan (cont.)
Coding Instructions for Q0400A, Is active discharge planning already
occurring for the resident to return to the community?
•

Code 0, No: if there is not active discharge planning already occurring for the resident

•

Code 1, Yes: if there is active discharge planning already occurring for the resident to

to return to the community.

return to the community.

Q0490: Resident’s Documented Preference to Avoid Being Asked
Question Q0500B

For Quarterly, Correction to Quarterly, and Non-OBRA Assessments. (A0310A=02, 06, or 99)

Item Rationale

This item directs a check of the resident’s clinical record to determine if the resident and/or
family, etc. have indicated on a previous OBRA comprehensive assessment (A0310A = 01, 03,
04 or 05) that they do not want to be asked question Q0500B until their next comprehensive
assessment. Some residents and their families do not want to be asked about their preference for
returning to the community and would rather not be asked about it. Item Q0490 allows them to
opt-out of being asked question Q0500B on Quarterly (non-comprehensive) assessments. If there
is a notation in the clinical record that the resident does not want to be asked again, and this is a
Quarterly assessment, then skip to item Q0610, Referral. Q0500B is, however, mandatory on all
comprehensive assessments.
Note: Let the resident know that they can change their mind about requesting information
regarding possible return to the community at any time and should be referred to the LCA if they
voice this request, regardless of schedule of MDS assessment(s).
If this is a comprehensive assessment, do not skip to item Q0610, continue to item Q0500B.

October 2024

Page Q-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0490: Resident’s Documented Preference to Avoid Being Asked
Question Q0500B (cont.)
Coding Instructions for Q0490, Does the resident’s clinical record
document a request that this question (Q0500B) be asked only
on comprehensive assessments?
•

Code 0, No: if there is no notation in the resident’s clinical record that they do not want

•

Code 1, Yes: if there is a notation in the resident’s clinical record to not ask Question

to be asked Question Q0500B.

Q0500B except on comprehensive assessments.

Unless this is a comprehensive assessment (A0310A=01, 03, 04, 05), skip to item Q0610,
Referral. If this is a comprehensive assessment, proceed to the next item, Q0500B.

Coding Tips
•

Carefully review the resident’s clinical record, including prior MDS 3.0 assessments, to
determine if the resident or other respondent has previously responded “No” to item
Q0550A.

If this is a comprehensive assessment, proceed to item Q0500B, regardless of the previous
responses to item Q0550A.

October 2024

Page Q-13

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0490: Resident’s Documented Preference to Avoid Being Asked
Question Q0500B (cont.)
Examples
1. Resident G is a 45-year-old individual weighing 300 pounds who is cognitively intact. They
have congestive heart failure and shortness of breath requiring oxygen at all times. Resident
G also requires 2 person assistance with bathing and transfers to the commode. They were
admitted to the NH 3 years ago after their adult child who was caring for them passed away.
During their Quarterly assessment, the NH social worker discussed options in which they
could be cared for in the community but Resident G refused to consider leaving the NH.
During the review of their clinical record, the assessor found that on their last MDS
assessment, Resident G stated that they did not want to be asked again about returning to
community living, that they have friends in the NH and really like the activities.

Coding: Q0490 would be coded 1, Yes, skip to Q0610; because this is a
Quarterly assessment.

If this was a comprehensive assessment, then proceed to the next item Q0500B.
Rationale: On their last MDS 3.0 assessment, Resident G indicated their preference to

not want to be asked again about returning to community living (0. No on Q0550A).

2. Resident R is an 82-year-old widowed individual with advanced Alzheimer’s disease. They
have resided at the nursing home for 4½ years and their family requests that they not be
interviewed because they become agitated and upset and cannot be cared for by family
members or in the community.
Coding: Q0490 would be coded 1, Yes, skip to Q0610.

If this is a comprehensive assessment proceed to the next item, Q0500B.
Rationale: Resident R’s family requests that they opt out of the return to the

community question because they become agitated when asked about return to
community. They are only asked with comprehensive assessments.

October 2024

Page Q-14

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0500: Return to Community
For Admission, Quarterly, and Annual Assessments.

D
Item Rationale

The goal of follow-up action is to initiate and maintain collaboration between the NH and the
LCA to support the resident’s expressed interest in talking to someone about the possibility of
leaving the facility and returning to live and receive services in the community. The underlying
intention of the return to the community item is to ensure that all individuals have the
opportunity to learn about home and community based services and have an opportunity to
receive long term services and supports in the least restrictive setting appropriate for their needs.
CMS has found that in many cases individuals requiring long term services, and/or their families,
are unaware of community based services and supports that could adequately support individuals
in community living situations. LCAs are experts in available home and community-based
service (HCBS) and can provide both the resident and the facility with valuable information.

Health-related Quality of Life

Returning home or to a non-institutional setting can be beneficial to the residents’ health
and quality of life.

•

This item identifies the resident’s desire to speak with someone about returning to
community living. Based on the Americans with Disabilities Act and the 1999 U.S.
Supreme Court decision in Olmstead v. L.C., residents needing long-term care services
have a civil right to receive services in the least restrictive and most integrated setting.

•

Item Q0500B requires that the resident be asked the question directly and formalizes the
opportunity for the resident to be informed of and consider their options to return to
community living. This ensures that the resident’s desire to learn about the possibility of
returning to the community will be honored and appropriate follow-up measures will be
taken.

•

The goal is to obtain the informed choice and preferences expressed by the resident and
to provide information about available community supports and services.

•

October 2024

Page Q-15

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0500: Return to Community (cont.)
Planning for Care
•

Many NH residents may be able to return to the community if they are provided
appropriate assistance to facilitate care in a non-institutional setting.

Steps for Assessment: Interview Instructions

1. At the initial Admission assessment and in subsequent follow-up assessments (as applicable),
make the resident comfortable by assuring them that this is a routine question that is asked of
all residents.
2. Ask the resident if they would like to speak with someone about the possibility of returning
to live and receive services in the community. Inform the resident that answering yes to this
item signals the resident’s request for more information and will initiate a contact by
someone with more information about supports available for living in the community. A
successful transition will depend on the resident’s preferences and choices and the services,
settings, and sometimes family supports that are available. In many cases individuals
requiring long term care services, and/or their families, are unaware of community based
services and supports that could adequately support individuals in community living
situations. Answering yes does not commit the resident to leaving the NH at a specific time;
nor does it ensure that the resident will be able to move back to the community. Answering
no is also not a permanent commitment. Also inform the resident that they can change their
decision (i.e., whether or not they want to speak with someone) at any time.
3. Explain that this item is meant to provide the opportunity for the resident to get information
and explore the possibility of different settings for receiving ongoing care. This step will help
the resident clarify their discharge goals and identify important information for the LCA or,
in some instances may indicate that the resident does not want to be referred to the LCA at
this time. Also explain that the resident can change their mind at any time.
4. If the resident is unable to communicate their preference either verbally or nonverbally, the
information can then be obtained from family or a significant other, as designated by the
individual. If family or significant others are not available, a guardian or legally authorized
representative, if one exists, can provide the information.
5. Ask the resident if they want information about different kinds of supports that may be
available to support community living. Responding “yes” will be a way for the individual—
and their family, significant other, or guardian or legally authorized representative—to obtain
additional information about services and supports that would be available to support
community living. It is simply a request for information, not a request for discharge.

October 2024

Page Q-16

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0500: Return to Community (cont.)
Coding Instructions for Q0500B, Ask the resident (or family or significant other
or guardian or legally authorized representative only if resident is unable to understand
or respond): “Do you want to talk to someone about the possibility of

leaving this facility and returning to live and receive services in the
community?”

A response code of 1, Yes, for this item indicates a desire to learn about home and community
based services, it is not a request for discharge.
•

Code 0, No: if the resident (or family or significant other, or guardian or legally

•

authorized representative) states that they do not want to talk to someone about the
possibility of returning to live and receive services in the community.
Code 1, Yes: if the resident (or family or significant other, or guardian or legally
authorized representative) states that they do want to talk to someone about the
possibility of returning to live and receive services in the community.
Code 9, Unknown or uncertain: if the resident cannot understand or respond and
the family or significant other is not available to respond on the resident’s behalf and a
guardian or legally authorized representative is not available or has not been appointed by
the court.

Coding Instructions for Q0500C, Indicate information source for
Q0500B
•

Code 1, Resident: if the resident is the source for completing this item.

•

Code 2, Family: if a family member is the source for completing this item because the

•

•
•

Code 3, Significant other: if a significant other of the resident is the source for
completing this item because the resident is unable to respond.
Code 4, Legal guardian: if a legal guardian of the resident is the source for
completing this item because the resident is unable to respond.
Code 5, Other legally authorized representative: if a legally authorized
representative of the resident is the source for completing this item because the resident is
unable to respond.
Code 9, None of the above: if the resident cannot respond and the family,
significant other, guardian, or legally authorized representative does not exist or cannot
be contacted or is unable to respond (Q0310A = 9).

October 2024

•

resident is unable to respond.

Page Q-17

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0500: Return to Community (cont.)
Coding Tips
•
•

•

•
•

•

A “yes” response to item Q0500B will trigger follow-up care planning and contact with
the facility’s designated LCA.
Follow-up by the LCA is expected in a “reasonable” amount of time. Each state has its
own policy for follow-up. It is important to know your state’s policy. The level and type
of response needed by an individual is determined on a resident-by-resident basis. Some
States may determine that the LCAs can make an initial telephone contact to identify the
resident’s needs and/or set up the face-to-face visit/appointment. However, it is expected
that most residents will have a face-to-face visit. In some States, an initial meeting is set
up with the resident, facility staff, and LCA together to talk with the resident about their
needs and community care options.
Some residents will have a very clear expectation and some may change their
expectations over time. Residents may also be unsure or unaware of the opportunities
available to them for community living with needed services and supports.
The SNF/NH should not assume that the resident cannot transition out of the SNF/NH
due to their level of care needs. The SNF/NH and the resident should talk with the LCA
to see what options are available for living and receiving services in the community.
Return to community questions may upset residents who cannot understand what the
question means and result in them being agitated or saddened by being asked the
question. If the resident’s documented level of cognitive impairment is such that the
resident does not understand Q0500, a family member, significant other, guardian and/or
legally appointed decision-maker for that individual should be asked the question.
When Q0500B is answered 1 or 9, a care area trigger requires a return to community care
area assessment (CAA) and CAA 20 provides a step-by-step process for the facility to
use in order to provide the resident an opportunity to discuss returning to the community.

October 2024

Page Q-18

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0500: Return to Community (cont.)
Examples

1. Resident B is an 82-year-old individual with COPD. They were referred to the NH by their
physician for end-of-life palliative care. They responded, “I’m afraid I can’t” to item
Q0500B. The assessor should ask follow-up questions to understand why Resident B is afraid
and explain that obtaining more information may help overcome some of their fears. They
should also be informed that someone from an LCA is available to provide them with more
information about receiving services and supports in the community. At the close of this
discussion, Resident B says that they would like more information on community supports.
Coding: Q0500B would be coded 1, Yes.
Rationale: Coding Q0500B as yes should trigger a visit by the NH social worker to
assess fears and concerns, as well as the designated LCA within a specified time frame
established according to state policy.

2. Resident C is a 45-year-old individual with cerebral palsy and a learning disability who has
been living in the facility for the past 20 years. They once lived in a group home but became
ill and required hospitalization for pneumonia. After recovering in the hospital, Resident C
was sent to the NH because they required regular chest physical therapy and were told that
they could no longer live in their previous group home because their needs were more
intensive. No one had asked them about returning to the community until now. When
administered the MDS assessment, they responded yes to item Q0500B.
Coding: Q0500B would be coded 1, Yes.
Rationale: Resident C’s discussions with staff in the NH should be noted in their care
plan, and care planning should be initiated to assess their preferences and needs for
possible transition to the community. NH staff should contact the designated LCA
according to established state guidelines, for them to initiate discussions with Resident C
about options for returning to community living.
3. Resident D is a 65-year-old individual with a severe heart condition and interstitial
pulmonary fibrosis. At the last Quarterly assessment, Resident D had been asked about
returning to the community and their response was no. They also responded no to item
Q0500B. The assessor should ask why they responded no. Depending upon this response,
follow-up questions could include, “Is it that you think you cannot get the care you need in
the community? Do you have a home to return to? Do you have any family or friends to
assist you in any way?” Resident D responds no to the follow-up questions and does not want
to offer any more information or talk about it any further.
Coding: Q0500B would be coded 0, No.
Rationale: During this assessment, they were asked about returning to the community
and they responded no.

October 2024

Page Q-19

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0550: Resident’s Preference to Avoid Being Asked Question
Q0500B

Item Rationale

Some individuals, such as those with cognitive impairments, mental illness, or end-stage
conditions, may be upset by asking them if they want to return to the community. CMS pilot
tested Q0500 language and determined that respondents would be less likely to be upset by being
asked if they want to talk to someone about returning to the community if they were given the
opportunity to opt-out of being asked the question every quarter. The intent of the item is to
achieve a better balance between giving residents a voice and a choice about the services they
receive, while being sensitive to those individuals who may be unable to voice their preferences
or be upset by being asked question Q0500B in the assessment process.

Coding Instructions for Q0550A, Does the resident (or family or
significant other or guardian or legally authorized representative
only if resident is unable to understand or respond) want to be
asked about returning to the community on all assessments?
(Rather than on comprehensive assessments alone)
Code 0, No: if the resident (or family or significant other, or guardian or legally
authorized representative) states that they do not want to be asked again on Quarterly
assessments about returning to the community. In this case, document in resident’s
clinical record and ask question Q0500B again only on the next comprehensive
assessment.

•

Code 1, Yes: if the resident (or family or significant other, or guardian or legally

•

Code 8, Information not available: if the resident cannot respond and the family

•

authorized representative) states that they do want to be asked the return to community
question, Q0500B, on all assessments.

or significant other is not available to respond on the resident’s behalf and a guardian or
legally authorized representative is not available or has not been appointed by the court.

October 2024

Page Q-20

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0550: Resident’s Preference to Avoid Being Asked Question
Q0500B (cont.)
Coding Instructions for Q0550C, Indicate information source for
Q0550A
Code 1, Resident: if resident responded to Q0550A.

•

Code 2, Family.

•

Code 3, Significant other.

•

Code 4, Legal guardian.

•

Code 5, Other legally authorized representative.

•

Code 9, None of the above.

•

Example

1. Resident W is an 81-year-old individual who was admitted after a fall that broke their hip,
wrist and collar bone. Their recovery is slow and their family visits regularly. Their
apartment is awaiting them and they hope within the next 4–6 months to be discharged home.
When asked, resident W stated that they would like to be asked about discharging to the
community on all assessments.
Coding: Q0550A would be coded 1, Yes.
Q0550C would be coded 1, Resident.
Rationale: Resident W responded yes to item Q0550A, indicating they want to be

asked about returning to the community on all assessments.

ft
October 2024

Page Q-21

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0610: Referral

Item Rationale
Health-related Quality of Life
•

Returning home or transitioning to a non-institutional setting can be very important to the
resident’s health and quality of life.

Planning for Care
•

Some NH residents may be able to return to the community if they are provided
assistance and referral to appropriate community resources to facilitate care in a noninstitutional setting.

Coding Instructions for Q0610, Has a referral been made to the Local
Contact Agency (LCA)?
Code 0, No: if a referral has not been made.

•

Code 1, Yes: if a referral has been made. If a referral has been made skip to V0100.

•

Items From the Most Recent Prior OBRA or Scheduled PPS Assessment.

ft
October 2024

Page Q-22

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0610: Referral (cont.)
Coding Tips
State Medicaid Agencies (SMAs) are required to have designated LCA and a State point
of contact (POC). The SMA is responsible for coordinating implementation of Section Q
and designating LCAs for their State’s SNFs and NHs. These LCAs may be single entry
point agencies, Aging and Disability Resource Centers, Money Follows the Person
programs, Area Agencies on Aging, Centers for Independent Living, or other entities the
State may designate. LCAs have a Data Use Agreement (DUA) with the SMA to allow
them access to MDS data. It is important that each facility know who their LCA and POC
are and how to contact them.

•

Resource availability and eligibility varies across States and local communities and may
present barriers to allowing some residents to return to their community. The NH and
LCA staff members should guard against raising the expectations of residents and their
family members of what can occur until more information is obtained.

•

Close collaboration between the NH and the LCA is needed to evaluate the resident’s
medical needs, finances and available community transition resources.

•

The LCA can provide information to the SNF/NH on the available community living
situations, and options for community based supports and services including the level and
scope of what is possible.

•

The LCA team will explore community care options/supports and conduct appropriate
care planning to determine if transition back to the community is possible.

•

Resident support and interventions by the NH staff may be necessary if the LCA
transition is not successful because of unanticipated changes to the resident’s medical
condition, problems with securing appropriate caregiving supports, community resource
gaps, etc., preventing discharge to the community.

•

October 2024

Page Q-23

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0610: Referral (cont.)
Examples
1. Resident S is a 48-year-old individual who suffered a stroke, resulting in paralysis below the
waist. They are responsible for their 8-year-old child, who now stays with their grandparent.
At the last Quarterly assessment, Resident S had been asked about returning to the
community and their response was “Yes” to item Q0500B and they report no contact from
the LCA. Resident S is more hopeful they can return home as they become stronger in
rehabilitation. They want a location to be able to remain active in their child’s school and use
accessible public transportation when they find employment. They are worried whether they
can afford or find accessible housing with wheelchair accessible sinks, cabinets, countertops,
appliances, doorways, etc. The social worker documented the resident’s responses and made
a referral to the LCA.

Coding: Q0500B would be coded 1, Yes;
Q0610A would be coded 1, Yes.
Rationale: The social worker or discharge planner would make a referral to the

designated LCA for their area and Q0610A would be coded as 1, Yes, because a referral
to the designated LCA was made.

2. Resident V is an 82-year-old individual with right sided paralysis, mild dementia, and
diabetes who was admitted by the family because of safety concerns due to falls and
difficulties cooking and proper nutrition. Resident V said no to Q0500B, but that they may
wish this information at a later date, expressing their feeling that they are not yet ready to
plan for community transition. They need to continue their rehabilitation therapy and regain
their strength and ability to transfer. The social worker plans to talk to the resident and their
family during future Quarterly assessments to determine whether a referral to the LCA is
needed for Resident V to return to the community.

Coding: Q0610A would be coded 0, No.
Rationale: Resident V indicated that they wanted to have an opportunity to talk to

someone about return to community, but that they were not yet ready. The NH staff will
focus on their therapies and talk to them and their family to obtain more information for
discharge planning in future months. Q0610A would be coded as 0, No. The Care Area
Assessment #20 is triggered and it will be used to guide the follow-up process. Because a
referral was not made at this time, care planning and progress notes should indicate the
status of discharge planning and why a referral was not initiated to the designated LCA.

October 2024

Page Q-24

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0620: Reason Referral to Local Contact Agency (LCA) Not
Made
Complete only if Q0610 = 0.

Item Rationale

Health-related Quality of Life

•

Understanding the reason that referrals to the LCA were not made can help the care team
support the resident to receive care that supports them to achieve their highest practicable
level of functioning in the least restrictive setting.

Planning for Care

•

Understanding the reason that referrals to the LCA were not made allows for
comprehensive care planning by the facility team in conjunction with the resident and
their family.

Steps for Assessment

1. If Q0610: Referral = 0, No, indicate the primary reason that the referral has not been made to
the LCA.

Coding Instructions for Q0620, Reason Referral to Local Contact
Agency (LCA) Not Made
Code 1, LCA unknown

•

Code 2, Referral previously made: if a referral has previously been made to the

•

LCA, which is currently working with the resident and facility staff on an active
discharge plan to return to the community.

•

Code 3, Referral not wanted: if the resident (or family, significant other, legal

•

Code 4, Discharge date 3 or fewer months away: if the resident has an

•

Code 5, Discharge date more than 3 months away: if the resident has an

guardian, or other legally authorized representative only if resident doesn’t understand or
is unable to respond) responded they do not want a referral (Q0500B = 0).
expected discharge date of three (3) months or fewer, has an active discharge plan in
progress, and the discharge plan could not be improved upon with a referral to the LCA.
expected discharge date of more than three (3) months and discharge plan is actively in
progress.

October 2024

Page Q-25

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Q]

Q0620: Reason Referral to Local Contact Agency (LCA) Not
Made (cont.)
Examples
1. Resident S has been in the nursing home for several months following an automobile
accident. They plan to return home after their therapy regime ends, which is expected in three
to four weeks. In conjunction with Resident S’s Admission assessment, the facility team
made a referral to the LCA but the agency is not currently working with the resident. The
interdisciplinary team and the resident have developed a safe discharge plan for Resident S
that could not be improved upon with a referral to the LCA.
Coding: Q0620 would be coded 4, Discharge date 3 or fewer months away.
Rationale: Resident S’s discharge is expected within three to four weeks, and their

discharge plan could not be improved upon with a referral to the LCA.

2. Resident J is unable to communicate verbally due to severe dementia. Their spouse met with
the care team, and the spouse and care team agree that long-term nursing home placement on
the secure dementia unit is appropriate for Resident J. The spouse declined a referral to the
LCA.

Coding: Q0620 would be coded 3, Referral not wanted.
Rationale: Resident J is unable to communicate verbally due to severe dementia. Their

spouse declined a referral to the LCA as they and the care team agree that long-term
placement on the secure dementia unit is appropriate for Resident J.

ft
October 2024

Page Q-26

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [S]

SECTION S IS RESERVED FOR ADDITIONAL STATE-DEFINED ITEMS. THERE IS
NO SECTION S IN THE FEDERAL MDS VERSION 3.0 ITEM SET. YOUR STATE
MAY CHOOSE TO DESIGNATE A SECTION S.

D
October 2024

Page S-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [V]

SECTION V: CARE AREA ASSESSMENT (CAA) SUMMARY
Intent: The MDS does not constitute a comprehensive assessment. Rather, it is a preliminary
assessment to identify potential resident problems, strengths, and preferences. Care Areas are
triggered by MDS item responses that indicate the need for additional assessment based on
problem identification, known as “triggered care areas,” which form a critical link between the
MDS and decisions about care planning.
There are 20 CAAs in Version 3.0 of the RAI, which includes the addition of “Pain” and “Return
to the Community Referral.” These CAAs cover the majority of care areas known to be
problematic for nursing home residents. The Care Area Assessment (CAA) process provides
guidance on how to focus on key issues identified during a comprehensive MDS assessment and
directs facility staff and health professionals to evaluate triggered care areas.

The interdisciplinary team (IDT) then identifies relevant assessment information regarding the
resident’s status. After obtaining input from the resident, the resident’s family, significant other,
guardian, or legally authorized representative, the IDT decides whether or not to develop a care
plan for triggered care areas. Chapter 4 of this manual provides detailed instructions on the CAA
process and development of an individualized care plan.

Whereas the MDS identifies actual or potential problem areas, the CAA process provides for
further assessment of the triggered areas by guiding staff to look for causal or confounding
factors, some of which may be reversible. It is important that the CAA documentation include
the causal or unique risk factors for decline or lack of improvement. The plan of care then
addresses these factors, with the goal of promoting the resident’s highest practicable level of
functioning: (1) improvement where possible, or (2) maintenance and prevention of avoidable
declines. Documentation should support your decision making regarding whether to proceed
with a care plan for a triggered CAA and the type(s) of care plan interventions that are
appropriate for a particular resident. Documentation may appear anywhere in the clinical record,
e.g., progress notes, consults, flowsheets, etc.

October 2024

Page V-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [V]

V0100: Items From the Most Recent Prior OBRA or Scheduled
PPS Assessment

D
Item Rationale

The items in V0100 are used to determine whether to trigger several of the CAAs that compare a
resident’s current status with their prior status. The values of these items are derived from a prior
OBRA or scheduled PPS assessment that was performed since the most recent admission of any
kind (i.e., since the most recent entry or reentry), if one is available. Items V0100A, B, C, D, E
and F are skipped on the first assessment (OBRA or PPS) following the most recent admission of
any kind (i.e., when A0310E = 1, Yes). Complete these items only if a prior assessment has been
completed since the most recent admission of any kind to the facility (i.e., when A0310E = 0,
No) and if the prior assessment is an OBRA or a scheduled PPS assessment. If such an
assessment is available, the values of V0100A, B, C, D, E, and F should be copied from the
corresponding items on that prior assessment.

Coding Instructions for V0100A, Prior Assessment Federal OBRA
Reason for Assessment (A0310A Value from Prior Assessment)
•

Record in V0100A the value for A0310A (Federal OBRA Reason for Assessment) from
the most recent prior OBRA or scheduled PPS assessment, if one is available (see “Item
Rationale,” above, for details). One of the available values (01 through 06 or 99) must be
selected.

October 2024

Page V-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [V]

V0100: Items From the Most Recent Prior OBRA or Scheduled
PPS Assessment (cont.)
Coding Instructions for V0100B, Prior Assessment PPS Reason for
Assessment (A0310B Value from Prior Assessment)
•

Record in V0100B the value for A0310B (PPS Assessment) from the most recent prior
OBRA or scheduled PPS assessment, if one is available (see “Item Rationale,” above, for
details). One of the available values (01 or 08 or 99) must be selected.
Note: The values for V0100A and V0100B cannot both be 99, indicating that the prior
assessment is neither an OBRA nor a PPS assessment. If the value of V0100A is 99 (None
of the above), then the value for V0100B must be 01 or 08, indicating a PPS assessment. If
the value of V0100B is 99 (None of the above), then the value for V0100A must be 01
through 06, indicating an OBRA assessment.

Coding Instructions for V0100C, Prior Assessment Reference Date
(A2300 Value from Prior Assessment)
•

Record in V0100C the value of A2300 (Assessment Reference Date) from the most
recent prior OBRA or scheduled PPS assessment, if one is available (see “Item
Rationale,” above, for details).

•

Coding Instructions for V0100D, Prior Assessment Brief Interview for
Mental Status (BIMS) Summary Score (C0500 Value from Prior
Assessment)

Record in V0100D, the value for C0500 Mental Status (BIMS) Summary Score from the
most recent prior OBRA or scheduled PPS assessment, if one is available (see “Item
Rationale,” above, for details). This item will be compared with the corresponding item
on the current assessment to evaluate resident improvement or decline in the Delirium
care area.

•

Coding Instructions for V0100E, Prior Assessment Resident Mood
Interview (PHQ-2 to 9©) Total Severity Score (D0160 Value from
Prior Assessment)

Record in V0100E the value of D0160 (Resident Mood Interview [PHQ-2 to 9©] Total
Severity Score) from the most recent prior OBRA or scheduled PPS assessment, if one is
available (see “Item Rationale,” above, for details). This item will be compared with the
corresponding item on the current assessment to evaluate resident decline in the Mood
State care area.

Coding Instructions for V0100F, Prior Assessment Staff Assessment
of Resident Mood (PHQ-9-OV©) Total Severity Score (D0600
Value from Prior Assessment)
•

Record in V0100F the value for item D0600 (Staff Assessment of Resident Mood [PHQ9-OV©] Total Severity Score) from the most recent prior OBRA or scheduled PPS
assessment, if one is available (see “Item Rationale,” above, for details). This item will be
compared with the corresponding item on the current assessment to evaluate resident
decline in the Mood State care area.

October 2024

Page V-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [V]

V0200: CAAs and Care Planning

D
October 2024

Page V-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [V]

V0200: CAAs and Care Planning (cont.)
Item Rationale
•

Items V0200A 01 through 20 document which triggered care areas require further
assessment, decision as to whether or not a triggered care area is addressed in the resident
care plan, and the location and date of CAA documentation. The CAA Summary
documents the interdisciplinary team’s and the resident, resident’s family or
representative’s final decision(s) on which triggered care areas will be addressed in the
care plan.

Coding Instructions for V0200A, CAAs
•

Facility staff are to use the RAI triggering mechanism to determine which care areas
require review and additional assessment. The triggered care areas are checked in
Column A “Care Area Triggered” in the CAAs section. For each triggered care area, use
the CAA process and current standard of practice, evidence-based or expert-endorsed
clinical guidelines and resources to conduct further assessment of the care area.
Document relevant assessment information regarding the resident’s status. Chapter 4 of
this manual provides detailed instructions on the CAA process, care planning, and
documentation.

•

For each triggered care area, Column B “Care Planning Decision” is checked to indicate
that a new care plan, care plan revision, or continuation of the current care plan is
necessary to address the issue(s) identified in the assessment of that care area. The “Care
Planning Decision” column must be completed within 7 days of completing the RAI, as
indicated by the date in V0200C2, which is the date that the care planning decision(s)
were completed and that the resident’s care plan was completed. For each triggered care
area, indicate the date and location of the CAA documentation in the “Location and Date
of CAA Documentation” column. Chapter 4 of this manual provides detailed instructions
on the CAA process, care planning, and documentation.

V0200B1, Signature
•

Signature of the RN coordinating the CAA process.

V0200B2, Date
•

Coding Instructions for V0200B, Signature of RN Coordinator for CAA
Process and Date Signed

Date that the RN coordinating the CAA process certifies that the CAAs have been
completed. The CAA review must be completed no later than the 14th day of admission
(admission date + 13 calendar days) for an Admission assessment and within 14 days of
the Assessment Reference Date (A2300) for an Annual assessment, Significant Change in
Status Assessment, or a Significant Correction to Prior Comprehensive Assessment. This
date is considered the date of completion for the RAI.

October 2024

Page V-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [V]

V0200: CAAs and Care Planning (cont.)
Coding Instructions for V0200C, Signature of Person Completing Care
Plan Decision and Date Signed
V0200C1, Signature
•

Signature of the staff person facilitating the care planning decision-making. Person
signing does not have to be an RN.

V0200C2, Date
•

The date on which a staff member completes the Care Planning Decision column
(V0200A, Column B), which is done after the care plan is completed. The care plan must
be completed within 7 days of the completion of the comprehensive assessment (MDS
and CAAs), as indicated by the date in V0200B2.

•

Following completion of the MDS, CAAs (V0200A, Columns A and B) and the care
plan, the MDS 3.0 comprehensive assessment record must be transmitted to iQIES within
14 days of the V0200C2 date.

Clarifications
•

The signatures at V0200B1 and V0200C1 can be provided by the same person, if the
person actually completed both functions. However, it is not a requirement that the same
person complete both functions.

•

If a resident is discharged prior to the completion of Section V, a comprehensive
assessment may be in progress when a resident is discharged. Although the resident has
been discharged, the facility may complete and submit the assessment. The following
guidelines apply to completing a comprehensive assessment* when the resident has
been discharged:
1. Complete all required MDS items from Section A through Section Z and
indicate the date of completion in Z0500B. Encode and verify these items.
2. Complete the care area triggering process by checking all triggered care areas
in V0200A, Column A.
3. Sign and enter the date the CAAs were completed at V0200B1 and V0200B2.
4. Dash fill all of the “Care Planning Decision” items in V0200A, Column B,
which indicates that the decisions are unknown.
5. Sign and enter the date that care planning decisions were completed at
V0200C1 and V0200C2. Use the same date used in V0200B2.
6. Submit the record.
*Please see Chapter 2 for additional detailed instructions regarding options for when
residents are discharged prior to completion of the RAI.

October 2024

Page V-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

SECTION X: CORRECTION REQUEST

Intent: The purpose of Section X is to identify an MDS record to be modified or inactivated.
The following items identify the existing assessment record that is in error. Section X is only
completed if Item A0050, Type of Record, is coded a 2 (Modify existing record) or a 3
(Inactivate existing record). In Section X, the facility must 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 Internet Quality Improvement and
Evaluation System (iQIES).
A modification request is used to correct an iQIES record containing incorrect MDS item values
due to:
• transcription errors,
• data entry errors,
• software product errors,
• item coding errors, and/or
• other error requiring modification
The modification request record contains correct values for all MDS items (not just the values
previously in error), including the Section X items. The corrected record will replace the prior
erroneous record in iQIES.
In some cases, an incorrect MDS record requires a completely new assessment of the resident in
addition to a modification request for that incorrect record. Please refer to Chapter 5 of this
manual, Submission and Correction of the MDS Assessments, to determine if a new assessment
is required in addition to a modification request.
An inactivation request is used to move an existing record in iQIES from the active file to an
archive (history file) so that it will not be used for reporting purposes. Inactivations should be
used when the event did not occur (e.g., a discharge was submitted when the resident was not
discharged). The inactivation request only includes Item A0050 and the Section X items. All
other MDS sections are skipped.
The modification and inactivation processes are automated and neither completely removes the
prior erroneous record from iQIES. The erroneous record is archived in a history file. In certain
cases, it is necessary to delete a record and not retain any information about the record in iQIES.
This requires a request from the facility to the facility’s state agency to manually delete all traces of
a record from iQIES. The policy and procedures for a Manual Correction/Deletion Request are
provided in Chapter 5 of this Manual.
A Manual Deletion Request is required only in the following three cases:
1. Item A0410 Submission Requirement is incorrect. Submission of MDS assessment
records to iQIES constitutes a release of private information and must conform to privacy
laws. Only records required by the State and/or the Federal governments may be stored in
the iQIES. If a record has been submitted with the incorrect Submission Requirement
value in Item A0410, then that record must be manually deleted and, in some cases, a
new record with a corrected A0410 value submitted. Item A0410 cannot be corrected by
modification or inactivation. See Chapter 5 of this Manual for details.

October 2024

Page X-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

2. Inappropriate submission of a test record as a production record. Removal of a test
record from iQIES requires manual deletion. Otherwise information for a “bogus”
resident will be retained in the database and this resident will appear on some reports to
the facility.
3. Record was submitted for the wrong facility. If a record was submitted to iQIES for an
incorrect facility, the record must be removed manually and then a new record for the
correct facility must be submitted to iQIES. Manual deletion of the record for the
wrong facility is necessary to ensure that the resident is not associated with that facility
and does not appear on reports to that facility.

X0150: Type of Provider (A0200 on existing record to be
modified/inactivated)

This item contains the type of provider identified from the prior erroneous record to be modified/
inactivated.

Coding Instructions for X0150, Type of Provider

Enter the type of provider code 1 “Nursing Home (SNF/NF)” or code 2 “Swing Bed” exactly as
submitted for item A0200 “Type of Provider” on the prior erroneous record to be
modified/inactivated.
• Code 1, Nursing home (SNF/NF): if the facility is a Nursing home (SNF/NF).
• Code 2, Swing Bed: if the facility is a Swing Bed facility.

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

These items contain the resident’s name from the prior erroneous record to be modified/
inactivated.

Coding Instructions for X0200A, First Name
•
•

Enter the first name of the resident exactly as submitted for item A0500A “Legal Name
of Resident—First Name” on the prior erroneous record to be modified/inactivated. Start
entry with the leftmost box.
Note that the first name in X0200A does not have to match the current value of A0500A
on a modification request. The entries may be different if the modification is correcting
the first name.

October 2024

Page X-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

X0200: Name of Resident (A0500 on existing record to be
modified/inactivated) (cont.)
Coding Instructions for X0200C, Last Name
•
•

Enter the last name of the resident exactly as submitted for item A0500C “Legal Name of
Resident— Last Name” on the prior erroneous record to be modified/inactivated. Start
entry with the leftmost box. The last name in X0200C cannot be blank.
Note that the last name in X0200C does not have to match the current value of A0500C
on a modification request. The entries may be different if the modification is correcting
the last name.

X0300: Gender (A0800 on existing record to be
modified/inactivated)

Coding Instructions for X0300, Gender
Enter the gender code 1 “Male,” 2 “Female,” or – (dash value indicating unable to
determine) exactly as submitted for item A0800 “Gender” 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 gender in X0300 does not have to match the current value of A0800 on a
modification request. The entries may be different if the modification is correcting the
gender.

•

October 2024

Page X-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

X0400: Birth Date (A0900 on existing record to be
modified/inactivated)

Coding Instructions for X0400, Birth Date
•

Fill in the boxes with the birth date exactly as submitted for item A0900 “Birth Date” on
the prior erroneous record to be modified/inactivated. If the month or day contains only a
single digit, fill in the first box with a 0 For example, January 2, 1918, should be entered
as:
0

If the birth date in MDS item A0900 on the prior record was a partial date, with day of
the month unknown and the day of the month boxes were left blank, then the day of the
month boxes must be blank in X0400. If the birth date in MDS item A0900 on the prior
record was a partial date with both month and day of the month unknown and the month
and day of the month boxes were left blank, then the month and day of the month boxes
must be blank in X0400.

•

Note that the birth date in X0400 does not have to match the current value of A0900 on a
modification request. The entries may be different if the modification is correcting the
birth date.

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

Coding Instructions for X0500, Social Security Number
Fill in the boxes with the Social Security number exactly as submitted for item A0600
“Social Security and Medicare numbers" on the prior erroneous record to be
modified/inactivated. If the Social Security number was unknown or unavailable and left
blank on the prior record, leave X0500 blank.

•

Note that the Social Security number in X0500 does not have to match the current value
of A0600 on a modification request. The entries may be different if the modification is
correcting the Social Security number.

October 2024

•

Page X-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

X0600: Type of Assessment/Tracking (A0310 on existing record
to be modified/inactivated)
These items contain the reasons for assessment/tracking from the prior erroneous record to be
modified/inactivated.

D
Coding Instructions for X0600A, Federal OBRA Reason for
Assessment
•

•

Fill in the boxes with the Federal OBRA reason for assessment/tracking code exactly as
submitted for item A0310A “Federal OBRA Reason for Assessment” on the prior
erroneous record to be modified/inactivated.
Note that the Federal OBRA reason for assessment/tracking code in X0600A must match
the current value of A0310A on a modification request.
If item A0310A was incorrect on an assessment that was previously submitted and
accepted by iQIES, then the original assessment must be modified or inactivated per the
instructions in Chapter 5 (Section 5.7).

Coding Instructions for X0600B, PPS Assessment
•
•
•

Fill in the boxes with the PPS assessment type code exactly as submitted for item
A0310B “PPS Assessment” on the prior erroneous record to be modified/inactivated.
Note that the PPS assessment code in X0600B must match the current value of A0310B
on a modification request.
If item A0310B was incorrect on an assessment that was previously submitted and
accepted by iQIES, then the original assessment must be modified or inactivated per the
instructions in Chapter 5 (Section 5.7).

October 2024

Page X-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

X0600: Type of Assessment/Tracking (A0310 on existing record
to be modified/inactivated) (cont.)
Coding Instructions for X0600F, Entry/Discharge Reporting
•

Enter the number corresponding to the entry/discharge code exactly as submitted for item
A0310F “Entry/discharge reporting” on the prior erroneous record to be
modified/inactivated.
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

D
•

Note that the Entry/discharge code in X0600F must match the current value of A0310F on a
modification request.

•

If item A0310F was incorrect on an assessment that was previously submitted and
accepted by iQIES, then the original assessment must be modified or inactivated per the
instructions in Chapter 5 (Section 5.7).

•
•
•
•

Enter the code exactly as submitted for item A0310H, “Is this a Part A PPS Discharge
Assessment?” on the prior erroneous record to be modified/inactivated.
Code 0, no: if this is not a Part A PPS Discharge assessment.
Code 1, yes: if this is a Part A PPS Discharge assessment.

Note that the code in X0600H must match the current value of A0310H on a modification
request.
If item A0310H was incorrect on an assessment that was previously submitted and
accepted by iQIES, then the original assessment must be modified or inactivated per the
instructions in Chapter 5 (Section 5.7).

October 2024

•

Coding Instructions for X0600H, Is this a Part A PPS Discharge
Assessment?

Page X-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

X0700: Date on Existing Record to Be Modified/Inactivated –
Complete one only
The item that is completed in this section is the event date for the prior erroneous record to be
modified/inactivated. The event date is the assessment reference date for an assessment record,
the discharge date for a discharge record, or the entry date for an entry record. In iQIES, this date
is often referred to as the “target date.” Enter only one (1) date in X0700.

D
•
•

Coding Instructions for X0700A, Assessment Reference Date—
(A2300 on existing record to be modified/inactivated) – Complete
Only if X0600F = 99
If the prior erroneous record to be modified/inactivated is an OBRA assessment or a PPS
assessment, where X0600F = 99, enter the assessment reference date here exactly as
submitted in item A2300 “Assessment Reference Date” on the prior record.
Note that the assessment reference date in X0700A must match the current value of
A2300 on a modification request.

•

Coding Instructions for X0700B, Discharge Date—(A2000 on existing
record to be modified/inactivated) – Complete Only If X0600F =
10, 11, or 12

If the prior erroneous record to be modified/inactivated is a discharge record (indicated by
X0600F = 10, 11, or 12), enter the discharge date here exactly as submitted for item
A2000 “Discharge Date” on the prior record. If the prior erroneous record was a
discharge combined with an OBRA or PPS assessment, then that prior record will contain
both a completed assessment reference date (A2300) and discharge date (A2000) and
these two dates will be identical. If such a record is being modified or inactivated, enter
the prior discharge date in X0700B and leave the prior assessment reference date in
X0700A blank.
Note that the discharge date in X0700B must match the current value of A2000 on a
modification request.

October 2024

Page X-7

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

X0700: Date on Existing Record to Be Modified/Inactivated (cont.)
Coding Instructions for X0700C, Entry Date—(A1600 on existing
record to be modified/inactivated) – Complete Only If
X0600F = 01
•
•

If the prior erroneous record to be modified/inactivated is an entry record (indicated by
X0600F = 01), enter the entry date here exactly as submitted for item A1600 “Entry Date
[date of admission/reentry into the facility]” on the prior record.
Note that the entry date in X0700C must match the current value of A1600 on a
modification request.

X0800: Correction Attestation Section

The items in this section indicate the number of times a record accepted into iQIES has been
corrected, the reason for the current modification/inactivation request, the person attesting to the
modification/inactivation request, and the date of the attestation.
This item may be populated automatically by the nursing home’s data entry software; however,
if it is not, the nursing home should enter this information.

Coding Instructions for X0800, Correction Number
•
•

October 2024

•

Enter the total number of correction requests to modify/inactivate the record in iQIES
that is in error. Include the present modification/inactivation request in this number.
For the first correction request (modification/inactivation) for an MDS record, code a
value of 01 (zero-one); for the second correction request, code a value of 02 (zero-two);
etc. With each succeeding request, X0800 is incremented by one. For values between one
and nine, a leading zero should be used in the first box. For example, enter “01” into the
two boxes for X0800.
This item identifies the total number of correction requests following the original
assessment or tracking record, including the present request. Note that Item X0800 is
used to track successive correction requests in iQIES.

Page X-8

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

X0900: Reasons for Modification
The items in this section indicate the possible reasons for the modification request of the record
in iQIES. Check all that apply. These items should only be completed when A0050 = 2,
indicating a modification request. If A0050 = 3, indicating an inactivation request, these items
should be skipped.

Coding Instructions for X0900A, Transcription Error
•

•

Check the box if any errors in the prior record accepted into iQIES were caused by data
transcription errors.
A transcription error includes any error made recording MDS assessment or tracking
form information from other sources. An example is transposing the digits for the
resident’s weight (e.g., recording “191” rather than the correct weight of “119” that
appears in the medical record).

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 O0400C1 is incorrectly encoded as
“3000” minutes rather than the correct number of “0030” minutes.

Coding Instructions for X0900C, Software Product Error
•
•

Check the box if any errors in the prior record accepted into iQIES were caused by
software product errors.
A software product error includes any error created by the encoding software, such as
storing an item in the wrong format (e.g., storing weight as “020” instead of “200”).

Coding Instructions for X0900D, Item Coding Error
•

Check the box if any errors in the prior record accepted into iQIES were caused by item
coding errors.

October 2024

Page X-9

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

X0900: Reasons for Modification (cont.)
•

An item coding error includes any error made coding an MDS item (for exceptions when
certain items may not be modified see Chapter 5), such as choosing an incorrect code for
the Functional Abilities – Mobility item GG0170A, Roll left and right (e.g., choosing a
code of “02” for a resident who requires supervision and should be coded as “04”). Item
coding errors may result when an assessor makes an incorrect judgment or
misunderstands the RAI coding instructions.

Coding Instructions for X0900Z, Other Error Requiring Modification
•
•

Check the box if any errors in the prior record accepted into iQIES were caused by other
types of errors not included in Items X0900A through X0900D.
Such an error includes any other type of error that causes a record accepted into iQIES to
require modification under the Correction Policy. An example would be when a record is
prematurely submitted prior to final completion of editing and review. Facility staff
should describe the “other error” in the space provided with the item.

X1050: Reasons for Inactivation

The items in this section indicate the possible reasons for the inactivation request. Check all that
apply. These items should only be completed when A0050 = 3, indicating an inactivation
request. If A0050 = 2, indicating a modification request, these items should be skipped.

Coding Instructions for X1050A, Event Did Not Occur
•

•

Check the box if the record accepted into iQIES does not represent an event that actually
occurred.
An example would be a Discharge assessment submitted for a resident, but there was no
actual discharge. There was no event.

Coding Instructions for X1050Z, Other Reason Requiring Inactivation
•
•

Check the box if any errors in the record accepted into iQIES were caused by other types
of errors not included in Item X1050A.
Facility staff should describe the “other error” in the space provided with the item.

October 2024

Page X-10

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

X1100: RN Assessment Coordinator Attestation of Completion
The items in this section identify the RN coordinator attesting to the correction request and the
date of the attestation.

Coding Instructions for X1100A, Attesting Individual’s First Name
•

Enter the first name of the facility staff member attesting to the completion of the
corrected information. Start entry with the leftmost box.

Coding Instructions for X1100B, Attesting Individual’s Last Name
•

Enter the last name of the facility staff member attesting to the completion of the
corrected information. Start entry with the leftmost box.

Coding Instructions for X1100C, Attesting Individual’s Title
•

Enter the title of the facility staff member attesting to the completion of the corrected
information on the line provided.

•

Coding Instructions for X1100D, Signature

The attesting individual must sign the correction request here, certifying the completion
of the corrected information. The entire correction request should be completed and
signed within 14 days of detecting an error in a record accepted into iQIES. The
correction request, including the signature of the attesting facility staff, must be kept with
the modified or inactivated MDS record and retained in the resident’s medical record or
electronic medical record.

Coding Instructions for X1100E, Attestation Date
•

Enter the date the attesting facility staff member attested to the completion of the
corrected information.

•

Do not leave any boxes blank. For a one-digit month or day, place a zero in the first box.
For example, January 2, 2011, should be entered as:
0

October 2024

Page X-11

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [X]

X1100: RN Assessment Coordinator Attestation of Completion
(cont.)
Coding Tip for X1100, RN Assessment Coordinator Attestation of
Completion
•

If an inactivation is being completed, Z0400 must also be completed.

D
October 2024

Page X-12

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Z]

SECTION Z: ASSESSMENT ADMINISTRATION
Intent: The intent of the items in this section is to provide billing information and signatures of
persons completing the assessment.

Z0100: Medicare Part A Billing

Item Rationale
•

Used to capture the Patient Driven Payment Model
(PDPM) case mix version code followed by Health
Insurance Prospective Payment System (HIPPS)
modifier based on type of assessment.

•
•

•

Typically, the software data entry product will calculate this value.
The HIPPS code is a Skilled Nursing Facility (SNF) Part A five-position billing code; the
first four positions represent the PDPM case mix version code and the fifth is the
assessment type indicator. For information on HIPPS, access:
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ProspMedicareFeeSvcPmtGen/index.html.
If the value for Z0100A is not automatically calculated
DEFINITION
by the software data entry product, enter the HIPPS
code in the spaces provided (see Chapter 6 of this
HIPPS CODE
manual, Medicare Skilled Nursing Facility Prospective
Is comprised of the PDPM case
Payment System (SNF PPS), for a step-by-step
mix code, which is calculated
worksheet for manually determining the PDPM case
from the assessment data. The
mix version code and a table that defines the assessment first four positions of the HIPPS
indicator).
code contain the PDPM
This HIPPS code is usually used for Medicare SNF Part classification codes for each
PDPM component to be billed
A billing by the provider.
for Medicare reimbursement,
Left-justify the 5-character HIPPS code. The extra two
followed by an indicator of the
spaces are supplied for future use, if necessary.

•

MEDICARE-COVERED
STAY
Skilled Nursing Facility stays
billable to Medicare Part A.
Does not include stays
billable to other payers (e.g.,
Medicare Advantage plans).

Coding Instructions for Z0100A, Medicare Part
A HIPPS Code

DEFINITION

type of assessment that was
completed.

October 2024

Page Z-1

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Z]

Z0100: Medicare Part A Billing (cont.)
Coding Instructions for Z0100B, Version Code
•

Typically, the software data entry product will calculate this value.

•

If the value for Z0100B is not automatically calculated by the software data entry
product, enter the PDPM version code in the spaces provided.

Z0200: State Medicaid Billing (if required by the state)

D
Item Rationale
•

Used to capture the payment code in states that employ the MDS for Medicaid case-mix
reimbursement.

•

Coding Instructions for Z0200A, Case Mix Group

If the state has selected a standard payment model, this item will usually be populated
automatically by the software data entry product. Otherwise, enter the case-mix code
calculated based on the MDS assessment.

Coding Instructions for Z0200B, Version Code
•

If the state has selected a standard payment model, this item will usually be populated
automatically by the software data entry product. Otherwise, enter the case mix version
code in the spaces provided. This is the version code appropriate to the code in Item
Z0200A.

Coding Instructions for Z0200C, Is this a Short Stay assessment?
•

Code 0, no: if this is not a Short Stay assessment.

•

Code 1, yes: if this is a Medicare Short Stay assessment.

Coding Tip
•

The standard RUG-IV grouper automatically determines whether or not this is a Short
Stay assessment. MDS software typically makes this determination automatically.

October 2024

Page Z-2

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Z]

Z0250: Alternate State Medicaid Billing (if required by the state)

Item Rationale
•

Used to capture an alternate payment group in states that employ the MDS for Medicaid
case-mix reimbursement. States may want to capture a second payment group for
Medicaid purposes to allow evaluation of the fiscal impact of changing to a new payment
model or to allow blended payment between two models during a transition period.

Coding Instructions for Z0250A, Case Mix Group
•

Coding Instructions for Z0250B, Version Code
If the state has selected a standard payment model, this item will usually be populated
automatically by the software data entry product. Otherwise, enter the case mix version
code in the spaces provided. This is the version code appropriate to the code in Item
Z0250A.

•

Z0300: Insurance Billing

•

Item Rationale

Allows providers and vendors to capture case-mix codes required by other payers (e.g.
private insurance or the Department of Veterans Affairs).

Coding Instructions for Z0300A, Billing Code
•

If the other payer has selected a standard payment model, this item may be populated
automatically by the software data entry product. Otherwise, enter the billing code in the
space provided. This code is for use by other payment systems such as private insurance
or the Department of Veterans Affairs.

October 2024

Page Z-3

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Z]

Z0300: Insurance Billing (cont.)
Coding Instructions for Z0300B, Billing Version
•

If the other payer has selected a standard payment model, this item may be populated
automatically by the software data entry product. Otherwise, enter an appropriate billing
version in the spaces provided. This is the billing version appropriate to the billing code
in Item Z0300A.

Z0400: Signatures of Persons Completing the Assessment or
Entry/Death Reporting

•

D
Item Rationale

To obtain the signature of all persons who completed any part of the MDS. Legally, it is
an attestation of accuracy with the primary responsibility for its accuracy with the person
selecting the MDS item response. Each person completing a section or portion of a
section of the MDS is required to sign the Attestation Statement.

October 2024

Page Z-4

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Z]

Z0400: Signatures of Persons Completing the Assessment or
Entry/Death Reporting (cont.)
•

The importance of accurately completing and submitting the MDS cannot be overemphasized. The MDS is the basis for:
—
—
—
—
—
—
—

the development of an individualized care plan
the Medicare Prospective Payment System
Medicaid reimbursement programs
quality monitoring activities, such as the quality measure reports
the data-driven survey and certification process
the quality measures used for public reporting
research and policy development.

D
Coding Instructions

All staff who completed any part of the MDS must enter their signatures, titles, sections
or portion(s) of section(s) they completed, and the date completed.

•

If a staff member cannot sign Z0400 on the same day that they completed a section or
portion of a section, when the staff member signs, use the date the item originally was
completed.

•

Read the Attestation Statement carefully. You are certifying that the information you
entered on the MDS, to the best of your knowledge, most accurately reflects the
resident’s status. Penalties may be applied for submitting false information.

•

Coding Tips and Special Populations

Two or more staff members can complete items within the same section of the MDS.
When filling in the information for Z0400, any staff member who has completed a subset of items within a section should identify which item(s) they completed within that
section.

•

Nursing homes may use electronic signatures for medical record documentation,
including the MDS, when permitted to do so by state and local law and when authorized
by the nursing home’s policy. Nursing homes must have written policies in place that
meet any and all state and federal privacy and security requirements to ensure proper
security measures to protect the use of an electronic signature by anyone other than the
person to whom the electronic signature belongs.

•

Although the use of electronic signatures for the MDS does not require that the entire
record be maintained electronically, most facilities have the option to maintain a
resident’s record by computer rather than hard copy.

•

Whenever copies of the MDS are printed and dates are automatically encoded, be sure to
note that it is a “copy” document and not the original.

•

October 2024

Page Z-5

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Z]

Z0400: Signatures of Persons Completing the Assessment or
Entry/Death Reporting (cont.)
•

If an individual who completed a portion of the MDS is not available to sign it (e.g., in
situations in which a staff member is no longer employed by the facility and left MDS
sections completed but not signed for), there are portions of the MDS that may be
verified with the medical record and/or resident/staff/family interview as appropriate. For
these sections, the person signing the attestation must review the information to assure
accuracy and sign for those portions on the date the review was conducted. For sections
requiring resident interviews, the person signing the attestation for completion of that
section should interview the resident to ensure the accuracy of information and sign on
the date this verification occurred.

Z0500: Signature of RN Assessment Coordinator Verifying
Assessment Completion

Item Rationale
•

Federal regulation requires the RN assessment coordinator to sign and thereby certify that
the assessment is complete.

Steps for Assessment

Coding Instructions

1. Verify that all items on this assessment are complete.
2. Verify that Item Z0400 (Signature of Persons Completing the Assessment) contains
attestation for all MDS sections.
•

For Z0500B, use the actual date that the MDS was completed, reviewed, and signed as
complete by the RN assessment coordinator. This date must be equal to the latest date at
Z0400 or later than the date(s) at Z0400, which documents when portions of the
assessment information were completed by assessment team members.

•

If for some reason the MDS cannot be signed by the RN assessment coordinator on the
date it is completed, the RN assessment coordinator should use the actual date that it is
signed.

Coding Tips
•

The RN assessment coordinator is not certifying the accuracy of portions of the
assessment that were completed by other health professionals.

October 2024

Page Z-6

CMS’s RAI Version 3.0 Manual

CH 3: MDS Items [Z]

Z0500: Signature of RN Assessment Coordinator Verifying
Assessment Completion (cont.)
Nursing homes may use electronic signatures for medical record documentation,
including the MDS, when permitted to do so by state and local law and when authorized
by the nursing home’s policy. Nursing homes must have written policies in place that
meet any and all state and federal privacy and security requirements to ensure proper
security measures to protect the use of an electronic signature by anyone other than the
person to whom the electronic signature belongs.

•

Whenever copies of the MDS are printed and dates are automatically encoded, be sure to
note that it is a “copy” document and not the original.

•

October 2024

Page Z-7

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

CHAPTER 4: CARE AREA ASSESSMENT (CAA)
PROCESS AND CARE PLANNING
4.1 Background and Rationale
The Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) mandated that nursing facilities
provide necessary care and services to help each resident attain or maintain the highest
practicable well-being. Facilities must ensure that residents improve when possible and do not
deteriorate unless the resident’s clinical condition demonstrates that the decline was unavoidable.

Regulations require facilities to complete, at a minimum and at regular intervals, a
comprehensive, standardized assessment of each resident’s functional capacity and needs, in
relation to a number of specified areas (e.g., customary routine, vision, and continence). The
results of the assessment, which must accurately reflect the resident’s status and needs, are to be
used to develop, review, and revise each resident’s comprehensive plan of care.
This chapter provides information about the Care Area Assessments (CAAs), Care Area Triggers
(CATs), and the process for care plan development for nursing home residents.

4.2 Overview of the Resident Assessment Instrument (RAI)
and Care Area Assessments (CAAs)

As discussed in Chapter 1, the updated Resident Assessment Instrument (RAI) consists of three
basic components: 1) the Minimum Data Set (MDS) Version 3.0, 2) the Care Area Assessment
(CAA) process, and 3) the RAI Utilization Guidelines. The RAI-related processes help staff
identify key information about residents as a basis for identifying resident-specific issues and
objectives. In accordance with 42 CFR 483.21(b) the facility must develop a comprehensive care
plan for each resident that includes measurable objectives and timetables to meet a resident’s
medical, nursing, and mental and psychosocial needs that are identified in the comprehensive
assessment. The services that are to be furnished to attain or maintain the resident’s highest
practicable physical, mental, and psychosocial well-being and any services that would otherwise
be required but are not provided due to the resident’s exercise of rights including the right to
refuse treatment.

The MDS is a starting point. The Minimum Data Set (MDS) is a standardized instrument used
to assess nursing home residents. It is a collection of basic physical (e.g., medical conditions,
mood, and vision), functional (e.g., activities of daily living, behavior), and psychosocial (e.g.,
preferences, goals, and interests) information about residents. For example, assessing a resident’s
orientation and recall helps staff complete portions of the MDS that relate to cognition (Section
C), and weighing a resident and identifying their food intake helps staff complete portions

October 2024

Page 4-1

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

of the MDS related to nutritional status (Section K). When it is completed, the MDS provides a
foundation for a more thorough assessment and the development of an individualized care plan.
The MDS 3.0 manual explains in detail how to complete the MDS.
The information in the MDS constitutes the core of the required CMS-specified Resident
Assessment Instrument (RAI). Based on assessing the resident, the MDS identifies actual or
potential areas of concern. The remainder of the RAI process supports the efforts of nursing
home staff, health professionals, and practitioners to further assess these triggered areas of
concern in order to identify, to the extent possible, whether the findings represent a problem or
risk requiring further intervention, as well as the causes and risk factors related to the triggered
care area under assessment. These conclusions then provide the basis for developing an
individualized care plan for each resident.

The CAA process framework. The CAA process provides a framework for guiding the review
of triggered areas, and clarification of a resident’s functional status and related causes of
impairments. It also provides a basis for additional assessment of potential issues, including
related risk factors. The assessment of the causes and contributing factors gives the
interdisciplinary team (IDT) additional information to help them develop a comprehensive plan
of care.
When implemented properly, the CAA process should help staff:

•

Consider each resident as a whole, with unique characteristics and strengths that affect
their capacity to function;

•

Identify areas of concern that may warrant interventions;

•

Develop, to the extent possible, interventions to help improve, stabilize, or prevent
decline in physical, functional, and psychosocial well-being, in the context of the
resident’s condition, choices, and preferences for interventions; and

•

Address the need and desire for other important considerations, such as advanced care
planning and palliative care; e.g., symptom relief and pain management.

4.3 What Are the Care Area Assessments (CAAs)?

The completed MDS must be analyzed and combined with other relevant information to develop
an individualized care plan. To help nursing facilities apply assessment data collected on the
MDS, Care Area Assessments (CAAs) are triggered responses to items coded on the MDS
specific to a resident’s possible problems, needs or strengths. Specific “CAT logic” for each care
area is identified under section 4.10 (The Twenty Care Areas). The CAAs reflect conditions,
symptoms, and other areas of concern that are common in nursing home residents and are
commonly identified or suggested by MDS findings. Interpreting and addressing the care areas
identified by the CATs is the basis of the Care Area Assessment process, and can help provide
additional information for the development of an individualized care plan.

October 2024

Page 4-2

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Table 1. Care Area Assessments in the Resident Assessment Instrument, Version 3.0
1. Delirium

2. Cognitive Loss/Dementia

3. Visual Function

4. Communication

5. Activity of Daily Living (ADL) Functional /
Rehabilitation Potential

6. Urinary Incontinence and
Indwelling Catheter

7. Psychosocial Well-Being

8. Mood State

9. Behavioral Symptoms

10. Activities

11. Falls

12. Nutritional Status

13. Feeding Tubes

14. Dehydration/Fluid Maintenance

D
15. Dental Care

16. Pressure Ulcer/Injury

17. Psychotropic Medication Use

18. Physical Restraints

19. Pain

20. Return to Community Referral

The CAA process does not mandate any specific tool for completing the further assessment of
the triggered areas, nor does it provide any specific guidance on how to understand or interpret
the triggered areas. Instead, facilities are instructed to identify and use tools that are current and
grounded in current clinical standards of practice, such as evidence-based or expert-endorsed
research, clinical practice guidelines, and resources. When applying these evidence-based
resources to practice, the use of sound clinical problem solving and decision making (often called
“critical thinking”) skills is imperative.

By statute, the RAI must be completed within 14 days of admission. As an integral part of the
RAI, CAAs must be completed and documented within the same time frame. While a workup
cannot always be completed within 14 days, it is expected that nursing homes will assess resident
needs, plan care and implement interventions in a timely manner.
CAAs are not required for Medicare PPS assessments. They are required only for OBRA
comprehensive assessments (Admission, Annual, Significant Change in Status, or
Significant Correction of a Prior Comprehensive). However, when a Medicare PPS
assessment is combined with an OBRA comprehensive assessment, the CAAs must be
completed in order to meet the requirements of the OBRA comprehensive assessment.

4.4 What Does the CAA Process Involve?
Facilities use the findings from the comprehensive assessment to develop an individualized care
plan to meet each resident’s needs (42 CFR 483.20(d)). The CAA process discussed in this
manual refers to identifying and clarifying areas of concern that are triggered based on how
specific MDS items are coded on the MDS. The process focuses on evaluating these triggered
care areas using the CAAs, but does not provide exact detail on how to select pertinent
interventions for care planning. Interventions must be individualized and based on applying
October 2024

Page 4-3

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

effective problem solving and decision making approaches to all of the information available for
each resident.
Care Area Triggers (CATs) identify conditions that may require further evaluation because they
may have an impact on specific issues and/or conditions, or the risk of issues and/or conditions
for the resident. Each triggered item must be assessed further through the use of the CAA process
to facilitate care plan decision making, but it may or may not represent a condition that should or
will be addressed in the care plan. The significance and causes of any given trigger may vary for
different residents or in different situations for the same resident. Different CATs may have
common causes, or various items associated with several CATs may be connected.

CATs provide a “flag” for the IDT members, indicating that the triggered care area needs to be
assessed more completely prior to making care planning decisions. Further assessment of a
triggered care area may identify causes, risk factors, and complications associated with the care
area condition. The plan of care then addresses these factors with the goal of promoting the
resident’s highest practicable level of functioning: (1) improvement where possible or (2)
maintenance and prevention of avoidable declines.
A risk factor increases the chances of having a negative outcome or complication. For example,
impaired bed mobility may increase the risk of getting a pressure ulcer/injury. In this example,
impaired bed mobility is the risk factor, unrelieved pressure is the effect of the compromised bed
mobility, and the potential pressure ulcer is the complication.

A care area issue/condition (e.g., falls) may result from a single underlying cause (e.g.,
administration of a new medication that causes dizziness) or from a combination of multiple
factors (e.g., new medication, resident forgot walker, bed too high or too low, etc.). There can
also be a single cause of multiple triggers and impairments. For example, hypothyroidism is an
example of a common, potentially reversible medical condition that can have diverse physical,
functional, and psychosocial complications. Thus, if a resident has hypothyroidism, it is possible
that the MDS might trigger any or several of the following CAAs depending on whether or not
the hypothyroidism is controlled, there is an acute exacerbation, etc.: Delirium (#1), Cognitive
Loss/Dementia (#2), Visual Function (#3), Communication (#4), ADL Functional/Rehabilitation
(#5), Urinary Incontinence (#6), Psychosocial Well-Being (#7), Mood State (#8), Behavior
Symptoms (#9), Activities (#10), Falls (#11), Nutritional Status (#12), Dehydration (#14),
Psychotropic Medication Use (#17), and Pain (#19). Even if the MDS does not trigger a
particular care area, the facility can use the CAA process and resources at any time to further
assess the resident.

Recognizing the connection among these symptoms and treating the underlying cause(s) to the
extent possible, can help address complications and improve the resident’s outcome. Conversely,
failing to recognize the links and instead trying to address the triggers or MDS findings in
isolation may have little if any benefit for the resident with hypothyroidism or other complex or
mixed causes of impaired behavior, cognition, and mood.

For example, it is necessary to assess a resident’s orientation and recall in order to complete
portions of the MDS that relate to cognitive patterns (Section C) and to obtain a resident’s weight
and identify their food intake in order to complete MDS items related to nutritional status
(Section K). A positive finding in Section C may trigger one or several CAAs, including
Delirium (#1), Cognitive Loss/Dementia (#2), and ADL Functional/Rehabilitation Potential (#5).
October 2024

Page 4-4

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Additional evaluation is then required to identify whether the resident has delirium, dementia, or
both; how current symptoms and patterns compare to their usual or previous baseline, whether
potentially reversible causes are present, what else might be needed to identify underlying causes
(including medical diagnoses and history), and what symptomatic and cause-specific
interventions are appropriate for the resident. If the Nutritional Status (#12) CAA also triggered,
due to weight loss and the resident being found to have delirium, then it is possible that both
findings could have a common cause (e.g., an infection or medication side effects), that delirium
resulted in impaired nutritional status, or that impaired nutritional status led to delirium, or still
other possibilities. Thus, identifying the sequence of events is essential to understanding causes
and choosing appropriate interventions.

The RAI is not intended to provide diagnostic advice, nor is it intended to specify which
triggered areas may be related to one another or and how those problems relate to underlying
causes. It is up to the IDT, including the resident’s physician, to determine these connections and
underlying causes as they assess the triggered care areas and any other areas pertinent to the
individual resident.

Not all triggers identify deficits or problems. Some triggers indicate areas of resident strengths,
and can suggest possible approaches to improve a resident’s functioning or minimize decline. For
example, Section F identifies the resident’s preferences for customary routine and activities and
Section Q captures information about the resident’s desire to talk to someone about the
possibility of leaving this facility and returning to live and receive services in the community.
These and other MDS items can help focus the assessment and care plan on what is most
important to the resident and areas with the greatest potential for functional improvement.
In addition to identifying causes and risk factors that contribute to the resident’s care area issues
or conditions, the CAA process may help the IDT:
Identify and address associated causes and effects;

•

Determine whether and how multiple triggered conditions are related;

•

Identify a need to obtain additional medical, functional, psychosocial, financial, or other
information about a resident’s condition that may be obtained from sources such as the
resident, the resident’s family or other responsible party, the attending physician, direct
care staff, rehabilitative staff, or that requires laboratory and diagnostic tests;

•

Identify whether and how a triggered condition actually affects the resident’s function
and quality of life, or whether the resident is at particular risk of developing the
conditions;

•

Review the resident’s situation with a health care practitioner (e.g., attending physician,
medical director, or nurse practitioner), to try to identify links among causes and between
causes and consequences, and to identify pertinent tests, consultations, and interventions;

•

Determine whether a resident could potentially benefit from rehabilitative interventions;

•

Begin to develop an individualized care plan with measurable objectives and timetables
to meet a resident’s medical, functional, mental and psychosocial needs as identified
through the comprehensive assessment.

•

October 2024

Page 4-5

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

4.5 Other Considerations Regarding Use of the CAAs

Assigning responsibility for completing the MDS and CAAs. Per the OBRA statute, the
resident’s assessment must be conducted or coordinated by a registered nurse (RN) with the
appropriate participation of health professionals. It is common practice for facilities to assign
specific MDS items or portion(s) of items (and subsequently CAAs associated with those items)
to those of various disciplines (e.g., the dietitian completes the Nutritional Status and Feeding
Tube CAAs, if triggered). The proper assessment and management of CAAs that are triggered for
a given resident may involve aspects of diagnosis and treatment selection that exceed the scope
of training or practice of any one discipline involved in the care (for example, identifying
specific medical conditions or medication side effects that cause anorexia leading to a resident’s
weight loss). It is the facility’s responsibility to obtain the input that is needed for clinical
decision making (e.g., identifying causes and selecting interventions) that is consistent with
relevant clinical standards of practice. For example, a physician may need to get a more detailed
history or perform a physical examination in order to establish or confirm a diagnosis and/or
related complications.

Identifying policies and practices related to the assessment and care planning processes.
Under the OBRA regulations, 42 CFR 483.70(h)(1) identifies the medical director as being
responsible for overseeing the “implementation of resident care policies” in each facility, “and
the coordination of medical care in the facility.” Therefore, it is recommended that the facility’s
IDT members collaborate with the medical director to identify current evidence-based or expertendorsed resources and standards of practice that they will use for the expanded assessments and
analyses that may be needed to adequately address triggered areas. The facility should be able to
provide surveyors the resources that they have used upon request as part of the survey review
process. 1

•
•
•
•

CAA documentation. CAA documentation helps to explain the basis for the care plan by
showing how the IDT determined that the underlying causes, contributing factors, and risk
factors were related to the care area condition for a specific resident; for example, the
documentation should indicate the basis for these decisions, why the finding(s) require(s) an
intervention, and the rationale(s) for selecting specific interventions. Based on the review of the
comprehensive assessment, the IDT and the resident and/or the resident’s representative
determine the areas that require care plan intervention(s) and develop, revise, or continue the
individualized care plan.

Relevant documentation for each triggered CAA describes: causes and contributing
factors;
The nature of the issue or condition (may include presence or lack of objective data and
subjective complaints). In other words, what exactly is the issue/problem for this resident
and why is it a problem;
Complications affecting or caused by the care area for this resident;
Risk factors related to the presence of the condition that affects the staff’s decision to
proceed to care planning;

In Appendix C, CMS has provided CAA resources that facilities may choose to use but that are neither
mandatory nor endorsed by the government. Please note that Appendix C does not provide an all-inclusive list.

October 2024

Page 4-6

CMS’s RAI Version 3.0 Manual

•
•
•
•

CH 4: CAA Process and Care Planning

Factors that must be considered in developing individualized care plan interventions,
including the decision to care plan or not to care plan various findings for the individual
resident;
The need for additional evaluation by the attending physician and other health
professionals, as appropriate;
The resource(s), or assessment tool(s) used for decision-making, and conclusions that
arose from performing the CAA;
Completion of Section V (CAA Summary; see Chapter 3 for coding instructions) of the
MDS.

Written documentation of the CAA findings and decision making process may appear anywhere
in a resident’s record; for example, in discipline-specific flow sheets, progress notes, the care
plan summary notes, a CAA summary narrative, etc. Nursing homes should use a format that
provides the information as outlined in this manual and the State Operations Manual (SOM).
If it is not clear that a facility’s documentation provides this information, surveyors may ask
facility staff to provide such evidence.

Use the “Location and Date of CAA Documentation” column on the CAA Summary (Section V
of the MDS 3.0) to note where the CAA information and decision making documentation can be
found in the resident’s record. Also indicate in the column “Care Planning Decision” whether the
triggered care area is addressed in the care plan.

4.6 When Is the RAI Not Enough?

Federal requirements support a nursing home’s ongoing responsibility to assess residents. The
Quality of Care regulation requires that “each resident must receive and the facility must provide
the necessary care and services to attain or maintain the highest practicable physical, mental, and
psychosocial well-being, in accordance with the comprehensive assessment and plan of care” (42
CFR 483.25).

Services provided or arranged by the nursing home must also meet professional standards of
quality. Per 42 CFR 483.70(b), the facility must operate and provide services in compliance with
all applicable Federal, State, and local laws, regulations, and codes, and with accepted
professional standards and principles that apply to professionals providing services in such a
facility. Furthermore, surveyor guidance within OBRA (e.g., 42 CFR 483.25(b)(1) Pressure
Ulcers and 42 CFR 483.45(d) Unnecessary Medications) identifies additional elements of
assessment and care related to specific issues and/or conditions that are consistent with
professional standards.
Therefore, facilities are responsible for assessing and addressing all care issues that are relevant
to individual residents, regardless of whether or not they are covered by the RAI (42 CFR
483.20(b)), including monitoring each resident’s condition and responding with appropriate
interventions.
Limitations of the RAI-related instruments. The RAI provides tools related to assessment
including substantial detail for completing the MDS, how CATs are triggered, and a framework
for the CAA process. However, the process of completing the MDS and related portions of the
October 2024

Page 4-7

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

RAI does not constitute the entire assessment that may be needed to address issues and manage
the care of individual residents.
Neither the MDS nor the remainder of the RAI includes all of the steps, relevant factors,
analyses, or conclusions needed for clinical problem solving and decision making for the care of
nursing home residents. By themselves, neither the MDS nor the CAA process provide sufficient
information to determine if the findings from the MDS are problematic or merely incidental, or if
there are multiple causes of a single trigger or multiple triggers related to one or several causes.
Although a detailed history is often essential to correctly identify and address causes of
symptoms, the RAI was not designed to capture a history (chronology) of a resident’s symptoms
and impairments. Thus, it can potentially be misleading or problematic to care plan individual
MDS findings or CAAs without any additional thought or investigation.
The MDS may not trigger every relevant issue

•

Not all triggers are clinically significant

•

The MDS is not a diagnostic tool or treatment selection guide

•

The MDS does not identify causation or history of problems

•

Although facilities have the latitude to choose approaches to the CAA process, compliance with
various OBRA requirements can be enhanced by using additional relevant clinical problem
solving and decision making processes to analyze and address MDS findings and CAAs. Table 2
provides a framework for a more complete approach to clinical problem solving and decision
making essential to the appropriate care of individuals with multiple and/or complex illnesses
and impairments.

4.7 The RAI and Care Planning

As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary
communication tool. It must include measurable objectives and time frames and must describe
the services that are to be furnished to attain or maintain the resident’s highest practicable
physical, mental, and psychosocial well-being. The care plan must be reviewed and revised
periodically, and the services provided or arranged must be consistent with each resident’s
written plan of care. Refer to 42 CFR 483.20(d), which notes that a nursing home must maintain
all resident assessments completed within the previous 15 months in the resident’s active record
and use the results of the assessments to develop, review, and revise the resident’s comprehensive
plan of care. Regulatory requirements related to care planning in nursing homes are located at 42
CFR 483.20(b)(1) and (2) and are specified in the interpretive guidelines (F tags) in Appendix PP
of the State Operations Manual (SOM). The SOM can be found at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/index.html.
Good assessment is the starting point for good clinical problem solving and decision making and
ultimately for the creation of a sound care plan. The CAAs provide a link between the MDS and
care planning. The care plan should be revised on an ongoing basis to reflect changes in the
resident and the care that the resident is receiving (see 42 CFR 483.21(b), Comprehensive Care
Plans). This Chapter does not specify a care plan structure or format.

October 2024

Page 4-8

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Table 2. Clinical Problem Solving and Decision Making Process Steps and Objectives
Process Step / Objectives *
Recognition / Assessment
Gather essential information about the
individual
Problem definition
Define the individual's problems, risks,
and issues
Diagnosis / Cause-and-effect analysis

− Identify and collect information that is needed to identify an
individual’s conditions that enables proper definition of their
conditions, strengths, needs, risks, problems, and prognosis
− Obtain a personal and medical history
− Perform a physical assessment
− Identify any current consequences and complications of the
individual's situation, underlying condition and illnesses, etc.
− Clearly state the individual’s issues and physical, functional, and
psychosocial strengths, problems, needs, deficits, and concerns
− Define significant risk factors
− Identify causes of, and factors contributing to, the individual's
current dysfunctions, disabilities, impairments, and risks
− Identify pertinent evaluations and diagnostic tests
− Identify how existing symptoms, signs, diagnoses, test results,
dysfunctions, impairments, disabilities, and other findings relate to
one another
− Identify how addressing those causes is likely to affect consequences

Identify physical, functional, and
psychosocial causes of risks, problems,
and other issues, and relate to one
another and to their consequences

Key Tasks **

Identifying goals and objectives of
care

− Clarify prognosis
− Define overall goals for the individual
− Identify criteria for meeting goals

Clarify purpose of providing care and
of specific interventions, and the
criteria that will be used to determine
whether the objectives are being met
Selecting interventions / planning
care

Monitoring of progress
Review individual’s progress towards
goals and modify approaches as
needed

−
−
−
−
−
−
−

Identify and implement interventions
and treatments to address the
individual's physical, functional, and
psychosocial needs, concerns,
problems, and risks

− Identify specific symptomatic and cause-specific interventions
(physical, functional, and psychosocial)
− Identify how current and proposed treatments and services are
expected to address causes, consequences, and risk factors, and help
attain overall goals for the individual
− Define anticipated benefits and risks of various interventions
− Clarify how specific treatments and services will be evaluated for
their effectiveness and possible adverse consequences

Identify the individual’s response to interventions and treatments
Identify factors that are affecting progress towards achieving goals
Define or refine the prognosis
Define or refine when to stop or modify interventions
Review effectiveness and adverse consequences related to treatments
Adjust interventions as needed
Identify when care objectives have been achieved sufficiently to
allow for discharge, transfer, or change in level of care

* Refers to key steps in the care delivery process, related to clinical problem solving and decision making
** Refers to key tasks at each step in the care delivery process

The care plan is driven not only by identified resident issues and/or conditions but also by a
resident’s unique characteristics, strengths, and needs. A care plan that is based on a thorough

October 2024

Page 4-9

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

assessment, effective clinical decision making, and is compatible with current standards of
clinical practice can provide a strong basis for optimal approaches to quality of care and quality
of life needs of individual residents. A well developed and executed assessment and care plan:
•
•
•
•
•
•
•
•

•

Looks at each resident as a whole human being with unique characteristics and strengths;
Views the resident in distinct functional areas for the purpose of gaining knowledge about
the resident’s functional status (MDS);
Gives the IDT a common understanding of the resident;
Re-groups the information gathered to identify possible issues and/or conditions that the
resident may have (i.e., triggers);
Provides additional clarity of potential issues and/or conditions by looking at possible
causes and risks (CAA process);
Develops and implements an interdisciplinary care plan based on the assessment
information gathered throughout the RAI process, with necessary monitoring and followup;
Reflects the resident’s/resident representative’s input, goals, and desired outcomes;
Provides information regarding how the causes and risks associated with issues and/or
conditions can be addressed to provide for a resident’s highest practicable level of wellbeing (care planning);
Re-evaluates the resident’s status at prescribed intervals (i.e., quarterly, annually, or if a
significant change in status occurs) using the RAI and then modifies the individualized
care plan as appropriate and necessary.

Following the decision to address a triggered condition on the care plan, key staff or the IDT
should subsequently:
•
•

Review and revise the current care plan, as needed; and
Communicate with the resident or their family or representative regarding the resident,
care plans, and their wishes.

The overall care plan should be oriented towards:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Assisting the resident in achieving their goals.
Individualized interventions that honor the resident’s preferences.
Addressing ways to try to preserve and build upon resident strengths.
Preventing avoidable declines in functioning or functional levels or otherwise clarifying why
another goal takes precedence (e.g., palliative approaches in end of life situation).
Managing risk factors to the extent possible or indicating the limits of such interventions.
Applying current standards of practice in the care planning process.
Evaluating treatment of measurable objectives, timetables and outcomes of care.
Respecting the resident’s right to decline treatment.
Offering alternative treatments, as applicable.

October 2024

Page 4-10

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

10. Using an interdisciplinary approach to care plan development to improve the resident’s
abilities.
11. Involving resident, resident’s family and other resident representatives as appropriate.
12. Assessing and planning for care to meet the resident’s goals, preferences, and medical,
nursing, mental and psychosocial needs.
13. Involving direct care staff with the care planning process relating to the resident’s
preferences, needs, and expected outcomes.

4.8 CAA Tips and Clarifications

Example:

Subject
Resident
Jones
OR I

Care planning is a process that has several steps that may occur at the same time or in sequence.
The following key steps and considerations may help the IDT develop the care plan after
completing the comprehensive assessment:
1) Care Plan goals should be measurable. The IDT may agree on intermediate goal(s) that
will lead to outcome objectives. Intermediate goal(s) and objectives must be pertinent to
the resident’s goals, preferences, condition, and situation (i.e., not just automatically
applied without regard for their individual relevance), measurable, and have a time frame
for completion or evaluation.
2) Care plan goal statements should include the subject (first or third person), the verb,
the modifiers, the time frame, and the goal(s).

Verb

Modifiers

will walk

fifty feet daily with
the help of one
nursing assistant

Time frame

the next 30 days

Goal
in order to maintain
continence and eat
in the dining area

3) A separate care plan is not necessarily required for each area that triggers a CAA. Since a
single trigger can have multiple causes and contributing factors and multiple items can
have a common cause or related risk factors, it is acceptable and may sometimes be more
appropriate to address multiple issues within a single care plan segment or to cross
reference related interventions from several care plan segments. For example, if impaired
ADL function, mood state, falls and altered nutritional status are all determined to be
caused by an infection and medication-related adverse consequences, it may be
appropriate to have a single care plan that addresses these issues in relation to the
common causes.
4) The RN coordinator is required to sign and date the Care Area Assessment (CAA)
Summary after all triggered CAAs have been reviewed to certify completion of the
comprehensive assessment (CAAs Completion Date, V0200B2). Facilities have 7 days
after completing the RAI assessment to develop or revise the resident’s care plan.
Facilities should use the date at V0200B2 to determine the date at V0200C2 by which the
care plan must be completed (V0200B2 + 7 days).
5) The 7-day requirement for completion or modification of the care plan applies to the
Admission, SCSA, SCPA, and/or Annual RAI assessments. A new care plan does

October 2024

Page 4-11

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

not need to be developed after each SCSA, SCPA, or Annual reassessment. Instead, the
nursing home may revise an existing care plan using the results of the latest
comprehensive assessment.
6) The resident’s care plan must be reviewed after each assessment, as required by §483.20,
except discharge assessments, and revised based on changing goals, preferences and
needs of the resident and in response to current interventions.
7) Residents’ preferences and goals may change throughout their stay, so facilities should
have ongoing discussions with the resident and resident representative, if applicable, so
that changes can be reflected in the comprehensive care plan.

8) If the RAI (MDS and CAAs) is not completed until the last possible date (the end of
calendar day 14 of the stay), many of the appropriate care area issues, risk factors, or
conditions may have already been identified, causes may have been considered, and a
preliminary care plan and related interventions may have been initiated. A complete care
plan is required no later than 7 days after the RAI is completed.
9) Review of the CAAs after completing the MDS may raise questions about the need to
modify or continue services. Conditions that originally triggered the CAA may no longer
be present because they resolved, or consideration of alternative causes may be necessary
because the initial approach to an issue, risk, or condition did not work or was not fully
implemented.
10) On the Annual assessment, if a resident triggers the same CAA(s) that triggered on the
last comprehensive assessment, the CAA should be reviewed again. Even if the CAA is
triggered for the same reason (no difference in MDS responses), there may be a new or
changed related event identified during CAA review that might call for a revision to the
resident’s plan of care. The IDT with the input of the resident, family or resident’s
representative determines when a problem or potential problem needs to be addressed in
the care plan.
11) The RN Coordinator for the CAA process (V0200B1) does not need to be the same RN
as the RN Assessment Coordinator who verifies completion of the MDS assessment
(Z0500). The date entered in V0200B2 on the CAA Summary is the date on which the
RN Coordinator for the CAA process verified completion of the CAAs, which includes
assessment of each triggered care area and completion of the location and date of the
CAA assessment documentation section. See Chapter 2 for detailed instructions on the
RAI completion schedule.
12) The Signature of Person Completing Care Plan Decision (V0200C1) can be that of any
person(s) who facilitates the care plan decision making. It is an interdisciplinary process.
The date entered in V0200C2 is the day the RN certifies that the CAAs have been
completed and the day V0200C1 is signed.

4.9 Using the Care Area Assessment (CAA) Resources
Based on the preceding discussions in this Chapter, the following summarizes the steps involved
in the CAA process, for those facilities that choose to use the CAA resources in this manual.

October 2024

Page 4-12

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Please note: Because MDS 3.0 trigger logic is complex, please refer to the CAT Logic
tables within each CAA description (Section 4.10) for detailed
information on triggers.

Step 1: Identification of Triggered CAAs. After completing the MDS, identify triggered care
areas. Many facilities will use automated systems to trigger CAAs. The resulting set of triggered
CAAs generated by the software program should be matched against the trigger definitions to
make sure that triggered CAAs have been correctly identified. CMS has developed test files for
facility validation of a software program’s triggering logic. Generally, software vendors use these
test files to test their systems, but the nursing home is responsible for ensuring that the software
is triggering correctly.

It is prudent to consider whether or not the software has triggered relevant CAAs for individual
residents. For example, did the software miss some CAAs you thought should have been
triggered? Do some of the CAAs seem to be missing and are there other CAAs triggered that you
did not expect?

For nursing homes that do not use an automated system, the CAT logic will provide the
information necessary to manually identify triggered CAAs. The CAT logic is found within the
CAT logic tables of each care area’s description in section 4.10. These tables provide the MDS
items that trigger the 20 (twenty) care areas. Facilities are not required to use this information or
to maintain it in the resident’s clinical record. Rather, the information is a resource that may be
used by the IDT members to determine which CAAs are triggered from a completed MDS.
To identify the triggered CAAs manually using the CAT logic tables in section 4.10:
1. Compare the completed MDS with the CAT logic tables to determine which CAAs have
been triggered for review.

2. The CAT logic table will list the MDS item numbers and specific codes that will trigger the
particular CAA. To identify a triggered CAA, match the resident’s MDS item responses with
the MDS item number(s) and code(s) for each care area as listed in the CAT logic tables
within section 4.10. If a particular item response matches a code in the CAT logic table for a
particular care area, read through the logic statement and qualifiers (i.e., ‘IF’, ‘AND’, and
‘OR’) for that particular care area to determine if that care area is triggered. This means that
further assessment using the CAA process is required for that particular care area.
3. Note which CAAs are triggered by particular MDS items. If desired, circle or highlight the
trigger indicator or the title of the column.
4. Continue through the CAT logic tables for each of the 20 (twenty) care areas matching
recorded MDS item responses with trigger indicators until all triggered CAAs have been
identified.

5. When the CAT logic review is completed, document on the CAA Summary which CAAs
were triggered by checking the boxes in the column titled “Care Area Triggered.”
Step 2: Analysis of Triggered CAAs. Review a triggered CAA by doing an in-depth, residentspecific assessment of the triggered condition in terms of the potential need for care plan
interventions. While reviewing the CAA, consider what MDS items caused the CAA to be
triggered. This is also an opportunity to consider any issues and/or conditions that may contribute
to the triggered condition, but are not necessarily captured in MDS data. Review of CAAs helps
October 2024

Page 4-13

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

staff to decide if care plan intervention is necessary, and what types of intervention may be
appropriate.
Using the results of the assessment can help the interdisciplinary team (IDT) and the resident
and/or resident’s representative to identify areas of concern that:
•

Warrant intervention;

•

Affect the resident’s capacity to help identify and implement interventions to improve,
stabilize, or maintain current level of function to the extent possible, based upon the
resident’s condition and choices and preferences for interventions;
Can help to minimize the onset or progression of impairments and disabilities; and
Can help to address the need and desire for other specialized services (e.g. palliative care,
including symptom relief and pain management).

•
•

Example:

Use the information gathered thus far to make a clear issue or problem statement. An issue or
problem is different from a finding (e.g., a single piece of information from the MDS or a test
result). The chief complaint (e.g., the resident has a headache, is vomiting, or is not participating
in activities) is not the same thing as an issue or problem statement that clearly identifies the
situation. Trying to care plan a chief complaint may lead to inappropriate, irrelevant, or
problematic interventions.

Chief Complaint: New onset of falls

Problem Statement: Resident currently falling 2-3 times per week. Falls are preceded by
lightheadedness. Most falls occurred after they stood up and started walking; a few falls occurred
while attempting to stand up from a sitting or lying position.
It is clear that the problem statement reflects assessment findings from which the investigation
may continue and relevant conclusions drawn.

While the CAAs can help the IDT identify conditions or findings that could potentially be a
problem or risk for the resident, additional thought is needed to define these issues and determine
whether and to what extent the care area issue and/or condition is a problem or issue needing an
intervention (assessment, testing, treatment, etc.) or simply a minor or inconsequential finding
that does not need additional care planning. For example, a resident may exhibit sadness without
being depressed or may appear to be underweight despite having a stable nutritional status
consistent with their past history. The IDT should identify and document the functional and
behavioral implications of identified problematic issues/conditions, limitations, improvement
possibilities, and so forth (e.g., how the condition is a problem for the resident; how the condition
limits or impairs the resident’s ability to complete activities of daily living; or how the condition
affects the resident’s well-being in some way).
Identify links among triggers and their causes. CMS does not require that each care area
triggered be care planned separately. The IDT may find during their discussions that several
problematic issues and/or conditions have a related cause, or they might identify that those issues
and/or conditions stand alone and are unrelated. Goals and approaches for each problematic issue
October 2024

Page 4-14

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

and/or condition may overlap, and consequently the IDT may decide to address the problematic
issues and/or conditions collectively in the care plan.
For example, behavior, mood, cognition, communication, and psychosocial well-being typically
have common risk factors and common or closely related causes of related impairments. Thus,
the following CATs naturally coexist and could be combined, assessed through the CAA process,
and care planned together as a starting point for any resident: Delirium (CAA #1), Cognitive
Loss/Dementia (CAA #2), Communication (CAA #4), Psychosocial Well-Being (CAA #7),
Mood State (CAA #8) Behavioral Symptoms (CAA #9), and Psychotropic Drug Use (CAA #17).

Usually, illnesses and impairments happen in sequence (i.e., one thing leads to another, which
leads to another, and so on). The symptom or trigger often represents only the most recent or
most apparent finding in a series of complications or related impairments. Thus, a detailed
history is often essential to identifying causes and selecting the most beneficial interventions,
e.g., the sequence over time of how the resident developed incontinence, pain, or anorexia. While
the MDS presents diverse information about residents, and the CAAs cover various implications
and complications, neither one is designed to give a detailed or chronological medical,
psychosocial, or personal history. For example, knowing that the Behavioral Symptoms CAA
(#9) is triggered and that the resident also has a diagnosis of UTI is not enough information to
know whether the diagnosis of UTI is old or new, whether there is any link between the
behavioral issue and the UTI, and whether there are other conditions such as kidney stones or
bladder obstruction that might be causing or predisposing the resident to a UTI.
It is the facility’s responsibility to refer to sources as needed to help with clinical problem solving
and decision making that is consistent with professional standards of practice. It is often
necessary to involve the attending physician to identify specific underlying causes of problems,
including multiple causes of a single problem or multiple problems or complications related to
one or more underlying causes.

Steps 3 and 4: Decision Making and CAA Documentation. The care plan is driven not only by
identified resident issues and/or conditions but also by a resident’s unique characteristics, goals,
preferences, strengths, and needs. The resident, family, or resident’s representative should be an
integral part of the team care planning process. A care plan that is based on a thorough
assessment, effective clinical decision making, and is compatible with professional standards of
practice should support optimal approaches to addressing quality of care and quality of life needs
of individual residents.
Key components of the care plan may include, but are not limited to the following:
•

Resident goals and preferences

•

Measureable objective with established timeframes

•

Specific interventions, including those that address common causes of multiple issues

•

Additional follow-up and clarification

•

Items needing additional assessment, testing, and review with the practitioner

•

Items that may require additional monitoring but do not require other interventions

October 2024

Page 4-15

CMS’s RAI Version 3.0 Manual

•

CH 4: CAA Process and Care Planning

The resident’s preference and potential for future discharge and discharge plan

Staff who have participated in the assessment and who have provided pertinent information about
the resident’s status for triggered care areas should be a part of the IDT that develops the
resident’s care plan. In order to provide continuity of care for the resident and good
communication with all persons involved in the resident’s care, information from the assessment
that led the team to their care planning decision should be clearly documented. See Table 2.
Clinical Problem Solving and Decision Making Process Steps and Objectives.
Documentation related to CAAs should include the items previously discussed in Section 4.5.

4.10 The Twenty Care Areas

NOTE: Each of the following descriptions of the Twenty Care Areas includes a table listing the
Care Area Trigger (CAT) logical specifications. For those MDS items that require a numerical
response, the logical specifications will reference the numerical response that triggered the Care
Area. For those MDS items that require a check mark response (e.g. H0100, J0800, K0520, etc.),
the logical specifications will reference this response in numerical form when the check box
response is one that triggers a Care Area. Therefore, in the tables below, when a check mark has
been placed in a check box item on the MDS and triggers a Care Area, the logical specifications
will reference a value of “1.” Example: “H0100A=1” means that a check mark has been placed
in the check box item H0100A. Similarly, the Care Area logical specifications will reference a
value of "0" (zero) to indicate that a check box item is not checked. Example: "I4800=0" means
that a check mark has not been placed in the check box item I4800.

1. Delirium

Delirium is acute brain failure caused by medical conditions, which presents with psychiatric
symptoms, acute confusion, and fluctuations in levels of consciousness. It is a serious condition
that can be caused by medical issues/conditions such as medication-related adverse
consequences, infections, or dehydration. It can easily be mistaken for the onset or progression of
dementia, particularly in individuals with more advanced pre-existing dementia.
Unlike dementia, delirium typically has a rapid onset (hours to days). Typical signs include
fluctuating states of consciousness; disorientation; decreased environmental awareness and
behavioral changes; difficulty paying attention; fluctuating behavior or cognitive function
throughout the day; restlessness; sleepiness periodically during the day; rambling, nonsensical
speech; and altered perceptions, such as misinterpretations (illusions), seeing or feeling things
that are not there (hallucinations), or a fixed false belief (delusions).

October 2024

Page 4-16

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Delirium CAT Logic Table
Triggering Conditions (any of the following):
1. Symptoms of delirium are indicated by the presence of an acute mental status change
and/or the presence of inattention, disorganized thinking or altered mental status on the
current non-admission comprehensive assessment (A0310A = 03, 04 or 05) as indicated
by:
(a)
C1310A = 1
AND

C1310B = 1 or 2
AND EITHER

C1310C = 1 or 2 OR C1310D = 1 or 2

(b)

C1310B, C1310C or C1310D = 2
AND

C1310B = 1 or 2
AND EITHER

C1310C = 1 or 2 OR C1310D = 1 or 2

Delirium is never a part of normal aging, and it is associated with high mortality and morbidity
unless it is recognized and treated appropriately. Staff who are closely involved with residents
should report promptly any new onset or worsening of cognitive impairment and the other
aforementioned symptoms in that resident.

When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered if the resident is exhibiting an acute
change in mental status and/or the presence of inattention, disorganized thinking or altered
mental status.

The information gleaned from the assessment should be used to identify and address the
underlying clinical issue(s) and/or condition(s), as well as to identify related underlying causes
and contributing and/or risk factors. The next step is to develop an individualized care plan based
directly on these conclusions. The focus of the care plan should be to address the underlying
clinical issues/conditions identified through this assessment process (e.g., treating infections,
addressing dehydration, identifying and treating hypo- or hyperthyroidism, relieving pain and
depression, managing medications, and promoting adaptation and a comfortable environment for
the resident to function. Other simple preventive measures that can be applied in all settings

October 2024

Page 4-17

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

include addressing hearing and visual impairments to the extent possible (e.g., with the use of
glasses and hearing aids) and minimizing the use of indwelling urinary catheters.

2. Cognitive Loss/Dementia

Cognitive prerequisites for an independent life include the ability to remember recent events and
the ability to make safe daily decisions. Although the aging process may be associated with mild
impairment, decline in cognition is often the result of other factors such as delirium, another
mental health issue and/or condition, a stroke, and/or dementia. Dementia is not a specific
condition but a syndrome that may be linked to several causes. According to the Diagnostic and
Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR), the dementia syndrome is
defined by the presence of three criteria: a short-term memory issue and/or condition and trouble
with at least one cognitive function (e.g., abstract thought, judgment, orientation, language,
behavior) and these troubles have an impact on the performance of activities of daily living. The
cognitive loss/dementia CAA focuses on declining or worsening cognitive abilities that threaten
personal independence and increase the risk for long-term nursing home placement or impair the
potential for return to the community.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when a resident has evidence of cognitive
loss.

ra
Cognitive Loss/Dementia CAT Logic Table

Triggering Conditions (any of the following):

1. BIMS summary score is less than 13 as indicated by:
C0500 >= 00 AND C0500 < 13
2. BIMS summary score has a missing value and there is a problem with short-term memory
as indicated by:
(C0500 = 99, -, OR ^) AND
(C0700 = 1)
3. BIMS summary score has a missing value and there is a problem with long-term memory
as indicated by:
(C0500 = 99, -, OR ^) AND
(C0800 = 1)
4. BIMS summary score has missing value of 99 or – and at least some difficulty making
decisions regarding tasks of daily life as indicated by:
(C0500 = 99, -, OR ^) AND
(C1000 >= 1 AND C1000 <= 3)
5. BIMS, staff assessment or clinical record suggests presence of inattention, disorganized
thinking or altered level of consciousness as indicated by:
(C1310B = 1 OR C1310B = 2) OR

October 2024

Page 4-18

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Cognitive Loss/Dementia CAT Logic Table

(C1310C = 1 OR C1310C = 2) OR
(C1310D = 1 OR C1310D = 2)
6. Presence of any behavioral symptom (verbal, physical or other) as indicated by:
(E0200A >= 1 AND E0200A <= 3) OR
(E0200B >= 1 AND E0200B <= 3) OR
(E0200C >= 1 AND E0200C <= 3)
7. Rejection of care occurred at least 1 day in the past 7 days as indicated by:
E0800 >= 1 AND E0800 <= 3
8. Wandering occurred at least 1 day in the past 7 days as indicated by:
E0900 >= 1 AND E0900 <= 3

3. Visual Function

The information gleaned from the assessment should be used to evaluate the situation, to identify
and address (where possible) the underlying cause(s) of cognitive loss/dementia, as well as to
identify any related possible contributing and/or risk factors. The next step is to develop an
individualized care plan based directly on these conclusions. It is important to define the nature
of the impairment, e.g., identify whether the cognitive issue and/or condition is new or a
worsening or change in existing cognitive impairment—characteristics of potentially reversible
delirium—or whether it indicates a long-term, largely irreversible cognitive loss. If the issue
and/or condition is apparently not related to reversible causes, assessment should focus on the
details of the cognitive issue/condition (i.e., forgetfulness and/or impulsivity and/or behavior
issues/conditions, etc.) and risk factors for the resident presented by the cognitive loss, to
facilitate care planning specific to the resident’s needs, issues and/or conditions, and strengths.
The focus of the care plan should be to optimize remaining function by addressing underlying
issues identified through this assessment process, such as relieving pain, optimizing medication
use, ensuring optimal sensory input (e.g., with the use of glasses and hearing aids), and
promoting as much social and functional independence as possible while maintaining health and
safety.

The aging process leads to a decline in visual acuity, for example, a decreased ability to focus on
close objects or to see small print, a reduced capacity to adjust to changes in light and dark and
diminished ability to discriminate colors. The safety and quality consequences of vision loss are
wide ranging and can seriously affect physical safety, self-image, and participation in social,
personal, self-care, and rehabilitation activities.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when a resident has a diagnosis of
glaucoma, macular degeneration or cataracts or B1000 is coded 1-4.

October 2024

Page 4-19

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Visual Function CAT Logic Table
Triggering Conditions (any of the following):
1. Cataracts, glaucoma, or macular degeneration on the current assessment as indicated
by:
I6500 = 1
2. Vision item has a value of 1 through 4 indicating vision problems on the current
assessment as indicated by:
B1000 >= 1 AND B1000 <= 4

The information gleaned from the assessment should be used to identify and address the
underlying cause(s) of the resident’s declining visual acuity, identifying residents who have
treatable conditions that place them at risk of permanent blindness (e.g., glaucoma, diabetes,
retinal hemorrhage) and those who have impaired vision whose quality of life could be improved
through use of appropriate visual appliances, as well as to determine any possibly related
contributing and/or risk factors. The next step is to develop an individualized care plan based
directly on these conclusions. The focus of the care plan should be to prevent decline when
possible and to enhance vision to the extent possible when reversal of visual impairment is not
possible, as well as to address any underlying clinical issues and/or conditions identified through
the CAA or subsequent assessment process. This might include treating infections and glaucoma
or providing appropriate glasses or other visual appliances to improve visual acuity, quality of
life, and safety.

4. Communication

Normal communication involves related activities, including expressive communication (making
oneself understood to others, both verbally and via non-verbal exchange) and receptive
communication (comprehending or understanding the verbal, written, or visual communication
of others). Typical expressive issues and/or conditions include disruptions in language, speech,
and voice production. Typical receptive communication issues and/or conditions include changes
or difficulties in hearing, speech discrimination, vocabulary comprehension, and reading and
interpreting facial expressions. While many conditions can affect how a person expresses and
comprehends information, the communication CAA focuses on the interplay between the
person’s communication status and their cognitive skills for everyday decision making.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when a resident’s ability to hear, to
express ideas and wants, or to understand verbal content may be impaired.

October 2024

Page 4-20

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Communication CAT Logic Table
Triggering Conditions (any of the following):
1. Hearing item has a value of 1 through 3 indicating hearing problems on the current
assessment as indicated by:
B0200 >= 1 AND B0200 <= 3
2. Impaired ability to make self understood through verbal and non-verbal expression of
ideas/wants as indicated by:
B0700 >= 1 AND B0700 <= 3
3. Impaired ability to understand others through verbal content as indicated by:
B0800 >= 1 AND B0800 <= 3

The information gleaned from the assessment should be used to evaluate the characteristics of the
problematic issue/condition and the underlying cause(s), the success of any attempted remedial
actions, the person's ability to compensate with nonverbal strategies (e.g., the ability to visually
follow non-verbal signs and signals), and the willingness and ability of caregivers to ensure
effective communication. The assessment should also help to identify any related possible
contributing and/or risk factors. The next step is to develop an individualized care plan based
directly on these conclusions. The focus of the care plan should be to address any underlying
issues/conditions and causes, as well as verbal and nonverbal strategies, in order to help the
resident improve quality of life, health, and safety. In the presence of reduced language skills,
both caregivers and the resident can strive to expand their nonverbal communication skills, for
example, touch, facial expressions, eye contact, hand movements, tone of voice, and posture.

5. ADL Functional/Rehabilitation Potential

The ADL Functional/Rehabilitation CAA addresses the resident’s self-sufficiency in performing
basic activities of daily living, including dressing, personal hygiene, walking, transferring, toilet
use, bed mobility, and eating. Nursing home staff should identify and address, to the extent
possible, any issues or conditions that may impair function or impede efforts to improve that
function. The resident’s potential for improved functioning should also be clarified before
rehabilitation is attempted.

When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when a resident requires assistance to
improve performance or to prevent avoidable functional decline.

The information gleaned from the assessment should be used to identify the resident’s actual
functional deficits and risk factors, as well as to identify any possible contributing and/or risk
factors related to the functional issues/conditions. The next step is to develop an individualized
care plan based directly on these conclusions. The focus of the care plan should be to address the
underlying cause or causes, improving or maintaining function when possible, and preventing
additional decline when improvement is not possible. An ongoing assessment is critical to
identify and address risk factors that can lead to functional decline.
October 2024

Page 4-21

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

ADL Functional/Rehabilitation Potential CAT Logic Table
Triggering Conditions (any of the following):
Cognitive skills for daily decision making has a value of 0 through 2 or BIMS summary
score is 5 or greater:
((C1000 >= 0 AND C1000 <= 2) OR
(C0500 >= 5 AND C0500 <= 15)) AND
ADL assistance was required for any of the self-care or mobility activities as indicated by any
of the following:
GG0130X1 = 01–05 OR
GG0130A5 = 01–05 OR

GG0130B5 = 01–05 OR

GG0130C5 = 01–05 OR
GG0130E5 = 01–05 OR
GG0130F5 = 01–05 OR

GG0130G5 = 01–05 OR
GG0130H5 = 01–05 OR
GG0130I5 = 01–05 OR

GG0170X1 = 01–05 OR
GG0170A5 = 01–05 OR
GG0170B5 = 01–05 OR

GG0170C5 = 01–05 OR

GG0170D5 = 01–05 OR
GG0170E5 = 01–05 OR
GG0170F5 = 01–05 OR

GG0170FF5 = 01–05 OR
GG0170I5 = 01–05 OR

GG0170J5 = 01–05 OR

GG0170K5 = 01–05 OR
GG0170R5 = 01–05 OR
GG0170S5 = 01–05

October 2024

Page 4-22

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

6. Urinary Incontinence and Indwelling Catheter
Urinary incontinence is the involuntary loss or leakage of urine or the inability to urinate in a
socially acceptable manner. There are several types of urinary incontinence (e.g., functional,
overflow, stress, and urge) and the individual resident may experience more than one type at a
time (mixed incontinence).
Although aging affects the urinary tract and increases the potential for urinary incontinence,
urinary incontinence itself is not a normal part of aging. Urinary incontinence can be a risk factor
for various complications, including skin rashes, falls, and social isolation. Often, it is at least
partially correctable. Incontinence may affect a resident’s psychological well-being and social
interactions. Incontinence also may lead to the potentially troubling use of indwelling catheters,
which can increase the risk of life threatening infections.

This CAA is triggered if the resident is incontinent of urine or uses a urinary catheter. When this
CAA is triggered, nursing home staff should follow their facility’s chosen protocol or policy for
performing the CAA.
Urinary Incontinence and Indwelling Catheter CAT Logic Table

Triggering Conditions (any of the following):

1. ADL assistance for toileting hygiene or toilet transfer was needed as indicated by:
GG0130C1 = 01–05 OR GG0130C5 = 01–05 OR GG0170F1 = 01–05
OR GG0170F5 = 01–05
2. Resident requires an indwelling catheter as indicated by:
H0100A = 1
3. Resident requires an external catheter as indicated by:
H0100B = 1
4. Resident requires intermittent catheterization as indicated by:
H0100D = 1
5. Urinary incontinence has a value of 1 through 3 as indicated by:
H0300 >= 1 AND H0300 <= 3
6. Resident has moisture associated skin damage as indicated by:
M1040H = 1

Successful management will depend on accurately identifying the underlying cause(s) of the
incontinence or the reason for the indwelling catheter. Some of the causes can be successfully
treated to reduce or eliminate incontinence episodes or the reason for catheter use. Even when
incontinence cannot be reduced or resolved, effective incontinence management strategies can
prevent complications related to incontinence. Because of the risk of substantial complications
with the use of indwelling urinary catheters, they should be used for appropriate indications and
when no other viable options exist. The assessment should include consideration of the risks and

October 2024

Page 4-23

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

benefits of an indwelling (suprapubic or urethral) catheter, the potential for removal of the
catheter, and consideration of complications resulting from the use of an indwelling catheter
(e.g., urethral erosion, pain, discomfort, and bleeding). The next step is to develop an
individualized care plan based directly on these conclusions.

7. Psychosocial Well-Being
Involvement in social relationships is a vital aspect of life, with most adults having meaningful
relationships with family, friends, and neighbors. When these relationships are challenged, it can
cloud other aspects of life. Decreases in a person’s social relationships may affect psychological
well-being and have an impact on mood, behavior, and physical activity. Similarly, declines in
physical functioning or cognition or a new onset or worsening of pain or other health or mental
health issues/conditions may affect both social relationships and mood. Psychosocial well-being
may also be negatively impacted when a person has significant life changes such as the death of
a loved one. Thus, other contributing factors also must be considered as a part of this assessment.

When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when a resident exhibits minimal interest
in social involvement.
Psychosocial Well-Being CAT Logic Table

Triggering Conditions (any of the following):

1. Resident mood interview indicates the presence of little interest or pleasure in doing
things as indicated by:
D0150A1 = 1
2. Staff assessment of resident mood indicates the presence of little interest or pleasure
in doing things as indicated by:
D0500A1 = 1
3. Interview for activity preference item “How important is it to you to do your favorite
activities?” has a value of 3 or 4 as indicated by:
F0500F = 3 OR F0500F = 4
4. Staff assessment of daily and activity preferences did not indicate that resident prefers
participating in favorite activities:
F0800Q = 0
5. Physical behavioral symptoms directed toward others has a value of 1 through 3 and
neither dementia nor Alzheimer's disease is present as indicated by:
(E0200A >= 1 AND E0200A <= 3) AND
(I4800 = 0 OR I4800 = -) AND
(I4200 = 0 OR I4200 = -)
6. Verbal behavioral symptoms directed toward others has a value of 1 through 3 and
neither dementia nor Alzheimer's disease is present as indicated by:

October 2024

Page 4-24

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

(E0200B >=1 AND E0200B <= 3) AND
(I4800 = 0 OR I4800 = -) AND
(I4200 = 0 OR I4200 = -)
7. Any six items for interview for activity preferences has the value of 4 and resident is
primary respondent for daily and activity preferences as indicated by:
(Any 6 of F0500A through F0500H = 4) AND
(F0600 = 1)

The information gleaned from the assessment should be used to identify whether their minimal
involvement is typical or customary for that person or a possible indication of a problem. If it is
problematic, then address the underlying cause(s) of the resident’s minimal social involvement
and factors associated with reduced social relationships and engagement, as well as to identify
any related possible contributing and/or risk factors. The next step is to develop an individualized
care plan based directly on these conclusions. The focus of the care plan should be to address the
underlying cause or causes in order to stimulate and facilitate social engagement.

8. Mood State

Sadness and anxiety are normal human emotions, and fluctuations in mood are also normal. But
mood states (which reflect more enduring patterns of emotions) may become as extreme or
overwhelming as to impair personal and psychosocial function. Mood disorders such as
depression reflect a problematic extreme and should not be confused with normal sadness or
mood fluctuation.

The mood section of the MDS screens for—but is not intended to definitively diagnose—any
mood disorder, including depression. Mood disorders may be expressed by sad mood, feelings of
emptiness, anxiety, or uneasiness. They may also result in a wide range of bodily complaints and
dysfunctions, including weight loss, tearfulness, agitation, aches, and pains. However, because
none of these symptoms is specific for a mood disorder, diagnosis of mood disorders requires
additional assessment and confirmation of findings. In addition, other problems (e.g., lethargy,
fatigue, weakness, or apathy) with different causes, which require a very different approach, can
be easily confused with depression.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered if the Resident Mood Interview, Staff
Assessment of Mood, or certain other specific issues indicate a mood issue and/or condition may
be present.

October 2024

Page 4-25

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Mood State CAT Logic Table
Triggering Conditions (any of the following):
1. Resident has had thoughts they would be better off dead, or thoughts of hurting
themself as indicated by:
D0150I1 = 1
2. Staff assessment of resident mood suggests resident states life isn’t worth living,
wishes for death, or attempts to harm self as indicated by:
D0500I1 = 1

3. The resident mood interview total severity score has a non-missing value (0 to 27) on
both the current non-admission comprehensive assessment (A0310A = 03, 04, or 05)
and the prior assessment, and the resident interview summary score on the current
non-admission comprehensive assessment (D0160) is greater than the prior
assessment (V0100E) as indicated by:
((A0310A = 03) OR (A0310A = 04) OR (A0310A = 05)) AND
((D0160 >= 00) AND (D0160 <= 27)) AND

((V0100E >= 00) AND (V0100E <= 27)) AND
(D0160 > V0100E)

4. The resident mood interview is not successfully completed (missing value on D0160),
the staff assessment of resident mood has a non-missing value (0 to 30) on both the
current non-admission comprehensive assessment (A0310A = 03, 04, or 05) and the
prior assessment, and the staff assessment current total severity score on the current
non-admission comprehensive assessment (D0600) is greater than the prior
assessment (V0100F) as indicated by:

((A0310A = 03) OR (A0310A = 04) OR (A0310A = 05)) AND
((D0160 < 00) OR (D0160 > 27)) AND

((D0600 >= 00) AND (D0600 <= 30)) AND

((V0100F >= 00) AND (V0100F <= 30)) AND
(D0600 > V0100F)

5. The resident mood interview is successfully completed and the current total severity
score has a value of 10 through 27 as indicated by:
D0160 >= 10 AND D0160 <= 27

6. The staff assessment of resident mood is recorded and the current total severity score
has a value of 10 through 30 as indicated by:
D0600 >= 10 AND D0600 <= 30

October 2024

Page 4-26

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

The information gleaned from the assessment should be used as a starting point to assess further
in order to confirm a mood disorder and get enough detail of the situation to consider whether
treatment is warranted. If a mood disorder is confirmed, the individualized care plan should, in
part, focus on identifying and addressing underlying causes, to the extent possible.

9. Behavioral Symptoms
In the world at large, human behavior varies widely and is often dysfunctional and problematic.
While behavior may sometimes be related to or caused by illness, behavior itself is only a
symptom and not a disease. The MDS only identifies certain behaviors, but is not intended to
determine the significance of behaviors, including whether they are problematic and need an
intervention.

Therefore, it is essential to assess behavior symptoms carefully and in detail in order to
determine whether, and why, behavior is problematic and to identify underlying causes. The
behavior CAA focuses on potentially problematic behaviors in the following areas: wandering
(e.g., moving with no rational purpose, seemingly being oblivious to needs or safety), verbal
abuse (e.g., threatening, screaming at, or cursing others), physical abuse (e.g., hitting, shoving,
kicking, scratching, or sexually abusing others), other behavioral symptoms not directed at others
(e.g., making disruptive sounds or noises, screaming out, smearing or throwing food or feces,
hoarding, rummaging through other’s belongings), inappropriate public sexual behavior or public
disrobing, and rejection of care (e.g., verbal or physical resistance to taking medications, taking
injections, completing a variety of activities of daily living or eating). Understanding the nature
of the issue/condition and addressing the underlying causes have the potential to improve the
quality of the resident’s life and the quality of the lives of those with whom the resident interacts.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when the resident is identified as
exhibiting certain troubling behavioral symptoms.

ft
October 2024

Page 4-27

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Behavioral Symptoms CAT Logic Table
Triggering Conditions (any of the following):
1. Rejection of care has a value of 1 through 3 indicating resident has rejected evaluation
or care necessary to achieve their goals for health and well-being as indicated by:
E0800 >= 1 AND E0800 <= 3
2. Wandering has a value of 1 through 3 as indicated by:
E0900 >= 1 AND E0900 <= 3
3. Change in behavior indicates behavior, care rejection or wandering has gotten worse
since prior assessment as indicated by:
E1100 = 2

4. Presence of at least one behavioral symptom as indicated by:
E0300 = 1

The information gleaned from the assessment should be used to determine why the resident’s
behavioral symptoms are problematic in contrast to a variant of normal, whether and to what
extent the behavior places the resident or others at risk for harm, and any related contributing
and/or risk factors. The next step is to develop an individualized care plan based directly on these
conclusions. The focus of the care plan should be to address the underlying cause or causes,
reduce the frequency of truly problematic behaviors, and minimize any resultant harm.

10. Activities

The capabilities of residents vary, especially as abilities and expectations change, illness
intervenes, opportunities become less frequent, and/or extended social relationships become less
common. The purpose of the activities CAA is to identify strategies to help residents become
more involved in relevant activities, including those that have interested and stimulated them in
the past and/or new or modified ones that are consistent with their current functional and
cognitive capabilities.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when the resident may have evidence of
decreased involvement in social activities.

October 2024

Page 4-28

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Activities CAT Logic Table
Triggering Conditions (any of the following):
1. Resident has little interest or pleasure in doing things as indicated by:
D0150A1 = 1
2. Staff assessment of resident mood suggests resident states little interest or pleasure in
doing things as indicated by:
D0500A1 = 1
3. Any 6 items for interview for activity preferences has the value of 4 (not important at
all) or 5 (important, but cannot do or no choice) as indicated by:
Any 6 of F0500A through F0500H = 4 or 5

4. Any 6 items for staff assessment of activity preference item L through T are not
checked as indicated by:
Any 6 of F0800L through F0800T = 0

11. Falls

The information gleaned from the assessment should be used to identify residents who have
either withdrawn from recreational activities or who are uneasy entering into activities and social
relationships, to identify the resident’s interests, and to identify any related possible contributing
and/or risk factors. The next step is to develop an individualized care plan based directly on these
conclusions. The care plan should focus on addressing the underlying cause(s) of activity
limitations and the development or inclusion of activity programs tailored to the resident’s
interests and to their cognitive, physical/functional, and social abilities and improve quality of
life.

A “fall” refers to unintentionally coming to rest on the ground, floor, or other lower level but not
as a result of an 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.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when the resident has had recent history
of falls and balance problems.

October 2024

Page 4-29

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Falls CAT Logic Table
Triggering Conditions (any of the following):
1. Wandering occurs as indicated by a value of 1 through 3 as follows:
E0900 >= 1 AND E0900 <= 3
2. For OBRA admission assessment: fall history at admission indicates resident fell
anytime in the last month prior to admission as indicated by:
If A0310A = 01 AND J1700A = 1
3. For OBRA admission assessment: fall history at admission indicates resident fell
anytime in the last 2 to 6 months prior to admission as indicated by:
If A0310A = 01 AND J1700B = 1

4. Resident has fallen at least one time since admission or the prior assessment as
indicated by:
J1800 = 1

5. Resident received antianxiety medication during the last 7 days or since
admission/entry or reentry as indicated by:

N0415B1 = 1

6. Resident received antidepressant medication during the last 7 days or since
admission/entry or reentry as indicated by:
N0415C1 = 1

7. Trunk restraint used in bed as indicated by a value of 1 or 2 as follows:
P0100B = 1 OR P0100B = 2

8. Trunk restraint used in chair or out of bed as indicated by a value of 1 or 2 as follows:

P0100E = 1 OR P0100E = 2

The information gleaned from the assessment should be used to identify and address the
underlying cause(s) of the resident’s fall(s), as well as to identify any related possible causes and
contributing and/or risk factors. The next step is to develop an individualized care plan based
directly on these conclusions. The focus of the care plan should be to address the underlying
cause(s) of the resident’s fall(s), as well as the factors that place them at risk for falling.

12. Nutritional Status
Undernutrition is not a response to normal aging, but it can arise from many diverse causes, often
acting together. It may cause or reflect acute or chronic illness, and it represents a risk factor for
subsequent decline.
The Nutritional Status CAA process reflects the need for an in-depth analysis of residents with
impaired nutrition and those who are at nutritional risk. This CAA triggers when a resident has or
October 2024

Page 4-30

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

is at risk for a nutrition issue/condition. Some residents who are triggered for follow-up will
already be significantly underweight and thus undernourished, while other residents will be at
risk of undernutrition. This CAA may also trigger based on loss of appetite with little or no
accompanying weight loss and despite the absence of obvious, outward signs of impaired
nutrition.
Nutritional Status CAT Logic Table
Triggering Conditions (any of the following):

1. Dehydration is selected as a problem health condition as indicated by:
J1550C = 1
2. Body mass index (BMI) is too low or too high as indicated by:

BMI < 18.5000 OR BMI > 24.9000

3. Any weight loss as indicated by a value of 1 or 2 as follows:
K0300 = 1 OR K0300 = 2

4. Any planned or unplanned weight gain as indicated by a value of 1 or 2 as follows:
K0310 = 1 OR K0310 = 2

5. Parenteral/IV feeding while NOT a resident or while a resident is used as nutritional
approach as indicated by:
K0520A2 = 1 OR K0520A3 = 1

6. Mechanically altered diet while a resident is used as nutritional approach as indicated by:
K0520C3 = 1

7. Therapeutic diet while a resident is used as nutritional approach as indicated by:
K0520D3 = 1

8. Resident has one or more unhealed pressure ulcer(s) at Stage 2 or higher, or one or more
likely pressure ulcers that are unstageable at this time as indicated by:
((M0300B1 > 0 AND M0300B1 <= 9) OR
(M0300C1 > 0 AND M0300C1 <= 9) OR
(M0300D1 > 0 AND M0300D1 <= 9) OR
(M0300E1 > 0 AND M0300E1 <= 9) OR
(M0300F1 > 0 AND M0300F1 <= 9) OR
(M0300G1 > 0 AND M0300G1 <= 9))

13. Feeding Tubes
This CAA focuses on the long-term (greater than 1 month) use of feeding tubes. It is important to
balance the benefits and risks of feeding tubes in individual residents in deciding whether to
October 2024

Page 4-31

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

make such an intervention a part of the plan of care. In some acute and longer term situations,
feeding tubes may provide adequate nutrition that cannot be obtained by other means. In other
circumstances, feeding tubes may not enhance survival or improve quality of life, e.g., in
individuals with advanced dementia. Also, feeding tubes can be associated with diverse
complications that may further impair quality of life or adversely impact survival. For example,
tube feedings will not prevent aspiration of gastric contents or oral secretions and feeding tubes
may irritate or perforate the stomach or intestines.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when the resident has a need for a feeding
tube for nutrition.
Feeding Tubes CAT Logic Table

Triggering Conditions (any of the following):
1. Feeding tube while NOT a resident or while a resident is used as nutritional approach
as indicated by:
K0520B2 = 1 OR K0520B3 = 1

The information gleaned from the assessment should be used to identify and address the
resident’s status and underlying issues/conditions that necessitated the use of a feeding tube. In
addition, the CAA information should be used to identify any related risk factors. The next step is
to develop an individualized care plan based directly on these conclusions. The focus of the care
plan should be to address the underlying cause(s), including any reversible issues and conditions
that led to using a feeding tube.

14. Dehydration/Fluid Maintenance

Dehydration is a condition in which there is an imbalance of water and related electrolytes in the
body. As a result, the body may become less able to maintain adequate blood pressure and
electrolyte balance, deliver sufficient oxygen and nutrients to the cells, and rid itself of wastes. In
older persons, diagnosing dehydration is accomplished primarily by a detailed history, laboratory
testing (e.g., electrolytes, BUN, creatinine, serum osmolality, urinary sodium), and to a lesser
degree by a physical examination. Abnormal vital signs, such as falling blood pressure and an
increase in the pulse rate, may sometimes be meaningful symptoms of dehydration in the elderly.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA.

October 2024

Page 4-32

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Dehydration/Fluid Maintenance CAT Logic Table
Triggering Conditions (any of the following):
1. Fever is selected as a problem health condition as indicated by:
J1550A = 1
2. Vomiting is selected as a problem health condition as indicated by:
J1550B = 1
3. Dehydration is selected as a problem health condition as indicated by:
J1550C = 1
4. Internal bleeding is selected as a problem health condition as indicated by:

J1550D = 1

5. Infection present as indicated by:

(I1700 = 1) OR
(I2000 = 1) OR
(I2100 = 1) OR

(I2200 = 1) OR
(I2300 = 1) OR
(I2400 = 1) OR
(I2500 = 1) OR

((M1040A = 1))

6. Constipation present as indicated by:

H0600 = 1

7. Parenteral/IV feeding while NOT a resident or while a resident is used as nutritional
approach as indicated by:
K0520A2 = 1 OR K0520A3 = 1

8. Feeding tube while NOT a resident or while a resident is used as nutritional approach
as indicated by:
K0520B2 = 1 OR K0520B3 = 1

The information gleaned from the assessment should be used to identify whether the resident is
dehydrated or at risk for dehydration, as well as to identify any related possible causes and
contributing and/or risk factors. The next step is to develop an individualized care plan based
directly on these conclusions. The focus of the care plan should be to prevent dehydration by
addressing risk factors, to maintain or restore fluid and electrolyte balance, and to address the
underlying cause or causes of any current dehydration.

October 2024

Page 4-33

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

15. Dental Care
The ability to chew food is important for adequate oral nutrition. Having clean and attractive
teeth or dentures can promote a resident’s positive self-image and personal appearance, thereby
enhancing social interactions. Medical illnesses and medication-related adverse consequences
may increase a resident’s risk for related complications such as impaired nutrition and
communication deficits. The dental care CAA addresses a resident’s risk of oral disease,
discomfort, and complications.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when a resident has indicators of an
oral/dental issue and/or condition.
Dental Care CAT Logic Table

Triggering Conditions (any of the following):

1. Any dental problem indicated by:

(L0200A = 1) OR
(L0200B = 1) OR

(L0200C = 1) OR
(L0200D = 1) OR
(L0200E = 1) OR
(L0200F = 1)

16. Pressure Ulcer/Injury

The information gleaned from the assessment should be used to identify the oral/dental issues
and/or conditions and to identify any related possible causes and/or contributing risk factors. The
next step is to develop an individualized care plan based directly on these conclusions. The focus
of the care plan should be to address the underlying cause or causes of the resident’s issues
and/or conditions.

A pressure ulcer can be defined as a localized injury to the skin and/or underlying tissue, usually
over a bony prominence, as a result of pressure or pressure in combination with shear and/or
friction. Pressure ulcers can have serious consequences for the elderly and are costly and time
consuming to treat. They are a common preventable and treatable condition among elderly
people with restricted mobility.

When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA.

October 2024

Page 4-34

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Pressure Ulcer/Injury CAT Logic Table
Triggering Conditions (any of the following):
1. ADL assistance for movement in bed was needed, or activity was not attempted, as
indicated by:
GG0170A1 does not = 06 OR GG0170A5 does not = 06 OR GG0170B1 does not = 06 OR
GG0170B5 does not = 06 OR GG0170C1 does not = 06 OR GG0170C5 does not = 06
2. Frequent urinary incontinence as indicated by:
H0300 = 2 OR H0300 = 3
3. Frequent bowel incontinence as indicated by:
H0400 = 2 OR H0400 = 3

4. Weight loss in the absence of physician-prescribed regimen as indicated by:
K0300 = 2

5. Resident at risk for developing pressure ulcers as indicated by:
M0150 = 1

6. Resident has one or more unhealed pressure ulcer(s) at Stage 2 or higher, or one or
more likely pressure ulcers that are unstageable at this time as indicated by:
((M0300B1 > 0 AND M0300B1 <= 9) OR
(M0300C1 > 0 AND M0300C1 <= 9) OR
(M0300D1 > 0 AND M0300D1 <= 9) OR
(M0300E1 > 0 AND M0300E1 <= 9) OR
(M0300F1 > 0 AND M0300F1 <= 9) OR
(M0300G1 > 0 AND M0300G1 <= 9))

7. Resident has one or more unhealed pressure ulcer(s) at Stage 1 as indicated by:
M0300A > 0 AND M0300A <= 9

8. Trunk restraint used in bed has value of 1 or 2 as indicated by:
P0100B = 1 OR P0100B = 2

9. Trunk restraint used in chair or out of bed has value of 1 or 2 as indicated by:
P0100E = 1 OR P0100E = 2

The information gleaned from the assessment should be used to draw conclusions about the
status of a resident’s pressure ulcers(s) and to identify any related causes and/or contributing risk
factors. The next step is to develop an individualized care plan based directly on these
conclusions. If a pressure ulcer is not present, the goal is to prevent them by identifying the
resident’s risks and implementing preventive measures. If a pressure ulcer is present, the goal is
to heal or close it.
October 2024

Page 4-35

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

17. Psychotropic Medication Use
Any medication, prescription or non-prescription, can have benefits and risks, depending on
various factors (e.g., active medical conditions, coexisting medication regimen). However,
psychotropic medications, prescribed primarily to affect cognition, mood, or behavior, are among
the most frequently prescribed agents for elderly nursing home residents. While these
medications can often be beneficial, they can also cause significant complications such as
postural hypotension, extrapyramidal symptoms (e.g., akathisia, dystonia, tardive dyskinesia),
and acute confusion (delirium).
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA.

The information gleaned from the assessment should be used to draw conclusions about the
appropriateness of the resident’s medication, in consultation with the physician and the
consultant pharmacist, and to identify any adverse consequences, as well as any related possible
causes and/or contributing risk factors. The next step is to develop an individualized care plan
based directly on these conclusions. Important goals of therapy include maximizing the resident’s
functional potential and well-being, while minimizing the hazards associated with medication
side effects.

Psychotropic Medication Use CAT Logic Table

Triggering Conditions (any of the following):

1. Antipsychotic medication administered to resident during the last 7 days or since
admission/entry or reentry as indicated by:
N0415A1 = 1

2. Antianxiety medication administered to resident during the last 7 days or since
admission/entry or reentry as indicated by:

N0415B1 = 1

3. Antidepressant medication administered to resident during the last 7 days or since
admission/entry or reentry as indicated by:
N0415C1 = 1

4. Hypnotic medication administered to resident during the last 7 days or since
admission/entry or reentry as indicated by:
N0415D1 = 1

October 2024

Page 4-36

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

18. Physical Restraints
A physical restraint is defined as any manual method or physical or mechanical device, material,
or equipment attached or adjacent to the resident’s body that the individual cannot remove easily
and that restricts freedom of movement or normal access to one’s body. The important
consideration is the effect of the device on the resident, and not the purpose for which the device
was placed on the resident. This category also includes the use of passive restraints such as chairs
that prevent rising.

Physical restraints are only rarely indicated, and at most, should be used only as a short-term,
temporary intervention to treat a resident’s medical symptoms. They should not be used for
purposes of discipline or convenience. Before a resident is restrained, the facility must determine
the presence of a specific medical symptom that would require the use of the restraint and how
the use of the restraint would treat the medical symptom, protect the resident’s safety, and assist
the resident in attaining or maintaining their highest practicable level of physical and
psychosocial well-being.
Restraints are often associated with negative physical and psychosocial outcomes (e.g., loss of
muscle mass, contractures, lessened mobility and stamina, impaired balance, skin breakdown,
constipation, and incontinence). Adverse psychosocial effects of restraint use may include a
feeling of shame, hopelessness, and stigmatization as well as agitation.

The physical restraint CAA identifies residents who are physically restrained during the lookback period. When this CAA is triggered, nursing home staff should follow their facility’s chosen
protocol or policy for performing the CAA.
Physical Restraints CAT Logic Table

Triggering Conditions (any of the following):

1. Bed rail restraint used in bed has value of 1 or 2 as indicated by:

P0100A = 1 OR P0100A = 2

2. Trunk restraint used in bed has value of 1 or 2 as indicated by:
P0100B = 1 OR P0100B = 2

3. Limb restraint used in bed has value of 1 or 2 as indicated by:
P0100C = 1 OR P0100C = 2

4. Other restraint used in bed has value of 1 or 2 as indicated by:
P0100D = 1 OR P0100D = 2

5. Trunk restraint used in chair or out of bed has value of 1 or 2 as indicated by:
P0100E = 1 OR P0100E = 2
6. Limb restraint used in chair or out of bed has value of 1 or 2 as indicated by:

P0100F = 1 OR P0100F = 2

October 2024

Page 4-37

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Physical Restraints CAT Logic Table
7. Chair restraint that prevents rising used in chair or out of bed has value of 1 or 2 as
indicated by:
P0100G = 1 OR P0100G = 2
8. Other restraint used in chair or out of bed has value of 1 or 2 as indicated by:
P0100H = 1 OR P0100H = 2
The information gleaned from the assessment should be used to identify the specific reasons for
and the appropriateness of the use of the restraint and any adverse consequences caused by or
risks related to restraint use.

19. Pain

The focus of an individualized care plan based directly on these conclusions should be to address
the underlying physical or psychological condition(s) that led to restraint use. By addressing
underlying conditions and causes, the facility may eliminate the medical symptom that led to
using restraints. In addition, a review of underlying needs, risks, or issues/conditions may help to
identify other potential kinds of treatments. The ultimate goal is to eliminate restraint use by
employing alternatives. When elimination of restraints is not possible, assessment must result in
using the least restrictive device possible.

Pain is “an unpleasant sensory and emotional experience associated with actual or potential
tissue damage.” Pain can be affected by damage to various organ systems and tissues, for
example, musculoskeletal (e.g., arthritis, fractures, injury from peripheral vascular disease,
wounds), neurological (e.g., diabetic neuropathy, herpes zoster), and cancer. The presence of pain
can also increase suffering in other areas, leading to an increased sense of helplessness, anxiety,
depression, decreased activity, decreased appetite, and disrupted sleep.

As with all symptoms, pain symptoms are subjective and require a detailed history and additional
physical examination, and sometimes additional testing, in order to clarify pain characteristics
and causes and identify appropriate interventions. This investigation typically requires
coordination between nursing staff and a health care practitioner.
When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when a resident has active symptoms of
pain.

October 2024

Page 4-38

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

Pain CAT Logic Table
Triggering Conditions (any of the following):
1. Pain has made it hard for resident to sleep at night over the past 5 nights as indicated
by:
J0510 = 2, 3, or 4
2. Resident has limited day-to-day activity because of pain over past 5 days as indicated
by:
J0530 = 2, 3, or 4
3. Pain numeric intensity rating has a value from 7 to 10 as indicated by:
J0600A >= 07 AND J0600A <=10

4. Verbal descriptor of pain is severe or very severe as indicated by a value of 3 or 4 as
follows:
J0600B = 3 OR J0600B = 4

5. Pain is frequent as indicated by a value of 3 or 4 and numeric pain intensity rating has
a value of 4 through 10 or verbal descriptor of pain has a value of 2 through 4 as
indicated by:
(J0410 = 3 OR J0410 = 4) AND

((J0600A >= 04 AND J0600A <= 10) OR
(J0600B >= 2 AND J0600B <= 4))

6. Staff assessment reports resident indicates pain or possible pain in body language as
indicated by:
(J0800A = 1) OR

(J0800B = 1) OR

(J0800C = 1) OR
(J0800D = 1)

The information gleaned from the assessment should be used to identify the characteristics and
possible causes, contributing factors, and risk factors related to the pain. The next step is to
develop an individualized care plan based directly on these conclusions. The focus of the care
plan should be to alleviate symptoms and, to the extent possible, address the underlying
condition(s) that cause the pain.

Management of pain may include various interventions, including medications and other
treatments that focus on improving the person’s quality of life and ability to function. Therefore,
it is important to tailor an individualized care plan related to pain to the characteristics, causes,
and consequences of pain in the context of a resident’s whole picture, including medical
conditions, cognitive capabilities, goals, wishes, and personal and psychosocial function.

October 2024

Page 4-39

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

20. Return to Community Referral
All individuals have the right to choose the services they receive and the settings in which they
receive those services. This right became law under the Americans with Disabilities Act (1990)
and with further interpretation by the U.S. Supreme Court in the Olmstead vs. L.C. decision in
1999. This ruling stated that individuals have a right to receive care in the least restrictive (most
integrated) setting and that governments (Federal and State) have a responsibility to enforce and
support these choices.

An individual in a nursing home with adequate decision making capacity, or through qualified
decision making supports, can choose to leave the facility and/or request to talk to someone
about returning to the community to receive needed supports at any time. The return to
community referral portion of MDS 3.0 uses a person-centered approach to ensure that all
individuals have the opportunity to learn about home and community based services and have an
opportunity to receive long-term care in the last restrictive setting possible. The CAA associated
with this portion of MDS 3.0 focuses on residents who want to talk to someone about returning
to the community and promotes opening the discussion about the individual’s preferences for
settings for receipt of services.

Individual choices related to returning to community living will vary, e.g., returning to a former
home or a different community home, or, the individual may choose to stay in the nursing home.
The discharge assessment process requires nursing home staff to apply a systematic and objective
protocol so that every individual has the opportunity to access meaningful information about
community living options and community service alternatives, with the goal being to assist the
individual in maintaining or achieving the highest level of functioning and integration possible.
This includes ensuring that the individual or surrogate is fully informed and involved in longterm care decision making, identifying individual strengths, assessing risk factors, implementing
a comprehensive plan of care, coordinating interdisciplinary care providers, fostering
independent functioning, and using rehabilitation programs and community referrals.

When this CAA is triggered, nursing home staff should follow their facility’s chosen protocol or
policy for performing the CAA. This CAA is triggered when a resident expresses interest in
returning to the community.
Return to Community Referral CAT Logic Table
Triggering Condition:

1. Resident wants to or may want to talk to someone about returning to community as
indicated by:
Q0500B = 1 or 9

The information gleaned from the assessment should be used to assess the resident’s situation
and begin appropriate care planning, discharge planning, and other follow-up measures. The next
step is to develop an individualized care plan based directly on these findings.

October 2024

Page 4-40

CMS’s RAI Version 3.0 Manual

CH 4: CAA Process and Care Planning

The goal of care planning is to initiate and maintain collaboration between the nursing facility
and the local contact agency (LCA) to support the individual’s expressed interest in being
transitioned to community living. The nursing home staff is responsible for making referrals to
the LCAs under the process that the State has established. The LCA is, in turn, responsible for
contacting referred residents and assisting with transition services planning. This includes facility
support for the individual in achieving their highest level of functioning and the involvement of
the designated local contact agency providing informed choices for community living. The LCA
is the entity that does the necessary community support planning (e.g. housing, home
modification, setting up a household, transportation, community inclusion planning, arranging of
care support, etc.). This collaboration will enable the State-designated local contact agency to
initiate communication by telephone or visit with the individual (and their family or significant
others, if the individual so chooses) to talk about opportunities for returning to community living.

4.11 Reserved

D
October 2024

Page 4-41

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

CHAPTER 5: SUBMISSION AND CORRECTION OF THE
MDS ASSESSMENTS
Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required
Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds
regardless of the payer source. Skilled nursing facilities (SNFs) and non-critical access hospitals
(non-CAH) with a swing bed agreement (swing beds) are required to transmit additional MDS
assessments for all Medicare beneficiaries in a Part A stay reimbursable under the SNF
Prospective Payment System (PPS).

5.1 Transmitting MDS Data

All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those
facilities, must transmit required MDS data records to CMS’ Internet Quality Improvement and
Evaluation System (iQIES). Required MDS records are those assessments and tracking records
that are mandated under OBRA and SNF PPS.

Assessments that are completed for purposes other than OBRA or SNF PPS reasons are not to be
submitted to iQIES, examples include, but are not limited to, private insurance and Medicare
Advantage Plans (i.e., Medicare Part C). After completion of the required assessment and/or
tracking records, each provider must create electronic transmission files that meet the
requirements detailed in the current MDS 3.0 Data Submission Specifications available on the
CMS MDS 3.0 website at:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html.
The provider indicates the certification or licensure of the unit on which the resident resides in
item A0410, Unit Certification or Licensure Designation. In addition to reflecting certification or
licensure of the unit, this item indicates the submission authority for a record.

•

Value = 1 Unit is neither Medicare nor Medicaid certified and MDS data is not required
by CMS or the State.

•

Value = 2 Unit is neither Medicare nor Medicaid certified but MDS data is required by
the State.

•

Value = 3 Unit is Medicare and/or Medicaid certified.

See Chapter 3, Section A for details concerning the coding of item A0410, Unit Certification or
Licensure Designation. Note: CMS certified non-CAH Swing Bed unit assessments are always
Value 3, Unit is Medicare and/or Medicaid certified.

October 2024

Page 5-1

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

When the transmission file is received by iQIES, the system performs a series of validation edits
to evaluate whether or not the data submitted meet the required standards. MDS records are
edited to verify that clinical responses are within valid ranges and are consistent, dates are
reasonable, and records are in the proper order with regard to records that were previously
accepted by iQIES for the same resident. The provider is notified of the results of this evaluation
by error and warning messages on a Final Validation Report. All error and warning messages are
detailed and explained in the Error Messages guide.

5.2 Timeliness Criteria
In accordance with the requirements at 42 CFR §483.20(f)(1), (f)(2), and (f)(3), long-term care
facilities participating in the Medicare and Medicaid programs must meet the following conditions:
•

Completion Timing:

•

— For all non-Admission OBRA and PPS assessments, the MDS Completion Date
(Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD)
(A2300).
— For the Admission assessment, the MDS Completion Date (Z0500B) must be no later
than 13 days after the Entry Date (A1600).
— For the Admission assessment, the Care Area Assessment (CAA) Completion Date
(V0200B2) must be no later more than 13 days after the Entry Date (A1600). For the
Annual assessment, the CAA Completion Date (V0200B2) must be no later than 14
days after the ARD (A2300).
— For the other comprehensive MDS assessments, Significant Change in Status
Assessment and Significant Correction to Prior Comprehensive Assessment, the CAA
Completion Date (V0200B2) must be no later than 14 days from the ARD (A2300)
and no later than 14 days from the determination date of the significant change in
status or the significant error, respectively.
— For Entry and Death in Facility tracking records, the MDS Completion Date
(Z0500B) must be no later than 7 days from the Event Date (A1600 for an entry
record; A2000 for a Death in Facility tracking record).
State Requirements: Many states have established additional MDS requirements for
Medicaid payment and/or quality monitoring purposes. For information on state
requirements, contact your State RAI Coordinator. (See Appendix B for a list of State
RAI Coordinators.)
Encoding Data: Within 7 days after completing a resident’s MDS assessment or tracking
record, the provider must encode the MDS data (i.e., enter the information into the
facility MDS software). The encoding requirements are as follows:
— For a comprehensive assessment (Admission, Annual, Significant Change in Status,
and Significant Correction to Prior Comprehensive), encoding must occur within 7
days after the Care Plan Completion Date (V0200C2 + 7 days).
— For a Quarterly, Significant Correction to Prior Quarterly, Discharge, or PPS
assessment, encoding must occur within 7 days after the MDS Completion Date
(Z0500B + 7 days).

October 2024

Page 5-2

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

— For a tracking record, encoding should occur within 7 days of the Event Date (A1600
+ 7 days for Entry records and A2000 + 7 days for Death in Facility records).
•

Submission Format: For submission, the MDS data must be in record and file formats
that conform to standard record layouts and data dictionaries, and pass standardized edits
defined by CMS and the State. Each MDS record must be a separate file in a required
XML format. The submission file is a compressed ZIP file that may contain multiple
XML files. See the MDS 3.0 Data Submission Specifications on the CMS MDS 3.0
website for details concerning file and record formats, XML structure, and ZIP files.

•

Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for
their State-specific instrument, including the Care Area Assessment (CAA) Summary
(Section V) and all tracking or correction information. Transmission requirements apply
to all MDS 3.0 records used to meet both federal and state requirements. Care plans are
not required to be transmitted.

— Assessment Transmission: Comprehensive assessments must be transmitted
electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14
days). All other MDS assessments must be submitted within 14 days of the MDS
Completion Date (Z0500B + 14 days).

— Tracking Information Transmission: For Entry and Death in Facility tracking
records, information must be transmitted within 14 days of the Event Date (A1600 +
14 days for Entry records and A2000 + 14 days for Death in Facility records).
Submission Time Frame for MDS Records
Secondary
Reason
(A0310B)

Entry/Discharge
Reporting
(A0310F)

Final
Completion
or Event
Date

Submit By

Admission Assessment

01, 99

10, 11, 99

V0200C2

V0200C2 + 14

Annual Assessment

01, 99

10, 11, 99

V0200C2

V0200C2 + 14

Sign. Change in Status
Assessment

01, 99

10, 11, 99

V0200C2

V0200C2 + 14

Sign. Correction to Prior
Comprehensive Assessment

Quarterly Review Assessment

Sign. Correction Prior
Quarterly Assessment

PPS Assessment

Type of
Assessment/Tracking

Primary
Reason
(A0310A)

01, 99

10, 11, 99

V0200C2

V0200C2 + 14

01, 99

10, 11, 99

Z0500B

Z0500B +14

01, 99

10, 11, 99

Z0500B

Z0500B + 14

01 or 08

10, 11, 99

Z0500B

Z0500B + 14

All values

01, 99

10 or 11

Z0500B

Z0500B + 14

Death in Facility Tracking

A2000

A2000 + 14

Entry Tracking

A1600

A1600 + 14

N/A

X1100E

X1100E + 14

Discharge Assessment

Correction Request
(Modification or Inactivation)

October 2024

Page 5-3

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

Table Legend:
Item

Description

V0200C2

Care Plan Completion Date: Date of the signature of the person completing the care planning
decision on the CAA Summary sheet (Section V), indicating which Care Areas are addressed in the
care plan. This is the date of care plan completion.

Z0500B

MDS Assessment Completion Date: Date of the RN assessment coordinator’s signature, indicating
that the MDS assessment is complete.

A2000

Date of discharge or death

A1600

Date of entry

X1100E

Date of the RN coordinator’s signature on the Correction Request (Section X) certifying
completion of the correction request information and the corrected assessment or tracking
information.

D
•

Assessment Schedule: An OBRA assessment (comprehensive or Quarterly) is due every
quarter unless the resident is no longer in the facility. There must be no more than 92
days between OBRA assessments. An OBRA comprehensive assessment is due every
year unless the resident is no longer in the facility. There must be no more than 366 days
between comprehensive assessments. PPS assessments follow their own schedule. See
Chapter 2 for details.

5.3 Validation Edits

iQIES has validation edits designed to monitor the timeliness and accuracy of MDS record
submissions. If transmitted MDS records do not meet the edit requirements, the system will
provide error and warning messages on the provider’s Final Validation Report.

Initial Submission Feedback. For each file submitted, the submitter will receive confirmation
that the file was received for processing and editing by iQIES. This confirmation information
includes the file submission identification number (ID), the date and time the file was received
for processing as well as the file name.
Validation and Editing Process. Each time a user accesses iQIES and transmits an MDS file,
iQIES performs three types of validation:

1. Fatal File Errors. If the file structure is unacceptable (e.g., it is not a ZIP file), the records in
the ZIP file cannot be extracted, or the file cannot be read, then the file will be rejected. The
Submitter Final Validation Report will list the Fatal File Errors. Files that are rejected must
be corrected and resubmitted.
2. Fatal Record Errors. If the file structure is acceptable, then each MDS record in the file is
validated individually for Fatal Record Errors. These errors include, but are not limited to:
•

Out of range responses (e.g., the valid codes for the item are 1, 2, 3, and 4 and the
submitted value is a 6).

October 2024

Page 5-4

CMS’s RAI Version 3.0 Manual

•

CH 5: Submission and Correction
of the MDS Assessments

Inconsistent relationships between items. One example is a skip pattern violation. The
resident is coded as comatose (B0100 = 1) but the Brief Interview for Mental Status is
conducted (C0100 = 1). Another example is an inconsistent date pattern, such as the
resident’s Birth Date (Item A0900) is later than the Entry Date (Item A1600).

Fatal Record Errors result in rejection of individual records by iQIES. The provider is
informed of Fatal Record Errors on the Final Validation Report. Rejected records must be
corrected and resubmitted, unless the Fatal Error is due to submission of a duplicate
assessment.

3. Non-Fatal Errors (Warnings). The record is also validated for Non-Fatal Errors. Non-Fatal
Errors include, but are not limited to, missing or questionable data of a non-critical nature or
item consistency errors of a non-critical nature. Examples are timing errors. Timing errors for
a Quarterly assessment include (a) the submission date is more than 14 days after the MDS
assessment completion date (Z0500B) or (b) the assessment completion is more than 14 days
after the ARD (A2300). Another example is a record sequencing error, where an Entry record
(A0310F = 01) is submitted after a Quarterly assessment record (A0310A = 02) with no
intervening Discharge assessment (A0310F = 10 or 11). Any Non-Fatal Errors are reported to
the provider in the Final Validation Report as warnings. The provider must evaluate each
warning to identify necessary corrective actions.

Storage to iQIES. If there are any Fatal Record Errors, the record will be rejected and not stored
in iQIES. If there are no Fatal Record Errors, the record is saved into iQIES, even if the record
has Non-Fatal Errors (Warnings).
Detailed information on the validation edits and the error and warning messages is available in
the MDS 3.0 Data Submission Specifications on the CMS MDS 3.0 website and in the Error
Messages guide.

5.4 Additional Medicare Submission Requirements that
Impact Billing Under the SNF PPS

As stated in CFR §413.343(a) and (b), providers reimbursed under the SNF PPS “are required to
submit the resident assessment data described at §483.20…. in the manner necessary to
administer the payment rate methodology described in §413.337.” This provision includes the
frequency, scope, and number of assessments required in accordance with the methodology
described in CFR §413.337(c) related to the adjustment of the Federal rates for case mix. SNFs
must submit assessments according to a standard schedule. This schedule must include
performance of resident assessments at specified windows during the Medicare Part A stay.
HIPPS Codes: Health Insurance Prospective Payment System (HIPPS) codes are billing codes
used when submitting Medicare Part A SNF payment claims to the Part A/Part B Medicare
Administrative Contractor (A/B MAC). The HIPPS code consists of five positions. Under
PDPM, the first position represents the Physical Therapy/Occupational Therapy (PT/OT)
Payment Group, the second position represents the Speech Language Pathology (SLP) Payment
Group, the third position represents the Nursing Payment Group, the fourth position represents
the Non-therapy Ancillary (NTA) Payment Group, and the fifth position represents the

October 2024

Page 5-5

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

Assessment Indicator (AI) code indicating which type of assessment was completed. Standard
“grouper” logic and software for PDPM and the AI code are provided by CMS on the MDS 3.0
website.
The standard grouper uses MDS 3.0 items to determine both the PDPM group and the AI code. It
is anticipated that MDS 3.0 software used by the provider will incorporate the standard grouper
to automatically calculate the PDPM group and AI code. Detailed logic for determining the
PDPM group and AI code is provided in Chapter 6.
The Medicare Part A HIPPS code (Item Z0100A) is most often used on the claim. The PDPM
version code in Item Z0100B documents which version of PDPM was used to determine the
PDPM payment groups represented in the Medicare Part A HIPPS code.

The HIPPS code (Z0100A) and PDPM version code (Z0100B) must be submitted to iQIES on all
Medicare PPS assessment records (indicated by A0310B = 01 or 08). Both of these values are
validated by iQIES. The final validation report will indicate if any of these items is in error and
the correct value for the item. Note that an error in one of these items is usually a non-fatal
warning and the record will still be accepted in iQIES.

The Medicare Part A SNF claim cannot be submitted until the corresponding MDS Medicare
PPS assessment has been accepted in iQIES. The claim must include the correct HIPPS code for
the assessment. If the HIPPS code on the assessment was in error, then the correct HIPPS code
from the Final Validation report must be used on the claim (warning error message -3935a).

5.5 MDS Correction Policy

Once completed, edited, and accepted into iQIES, providers may not change a previously
completed MDS assessment as the resident’s status changes during the course of the resident’s
stay—the MDS must be accurate as of the ARD. Minor changes in the resident’s status should be
noted in the resident’s record (e.g., in progress notes), in accordance with standards of clinical
practice and documentation. Such monitoring and documentation is a part of the provider’s
responsibility to provide necessary care and services. A significant change in the resident’s status
warrants a new comprehensive assessment (see Chapter 2 for details).
It is important to remember that the electronic record submitted to and accepted into iQIES is the
legal assessment. Corrections made to the electronic record after iQIES acceptance or to the
paper copy maintained in the medical record are not recognized as proper corrections. It is the
responsibility of the provider to ensure that any corrections made to a record are submitted to
iQIES in accordance with the MDS Correction Policy.
Several processes have been put into place to assure that the MDS data are accurate both at the
provider and in iQIES:
•

If an error is discovered within 7 days of the completion of an MDS and before
submission to iQIES, the response may be corrected using standard editing procedures on
the hard copy (cross out, enter correct response, initial and date) and/or correction of the
MDS record in the facility’s database. The resident’s care plan should also be reviewed
for any needed changes.

October 2024

Page 5-6

CMS’s RAI Version 3.0 Manual

•
•

CH 5: Submission and Correction
of the MDS Assessments

Software used by the provider to encode the MDS must run all standard edits as defined
in the data specifications released by CMS.
If an MDS record contains responses that are out of range, e.g., a 4 is entered when only
0-3 are allowable responses for an item, or item responses are inconsistent (e.g., a skip
pattern is not observed), the record is rejected. Rejected records are not stored in the
iQIES database.
If an error is discovered in a record that has been accepted by iQIES, Modification or
Inactivation procedures must be implemented by the provider to assure that iQIES
information is corrected.
Clinical corrections must also be undertaken as necessary to assure that the resident is
accurately assessed, the care plan is accurate, and the resident is receiving the necessary
care. A Significant Change in Status Assessment (SCSA), Significant Correction to Prior
Quarterly (SCQA), or a Significant Correction to Prior Comprehensive (SCPA) may be
needed as well as corrections to the information in iQIES. An SCSA is required only if a
change in the resident’s clinical status occurred. An SCPA or SCQA is required when an
uncorrected significant error is identified. See Chapter 2 for details.

The remaining sections of this chapter present the decision processes necessary to identify the
proper correction steps. A flow chart is provided at the end of these sections that summarizes
these decisions and correction steps.

5.6 Correcting Errors in MDS Records That Have Not Yet
Been Accepted Into iQIES

If an MDS assessment is found to have errors that incorrectly reflect the resident’s status, then
that assessment must be corrected. The correction process depends upon the type of error. MDS
assessments that have not yet been accepted in iQIES include records that have been submitted
and rejected, or records that have not been submitted at all. These records can generally be
corrected and retransmitted without any special correction procedures, since they were never
accepted by iQIES. The paper copy should be corrected according to standard procedures
detailed below.

Errors Identified During the Encoding Period

Facilities have up to 7 days to encode (enter into the software) and edit an MDS assessment after
the MDS has been completed. Changes may be made to the electronic record for any item during
the encoding and editing period, provided the response refers to the same observation period. To
make revisions to the paper copy, enter the correct response, draw a line through the previous
response without obliterating it, and initial and date the corrected entry. This procedure is similar
to how an entry in the medical record is corrected.
When the data are encoded into the provider’s MDS system from paper, the provider is
responsible for verifying that all responses in the computer file match the responses on the paper
form. Any discrepancies must be corrected in the computer file during the 7-day encoding
period.

October 2024

Page 5-7

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

In addition, the provider is responsible for running encoded MDS assessment data against CMS
and State-specific edits that software vendors are responsible for building into MDS Version 3.0
computer systems. For each MDS item, the response must be within the required range and also
be consistent with other item responses. During this 7-day encoding period that follows the
completion of the MDS assessment, a provider may correct item responses to meet required
edits. Only MDS assessments that meet all of the required edits are considered complete. For
corrected items, the provider must use the same observation period as was used for the original
item completion (i.e., the same ARD (A2300) and look-back period). Both the electronic and
paper copies of the MDS must be corrected.

Errors Identified After the Encoding Period

Errors identified after the encoding and editing period must be corrected within 14 days after
identifying the errors. If the record in error is an Entry tracking record, Death in Facility tracking
record, Discharge assessment, or PPS assessment record (i.e., MDS Item A0310A = 99), then the
record should be corrected and submitted to iQIES. The correction process may be more
complex if the record in error is an OBRA comprehensive or Quarterly assessment record (i.e.,
Item A0310A = 01 through 06).

Significant versus Minor Errors in a Nursing Home OBRA Comprehensive or Quarterly
Assessment Record. OBRA comprehensive and Quarterly assessment errors are classified as
significant or minor errors. Errors that inaccurately reflect the resident’s clinical status and/or
result in an inappropriate plan of care are considered significant errors. All other errors related
to the coding of MDS items are considered minor errors.
If the only errors in the OBRA comprehensive or Quarterly assessment are minor errors, then the
only requirement is for the record to be corrected and submitted to iQIES.

The correction process is more complicated for nursing home OBRA comprehensive or
Quarterly assessments with any significant errors identified after the end of the 7-day encoding
and editing period but before the records have been accepted into iQIES. First, the nursing home
must correct the original OBRA comprehensive or Quarterly assessment to reflect the resident’s
actual status as of the ARD for that original assessment and submit the record. Second, to ensure
an up-to-date view of the resident’s status and an appropriate care plan, the nursing home must
perform an additional new assessment, either a Significant Change in Status Assessment or
Significant Correction to Prior Assessment with a current observation period and ARD. If
correction of the error on the MDS revealed that the resident’s status met the criteria for a
Significant Change in Status Assessment, then a Significant Change in Status assessment is
required. If the criteria for a Significant Change in Status Assessment are not met, then a
Significant Correction to Prior Assessment is required. See Chapter 2 for details.
In summary, the nursing home must take the following actions for an OBRA comprehensive or
Quarterly assessment that has not been submitted to iQIES when it contains significant errors:
•

Correct the errors in the original OBRA comprehensive or Quarterly assessment.

•

Submit the corrected assessment.

October 2024

Page 5-8

CMS’s RAI Version 3.0 Manual

•

CH 5: Submission and Correction
of the MDS Assessments

Perform a new assessment – a Significant Change in Status Assessment or a Significant
Correction to Prior Assessment and update the care plan as necessary.

If the assessment was performed for Medicare purposes only (A0310A = 99 and A0310B = 01 or
08) or for a discharge (A0310A = 99 and A0310F = 10 or 11), no Significant Change in Status
Assessment or Significant Correction to Prior Assessment is required. The provider would
determine if the Medicare-required or Discharge assessment should be modified or inactivated.
Care Area Assessments (Section V) and updated care planning are not required with Medicareonly and Discharge assessments.

5.7 Correcting Errors in MDS Records That Have Been
Accepted Into iQIES

Facilities should correct any errors necessary to ensure that the information in iQIES accurately
reflects the resident’s identification, location, overall clinical status, or payment status. A
correction can be submitted for any accepted record within 2 years of the target date of the
record for facilities that are still open. If a facility is terminated, then corrections must be
submitted within 2 years of the facility termination date. A record may be corrected even if
subsequent records have been accepted for the resident.

Errors identified in iQIES records must be corrected within 14 days after identifying the errors.
Inaccuracies can occur for a variety of reasons, such as transcription errors, data entry errors,
software product errors, item coding errors or other errors. The following two processes have
been established to correct MDS records (assessments, Entry tracking records or Death in
Facility tracking records) that have been accepted into iQIES:
•

Modification

•

Inactivation

A Modification request moves the inaccurate record into history in iQIES and replaces it with the
corrected record as the active record. An Inactivation request also moves the inaccurate record
into history in iQIES, but does not replace it with a new record. Both the Modification and
Inactivation processes require the MDS Correction Request items to be completed in Section X
of the MDS 3.0.
The MDS Correction Request items in Section X contain the minimum amount of information
necessary to enable location of the erroneous MDS record previously submitted and accepted
into iQIES. Section X items are defined in the MDS 3.0 Data Submission Specifications posted
on the CMS MDS 3.0 website.

When a facility maintains the MDS electronically without the use of electronic signatures, a hard
copy of the Correction Request items in Section X must be kept with the corrected paper copy of
the MDS record in the clinical file to track the changes made with the modification. In addition,
the facility would keep a hard copy of the Correction Request items (Section X) with an
inactivated record. For details on electronic records, see Chapter 2, Section 2.4.

October 2024

Page 5-9

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

Modification Requests
A Modification Request should be used when an MDS record (assessment, Entry tracking record
or Death in Facility tracking record) is in iQIES, but the information in the record contains
clinical or demographic errors.
The Modification Request is used to modify MDS items not specifically listed under
inactivation. Some of the items include:
•

Target Date
— Entry Date (Item A1600) on an Entry tracking record (Item A0310F = 1)
— Discharge Date (Item A2000) on a Discharge/Death in Facility record (Item A0310F
= 10, 11, 12),

•
•

— Assessment Reference Date (Item A2300) on an OBRA or PPS assessment.*
Type of Assessment (Item A0310)**
Clinical Items (Items B0100-V0200C)

*Note: The ARD (Item A2300) can be changed when the ARD on the assessment represents a
data entry/typographical error. However, the ARD cannot be altered if it results in a change in
the look-back period and alters the actual assessment timeframe. Consider the following
examples:
When entering the assessment into the facility’s software, the ARD, intended to be
02/12/2021, was inadvertently entered as 02/02/2021. The interdisciplinary team (IDT)
completed the assessment based on the ARD of 02/12/2021 (that is, the seven day lookback period was 02/06/2021 through 02/12/2021). This would be an acceptable use of the
modification process to modify the ARD (A2300) to reflect 02/12/2021.

•

An assessment was completed by the team and entered into the software based on the
ARD of 01/10/2021 (and seven day look-back period of 01/04/2021 through 01/10/2021).
Three weeks later, the IDT determines that the date used represents a date that is not
compliant with the PPS schedule and proposes changing the ARD to 01/07/2021. This
would alter the look back period and result in a new assessment (rather than correcting a
typographical error); this would not be an acceptable modification and shall not occur.

•

**Note: The Type of Assessment items (Item A0310) can only be modified when the Item Set
Code (ISC) of that assessment does not change. In other words, if the Item Subset (full list can be
found in Chapter 2, Section 2.5) would change, the modification cannot be done. Consider the
following example:
•

An Admission assessment (ISC = NC) was completed and accepted into iQIES. The
provider intended to code the assessment as an Admission and a 5-day PPS assessment
(ISC = NC). The modification process could be used in this case as the ISC would not
change.

There are a few items for which the modification process shall not be used. These items require
the following correction measures if an error is identified:

October 2024

Page 5-10

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

•

An Inactivation of the existing record followed by submission of a new corrected record
is required to correct an error of the Type of Provider (Item A0200)

•

An MDS 3.0 Manual Assessment Correction/Deletion Request is required to correct:
—
—
—
—

Unit Certification or Licensure Designation (Item A0410)
State-assigned facility submission ID (FAC_ID) or State Code (STATE_CD)
Record submitted was not for OBRA or Medicare Part A purposes
Test record submitted as a production record

See Section 5.8 for details on the MDS 3.0 Manual Assessment Correction/Deletion Request.
When an error is discovered (except for those items listed in the preceding paragraph and
instances listed in Section 5.8) in an MDS 3.0 Entry tracking record, Death in Facility tracking
record, Discharge assessment, or PPS assessment that is not an OBRA assessment (where Item
A0310A = 99), the provider must take the following actions to correct the record:

1. Create a corrected record with all items included, not just the items in error.
2. Complete the required Correction Request Section X items and include with the corrected
record. Item A0050 should have a value of 2, indicating a modification request.
3. Submit this modification request record.

If errors are discovered in a nursing home OBRA comprehensive or Quarterly assessment (Item
A0310A = 01 through 06) in iQIES, then the nursing home must determine if there are any
significant errors. If the only errors are minor errors, the nursing home must take the following
actions to correct the OBRA assessment:
1. Create a corrected record with all items included, not just the items in error.
2. Complete the required Correction Request Section X items and include with the corrected
record. Item A0050 should have a value of 2, indicating a modification request.
3. Submit this modification request record.

When any significant error is discovered in an OBRA comprehensive or Quarterly assessment
in iQIES, the nursing home must take the following actions to correct the OBRA assessment:
1. Create a corrected record with all items included, not just the items in error.
2. Complete the required Correction Request Section X items and include with the corrected
record. Item A0050 should have a value of 2, indicating a modification request.
3. Submit this modification request record.
4. Perform a new Significant Correction to Prior Assessment or Significant Change in Status
Assessment and update the care plan as necessary.

A Significant Change in Status Assessment would be required only if correction of the MDS
item(s) revealed that the resident met the criteria for a Significant Change in Status Assessment.
If criteria for Significant Change in Status Assessment were not met, then a Significant
Correction to Prior Assessment is required.
When errors in an OBRA comprehensive or Quarterly assessment in iQIES have been corrected
in a more current OBRA comprehensive or Quarterly assessment (Item A0310A = 01 through
06), the nursing home is not required to perform a new additional assessment (Significant
October 2024

Page 5-11

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

Change in Status or Significant Correction to Prior assessment). In this situation, the nursing
home has already updated the resident’s status and care plan. However, the nursing home must
use the Modification process to assure that the erroneous assessment residing in iQIES is
corrected.
The Cross-Over Rule
When item sets are updated, a situation may exist that will prevent providers from
correcting the target date of any assessment crossing over from October 1 of a given year.
That is, providers may not submit a modification to change a target date on an assessment
completed prior to October 1 of a given year to a target date on or after October 1 of the
same year, nor can they submit a modification to change a target date on an assessment
completed on or after October 1 of a given year to a target date prior to October 1 of a
given year when the MDS item sets have had substantial changes.

•

When the MDS item sets have had significant changes, including the omission and
addition of many items or significant changes to existing items, clinicians will be
required to collect and code new items, may have different look-back periods, or may
need to code the MDS according to changes in the coding requirements. It is the target
date of the assessment that identifies the required version of the item set, and, because of
the substantial changes that may exist between versions of the item sets, they are not
interchangeable. Therefore, commonly when there are updates to item sets, providers may
not change target dates on assessments crossing over October 1 of specific years.

•

Inactivation Requests

An Inactivation should be used when a record has been accepted into iQIES but the
corresponding event did not occur. For example, a Discharge assessment was submitted for a
resident but there was no actual discharge. An Inactivation (Item A0050 = 3) must be completed
when any of the following items are inaccurate:
Type of Provider (Item A0200)

•

Type of Assessment (A0310) when the Item Subset would change had the MDS been
modified

•

Discharge Date (Item A2000) on a Discharge assessment record (Item A0310F = 10, 11)
when the look-back period and/or clinical assessment would change had the MDS
been modified

•

Assessment Reference Date (Item A2300) on an OBRA or PPS assessment when the
look-back period and/or clinical assessment would change had the MDS been
modified

•

When inactivating a record, the provider is required to submit an electronic Inactivation Request
record. This record is an MDS record but only the Section X items and item A0050 are
completed. This is sufficient information to locate the record in iQIES, inactivate the record and
document the reason for inactivation.

October 2024

Page 5-12

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

For instances when the provider determines that the Type of Provider is incorrect, the provider
must inactivate the record in iQIES, then complete and submit a new MDS 3.0 record with the
correct Type of Provider, ensuring that the clinical information is accurate.
Inactivations should be rare and are appropriate only under the narrow set of circumstances that
indicate a record is invalid.
In such instances a new ARD date must be established based on MDS requirements, which is the
date the error is determined or later, but not earlier. The new MDS 3.0 record being submitted to
replace the inactivated record must include new signatures and dates for all items based on the
look-back period established by the new ARD and according to established MDS assessment
completion requirements.

5.8 Special Manual Record Correction Request

A few types of errors in a record in iQIES cannot be corrected with an automated Modification
or Inactivation request. These errors are:

1. The record is a test record inadvertently submitted as production.
2. The record has the wrong unit certification or licensure designation in Item A0410.
3. The record has the wrong state code or facility ID in the control Items STATE_CD or
FAC_ID.
4. The record submitted was not for OBRA or Medicare Part A purposes.

In all of these cases, the facility must contact the State Agency to have the problems fixed. The
State Agency will send the facility the appropriate MDS 3.0 Manual Individual Assessment
Correction/Deletion Request form. The facility is responsible for completing the form. The
facility must submit the completed form to the State Agency. Completed forms with Protected
Health Information (PHI) must be sent via certified mail through the United States Postal Service
(USPS). The State Agency will review the request for completion and accuracy. After approving
the provider’s request, the State Agency must sign the form and send it to the iQIES Help Desk.
Completed forms with PHI must be sent via certified mail through the USPS.
When a test record is in iQIES, the problem must be evaluated and iQIES appropriately
corrected. A normal Inactivation request will not totally fix the problem, since it will leave the
test record in a history file and may also leave information about a fictitious resident. Manual
deletion is necessary to completely remove the test record and associated information.

An iQIES record with an incorrect unit certification or licensure designation in Item A0410 is a
very serious problem. Submission of MDS assessment records to iQIES constitutes a release of
private information and must conform to privacy laws. Item A0410 is intended to allow
appropriate privacy safeguards, controlling who can access the record and whether the record can
even be accepted into iQIES. A normal Modification or Inactivation request cannot be used to
correct the A0410 value, since a copy of the record in error will remain in the iQIES history file
with the wrong access control. Consider a record in iQIES with an A0410 value of 3 (Unit is
Medicare and/or Medicaid certified) when actually the unit is neither Medicare nor Medicaid
certified and MDS data is not required by the State (A0410 should have been 1). The record

October 2024

Page 5-13

CMS’s RAI Version 3.0 Manual

CH 5: Submission and Correction
of the MDS Assessments

should not be in iQIES at all and manual deletion is necessary to completely remove the record
from iQIES. Consider a record with an A0410 value of 3 indicating that the Unit is Medicare
and/or Medicaid certified but actually the unit is neither Medicare nor Medicaid certified but
MDS data is required by the State (A0410 should have been 2). In this case there is both federal
and state access to the record, but access should be limited to the state. Manual correction is
necessary to correct A0410 and reset access control, without leaving a copy of the record with
the wrong access in the iQIES history file.
If an iQIES record has the wrong state code or facility ID (control item STATE_CD, FAC_ID),
then the record must be removed without leaving any trace in iQIES. The record also should be
resubmitted with the correct STATE_CD and FAC_ID value.

D
October 2024

Page 5-14

CH 5: Submission and Correction
of the MDS Assessments

Page 5-15

CMS՚s RAI Version 3.0 Manual

October 2024
Manual deletion request is required if test record submitted as production record, if record contains incorrect STATE_CD or FAC_ID, or if record was
submitted with an incorrect Unit Certification or Licensure Designation (A0410), for example sent in as Unit is Medicare and/or Medicaid certified (A0410
= 3) but should have been Unit is neither Medicare nor Medicaid certified but MDS data is required by the State (A0410 = 2); or record is not for OBRA or
Medicare Part A (e.g., a PPS assessment submitted for resident whose stay is covered by a Medicare Advantage Plan) purposes.
2
Record has not been data entered, has not been submitted, or has been submitted and rejected by iQIES.
3
The event occurred if the record reflects an actual entry or discharge or if an assessment was actually performed for the resident. If a record was created in
error (e.g., a Discharge assessment was created for a resident who was not actually discharged), then the event did not occur.
4
OBRA comprehensive assessments with A0310A = 01, 03, 04, 05 and Quarterly assessments with A0310A = 02, 06.
5
The assessment contains a significant error which has not been corrected by a subsequent assessment.
6
Final completion date is item V0200C2 for a comprehensive and Z0500B for all other assessments.
1

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

CHAPTER 6: MEDICARE SKILLED NURSING FACILITY
PROSPECTIVE PAYMENT SYSTEM (SNF
PPS)
6.1 Background

The Balanced Budget Act of 1997 included the implementation of a Prospective Payment
System (PPS) for skilled nursing facilities (SNFs) and hospitals with a swing bed agreement,
consolidated billing, and a number of related changes. The PPS system replaced the retrospective
cost-based system for SNFs under Part A of the program (Federal Register Vol. 63, No. 91,
May 12, 1998, Final Rule). Effective with cost reporting periods beginning on or after July 1,
2002, SNF-level services furnished in rural swing bed hospitals are paid based on the SNF PPS
instead of the previous, cost-related method (Federal Register Vol. 66, No. 147, July 31, 2001,
Final Rule). However, the Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000 included an exemption of critical access hospital swing beds from the
SNF PPS.

The SNF PPS is the culmination of substantial research efforts beginning as early as the 1970s
that focus on the areas of nursing home payment and quality. In addition, it is based on a
foundation of knowledge and work by a number of States that developed and implemented
similar case-mix payment methodologies for their Medicaid nursing home payment systems.

The current focus in the development of the Federal payment system (i.e., PPS) for nursing home
care is based on recognizing the differences among residents, particularly in the utilization of
resources. Some residents require total assistance with their activities of daily living (ADLs) and
have complex nursing care needs. Other residents may require less assistance with ADLs but
may require rehabilitation or restorative nursing services. The recognition of these differences is
the premise of a case-mix system. Reimbursement levels differ based on the resource needs of
the residents. Residents with heavy care needs require more staff resources and payment levels
should be higher than for those residents with less intensive care needs. In a case-mix adjusted
payment system, the amount of reimbursement to the nursing home is based on the resource
intensity of the resident as measured by items on the Minimum Data Set (MDS). Case-mix
reimbursement has become a widely adopted method for financing nursing home care. The casemix approach serves as the basis for the PPS for skilled nursing facilities and swing bed hospitals
and is increasingly being used by States for Medicaid reimbursement for nursing homes.

6.2 Using the MDS in the Medicare Prospective Payment
System

The MDS assessment data is used to calculate the resident’s Patient Driven Payment Model
(PDPM) classification necessary for payment. The MDS contains extensive information on the
resident’s nursing and therapy needs, ADL status, cognitive status, behavioral problems, and
medical diagnoses. This information is used to define PDPM case-mix adjusted groups, within

October 2024

Page 6-1

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

which a hierarchy exists that assigns case-mix weights that capture differences in the relative
resources used for treating different types of residents.

Over half of the State Medicaid programs also use the MDS for their case-mix payment systems.
The Resource Utilization Group, Version IV (RUG-IV) system replaced the Resource Utilization
Group, Version III (RUG-III) system for Medicare starting on October 1, 2010. Starting October
1, 2019, PDPM replaced the RUG-IV system. However, State Medicaid agencies have the option
to use the RUG-III, RUG-IV, or PDPM classification systems. CMS also makes available for the
States alternative RUG-IV classification systems with 66, 57, or 48 groups with varying numbers
of Rehabilitation groups (similar to the RUG-III 53, 44, and 34 groups). States have the option of
selecting the system (RUG-III or RUG-IV) with the number of Rehabilitation groups that better
suits their Medicaid long-term care population. State Medicaid programs always have the option
to develop nursing home reimbursement systems that meet their specific program goals. The
decision to implement a certain classification system for Medicaid is a State decision. Please
contact your State Medicaid agency if you have questions about your State Medicaid
reimbursement system.

6.3 Patient Driven Payment Model (PDPM)

PDPM adjusts payment for each major element of a resident’s SNF care, specifically for physical
therapy (PT), occupational therapy (OT), speech-language pathology (SLP), nursing, and nontherapy ancillaries (NTA). In section 6.6 below, we provide a PDPM calculation worksheet. This
calculation worksheet was developed in order to provide clinical staff with a better
understanding of how PDPM works. The worksheet translates the standard software code into
plain language to assist staff in understanding the logic behind the classification system.

6.4 Relationship between the Assessment and the Claim

The SNF PPS establishes a schedule of PPS assessments. The 5-Day assessment is the only
required PPS assessment that is used to support PPS reimbursement. However, as described in
Chapter 2, Section 2.9, an optional assessment, the Interim Payment Assessment (IPA), may be
used to reclassify the resident into a new PDPM classification, and would also affect the
associated payment rate. See Chapter 2 of this manual for greater detail on assessment types and
requirements.

Numerous situations exist that impact the relationship between the assessment and the claim
above and beyond the information provided in this chapter. It is the responsibility of the provider
to ensure that claims submitted to Medicare are accurate and meet all Medicare requirements.
For example, if a resident’s status does not meet the criteria for Medicare Part A SNF coverage,
the provider is not to bill Medicare for any non-covered days. The assignment of a PDPM
classification is not an indication that the requirements for a SNF Part A stay have been met.
Once the resident no longer requires skilled services, the provider must not bill Medicare for
days that are not covered. Therefore, the following information is not to be considered allinclusive and definitive. Refer to the Medicare Claims Processing Manual, Chapter 6

October 2024

Page 6-2

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

(https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/clm104c06.pdf), for detailed claims processing
requirements and policies.
The SNF claim must include two data items derived from the MDS assessment:
Assessment Reference Date (ARD)
The ARD must be reported on the SNF claim. CMS has developed internal mechanisms to
link the MDS assessment and the claims processing system.
Health Insurance Prospective Payment System (HIPPS) Code

Each SNF claim contains a five-position HIPPS code for the purpose of billing Part A
covered days to the Medicare Administrative Contractor (MAC). The HIPPS code consists of
a series of codes representing the resident’s PDPM classification and the Assessment
Indicator (AI) as described below. CMS provides standard software and logic for HIPPS
code calculation.

PDPM Classification

The first four positions of the HIPPS code contain the PDPM classification codes for each
PDPM component to be billed for Medicare reimbursement. The PDPM classification is
calculated from the MDS assessment clinical data. See Section 6.6 for calculation details on
each PDPM group. CMS provides standard software, development tools, and logic for PDPM
calculation. CMS software, or private software developed with the CMS data specifications,
is used to encode and transmit the MDS assessment data and automatically calculates the
resident’s PDPM classification. CMS edits and validates the PDPM classification code of
transmitted MDS assessments. Skilled nursing facilities are not permitted to submit Medicare
Part A claims until the assessments have been accepted into the CMS database, and they
must use the PDPM classification code as validated by CMS when bills are filed, except in
cases in which the facility must bill the default code (ZZZZZ). See Section 6.8 for details.

October 2024

Page 6-3

Section GG
Function Score
0-5
6-9
10-23
24
0-5
6-9
10-23
24
0-5
6-9
10-23
24
0-5
6-9
10-23
24

PT/OT Case-Mix
Group
TA
TB
TC
TD
TE
TF
TG
TH
TI
TJ
TK
TL
TM
TN
TO
TP

HIPPS
Character
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P

CH 6: Medicare SNF PPS

Page 6-4

Clinical Category
Major Joint Replacement or Spinal Surgery
Major Joint Replacement or Spinal Surgery
Major Joint Replacement or Spinal Surgery
Major Joint Replacement or Spinal Surgery
Other Orthopedic
Other Orthopedic
Other Orthopedic
Other Orthopedic
Medical Management
Medical Management
Medical Management
Medical Management
Non-Orthopedic Surgery and Acute Neurologic
Non-Orthopedic Surgery and Acute Neurologic
Non-Orthopedic Surgery and Acute Neurologic
Non-Orthopedic Surgery and Acute Neurologic

CMS՚s RAI Version 3.0 Manual

October 2024

Table 1. First Character: PT/OT Component

Mechanically Altered Diet or
Swallowing Disorder
Neither
Either
Both
Neither
Either
Both
Neither
Either
Both
Neither
Either
Both

SLP Case-Mix
Group
SA
SB
SC
SD
SE
SF
SG
SH
SI
SJ
SK
SL

HIPPS
Character
A
B
C
D
E
F
G
H
I
J
K
L

CH 6: Medicare SNF PPS

Page 6-5

Presence of Acute Neurologic
Condition, SLP-Related
Comorbidity, or Cognitive
Impairment
None
None
None
Any one
Any one
Any one
Any two
Any two
Any two
All three
All three
All three

CMS՚s RAI Version 3.0 Manual

October 2024

Table 2. Second Character: SLP Component

RUG-IV
Nursing
RUG

ES2
ES1
HE2/HD2

0-14

ES3

0-14

ES2

Serious medical conditions
e.g., comatose, septicemia,
respiratory therapy
Serious medical conditions
e.g., comatose, septicemia,
respiratory therapy
Serious medical conditions
e.g., comatose, septicemia,
respiratory therapy
Serious medical conditions
e.g., comatose, septicemia,
respiratory therapy
Serious medical conditions
e.g., radiation therapy or
dialysis
Serious medical conditions
e.g., radiation therapy or
dialysis
Serious medical conditions
e.g., radiation therapy or
dialysis

0-14

ES1

Yes

0-5

HDE2

HC2/HB2

HC1/HB1

LE2/LD2

LE1/LD1

LC2/LB2

0-5

HDE1

Yes

6-14

HBC2

6-14

HBC1

Yes

0-5

LDE2

0-5

LDE1

Yes

6-14

LBC2

CH 6: Medicare SNF PPS

HIPPS
Character

Depression

Page 6-6

HE1/HD1

GG-based
Function
Score

Clinical Conditions

ES3

Extensive
Services
Tracheostomy
& Ventilator
Tracheostomy
or Ventilator
Infection

PDPM
Nursing
CaseMix
Group

# of
Restorative
Nursing
Services

CMS՚s RAI Version 3.0 Manual

October 2024

Table 3. Third Character: Nursing Component

Extensive
Services

LC1/LB1

CE1/CD1

CA2

CC1/CB1

CA1

BB2/BA2

BB1/BA1

PE2/PD2

6-14

LBC1

Yes

0-5

CDE2

0-5

CDE1

Yes

6-14

CBC2

Yes

15-16

CA2

6-14

CBC1

15-16

CA1

2 or more

11-16

BAB2

0-1

11-16

BAB1

2 or more

0-5

PDE2

CH 6: Medicare SNF PPS

Depression

Page 6-7

CC2/CB2

HIPPS
Character

CE2/CD2

Clinical Conditions
Serious medical conditions
e.g., radiation therapy or
dialysis
Conditions requiring complex
medical care e.g., pneumonia,
surgical wounds, burns
Conditions requiring complex
medical care e.g., pneumonia,
surgical wounds, burns
Conditions requiring complex
medical care e.g., pneumonia,
surgical wounds, burns
Conditions requiring complex
medical care e.g., pneumonia,
surgical wounds, burns
Conditions requiring complex
medical care e.g., pneumonia,
surgical wounds, burns
Conditions requiring complex
medical care e.g., pneumonia,
surgical wounds, burns
Behavioral or cognitive
symptoms
Behavioral or cognitive
symptoms
Assistance with daily living
and general supervision

GG-based
Function
Score

CMS՚s RAI Version 3.0 Manual

October 2024

RUG-IV
Nursing
RUG

PDPM
Nursing
CaseMix
Group

# of
Restorative
Nursing
Services

PE1/PD1

PC2/PB2

PA2

PC1/PB1
PA1

Clinical Conditions
Assistance with daily living
and general supervision
Assistance with daily living
and general supervision
Assistance with daily living
and general supervision
Assistance with daily living
and general supervision
Assistance with daily living
and general supervision

GG-based
Function
Score

HIPPS
Character

0-1

0-5

PDE1

2 or more

6-14

PBC2

2 or more

15-16

PA2

0-1

6-14

PBC1

0-1

15-16

PA1

Depression
-

Extensive
Services

CMS՚s RAI Version 3.0 Manual

October 2024

RUG-IV
Nursing
RUG

PDPM
Nursing
CaseMix
Group

# of
Restorative
Nursing
Services

Table 4. Fourth Character: NTA Component

HIPPS Character
A
B
C
D
E
F

Page 6-8

CH 6: Medicare SNF PPS

NTA Case-Mix Group
NA
NB
NC
ND
NE
NF

NTA Score Range
12+
9-11
6-8
3-5
1-2
0

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

The PDPM HIPPS code is recorded on the MDS 3.0 in item Z0100A (Medicare Part A
HIPPS code). The HIPPS code included on the SNF claim depends on the specific type of
assessment involved (as described below).
The HIPPS code in item Z0100A is validated by CMS when the assessment is submitted. If
the submitted code is incorrect, the validation report will include a warning giving the correct
code; the facility must enter this correct code in the HIPPS code item on the bill.

The provider must ensure that all PPS assessment requirements are met. When the provider
fails to meet the PPS assessment requirements, such as when the assessment is late (as
evidenced by a late ARD), the provider may be required to bill the default code. In these
situations, the provider is responsible to ensure that the default code and not the PDPM
classification-based HIPPS code validated by CMS in item Z0100A is billed for the
applicable number of days. See Section 6.8 of this chapter for greater detail.
AI Code

The last position of the HIPPS code represents the AI, identifying the assessment type. The
AI coding system indicates the different types of assessments that define different PPS
payment periods and is based on the coding of item A0310B. CMS provides standard
software, development tools, and logic for AI code calculation. CMS software, or private
software developed with the CMS tools, automatically calculates the AI code. The AI code is
validated by CMS when the assessment is submitted. If the submitted AI code is incorrect on
the assessment, the validation report will include a warning and provide the correct code. The
facility must enter this correct AI code in the HIPPS code item on the bill. The code consists
of one digit, which is defined below. In situations when the provider is to bill the default
code, the AI provided on the validation report is to be used along with the default code,
ZZZZZ, on the SNF claim.

Refer to the Medicare Claims Processing Manual, Chapter 6, for detailed claims
processing requirements and policies.

The AI code identifies the assessment used to establish the per diem payment rate for the
standard PPS payment periods. These assessments are the 5-Day assessment and Interim
Payment Assessment. Table 5 displays the AI code for each of the PPS assessment types and
the standard payment period for each assessment type.
Table 5. Assessment Indicator Table
AI Code

Assessment Type (abbreviation)

Interim Payment Assessment

5-Day

October 2024

Standard Payment
Period

See Chapter 2,
Section 2.9
Entire Part A Stay

Page 6-9

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

6.5 SNF PPS Eligibility Criteria
Under SNF PPS, beneficiaries must meet the established eligibility requirements for a Part A
SNF-level stay. These requirements are summarized in this section. Refer to the Medicare
General Information, Eligibility, and Entitlement Manual, Chapter 1 (Pub. 100-1), and the
Medicare Benefit Policy Manual, Chapter 8 (Pub. 100-2), for detailed SNF coverage
requirements and policies.

Technical Eligibility Requirements
The beneficiary must meet the following criteria:
Beneficiary is enrolled in Medicare Part A and has days available to use.

•

There has been a three-day prior qualifying hospital stay (i.e., three midnights).

•

Admission for SNF-level services is within 30 days of discharge from an acute care stay
or within 30 days of discharge from a SNF level of care.

•

Clinical Eligibility Requirements

A beneficiary is eligible for SNF extended care if all of the following requirements are met:
The beneficiary has a need for and receives medically necessary skilled care on a daily
basis, which is provided by or under the direct supervision of skilled nursing or
rehabilitation professionals.

•

As a practical matter, these skilled services can only be provided in an SNF.

•

The services provided must be for a condition:

•

— for which the resident was treated during the qualifying hospital stay, or
— that arose while the resident was in the SNF for treatment of a condition for which
they were previously treated in a hospital.

Physician Certification

The attending physician or a physician on the staff of the skilled nursing facility who has
knowledge of the case—or a nurse practitioner (NP), physician assistant (PA), or clinical nurse
specialist (CNS) who does not have a direct or indirect employment relationship with the facility
but who is working in collaboration with the physician—must certify and then periodically
recertify the need for extended care services in the skilled nursing facility.
•

Certifications are required at the time of admission or as soon thereafter as is reasonable
and practicable (42 CFR 424.20). The initial certification
— affirms, per the required content found in 42 CFR 424.20, that the resident meets the
existing SNF level of care definition, or
— validates via written statement that the resident’s assignment to one of the upper
PDPM groups (defined below) is correct.

October 2024

Page 6-10

CMS’s RAI Version 3.0 Manual

•

CH 6: Medicare SNF PPS

o Those nursing groups encompassed by the Extensive Services, Special Care
High, Special Care Low, and Clinically Complex nursing categories;
o PT and OT groups TA, TB, TC, TD, TE, TF, TG, TJ, TK, TN, and TO;
o SLP groups SC, SE, SF, SH, SI, SJ, SK, and SL; and
o The NTA component’s uppermost (12+) comorbidity group.
Re-certifications are used to document the continued need for skilled extended care
services.
— The first re-certification is required no later than the 14th day of the SNF stay.
— Subsequent re-certifications are required at no later than 30-day intervals after the
date of the first re-certification.
— The initial certification and first re-certification may be signed at the same time.

6.6 PDPM Calculation Worksheet for SNFs

In the PDPM, there are five case-mix adjusted components: PT, OT, SLP, NTA, and Nursing.
Each resident is to be classified into one and only one group for each of the five case-mix
adjusted components. In other words, each resident is classified into a PT group, an OT group, an
SLP group, an NTA group, and a nursing group. For each of the case-mix adjusted components,
there are a number of groups to which a resident may be assigned, based on the relevant MDS
3.0 data for that component. There are 16 PT groups, 16 OT groups, 12 SLP groups, 6 NTA
groups, and 25 nursing groups.
PDPM classifies residents into a separate group for each of the case-mix adjusted components,
each of which has its own associated case-mix indexes and base rates. Additionally, PDPM
applies variable per diem payment adjustments to three components, PT, OT, and NTA, to
account for changes in resource use over a stay. The adjusted PT, OT, and NTA per diem rates
are then added together with the unadjusted SLP and nursing component rates and the non-casemix component to determine the full per diem rate for a given resident.

ft
October 2024

Page 6-11

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

Calculation of PDPM Cognitive Level
The PDPM cognitive level is utilized in the SLP payment component of PDPM. One of four
PDPM cognitive performance levels is assigned based on the Brief Interview for Mental Status
(BIMS) or the Staff Assessment for Mental Status for the PDPM cognitive level. If neither the
BIMS nor the staff assessment for the PDPM cognitive level is complete, then the resident will be
classified as if the resident is cognitively intact.
STEP #1
Determine the resident’s BIMS Summary Score on the MDS 3.0 based on the resident interview.
Instructions for completing the BIMS are in Chapter 3, Section C. The BIMS involves the
following items:

C0200 Repetition of three words
C0300 Temporal orientation
C0400 Recall

Item C0500 provides a BIMS Summary Score that ranges from 00 to 15. If the resident interview
is not successful, then the BIMS Summary Score will equal 99.

Calculate the resident’s PDPM cognitive level using the following mapping:
Table 6: Calculation of PDPM Level from BIMS

PDPM Cognitive Level
Cognitively Intact
Mildly Impaired
Moderately Impaired
Severely Impaired

BIMS Score
13-15
8-12
0-7
-

PDPM Cognitive Level: __________

If the resident’s Summary Score is 99 (resident interview not successful) or the Summary Score
is blank (resident interview not attempted and skipped) or the Summary Score has a dash value
(not assessed), then proceed to Step #2 to use the Staff Assessment for Mental Status for the
PDPM cognitive level.
STEP #2

If the resident’s Summary Score is 99 or the Summary Score is blank or has a dash value, then
determine the resident’s cognitive status based on the Staff Assessment for Mental Status for the
PDPM cognitive level using the following steps:

October 2024

Page 6-12

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

A) The resident classifies as severely impaired if one of the following conditions exists:
a. Comatose (B0100 = 1) and completely dependent or activity did not occur at
admission (GG0130A1, GG0130C1, GG0170B1, GG0170C1, GG0170D1,
GG0170E1, and GG0170F1 all equal 01, 09, or 88). It should be noted that, in the
case of an IPA, the items used for calculation of the resident’s PDPM functional score
are the Interim Performance items (GG0XXXX5), rather than the Admission
Performance items (GG0XXXX1). For example, rather than GG0130B1, which is
used on the 5-Day to assess the resident’s Oral Hygiene Admission Performance, the
IPA uses item GG0130B5 in order to measure the resident’s Oral Hygiene Interim
Performance.
b. Severely impaired cognitive skills for daily decision making (C1000 = 3).

B) If the resident is not severely impaired based on Step A, then determine the resident’s Basic
Impairment Count and Severe Impairment Count.
For each of the conditions below that applies, add one to the Basic Impairment Count.
a. In Cognitive Skills for Daily Decision Making, the resident has modified
independence or is moderately impaired (C1000 = 1 or 2).

b. In Makes Self Understood, the resident is usually understood, sometimes understood,
or rarely/never understood (B0700 = 1, 2, or 3).
c. Based on the Staff Assessment for Mental Status, the resident has a memory problem
(C0700 = 1).
Sum a., b., and c. to get the Basic Impairment Count: _____

For each of the conditions below that applies, add one to the Severe Impairment Count.

a. In Cognitive Skills for Daily Decision Making, the resident is moderately impaired
(C1000 = 2).
b. In Makes Self Understood, the resident is sometimes understood or rarely/never
understood (B0700 = 2 or 3).

Sum a. and b. to get the Severe Impairment Count: _____
C) The resident classifies as moderately impaired if the Severe Impairment Count is 1 or 2 and
the Basic Impairment Count is 2 or 3.

D) The resident classifies as mildly impaired if the Basic Impairment Count is 1 and the Severe
Impairment Count is 0, 1, or 2, or if the Basic Impairment Count is 2 or 3 and the Severe
Impairment Count is 0.
E) The resident classifies as cognitively intact if both the Severe Impairment Count and Basic
Impairment Count are 0.
PDPM Cognitive Level: __________
October 2024

Page 6-13

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

PDPM Payment Component: PT
STEP #1
Determine the resident’s primary diagnosis clinical category using the ICD-10-CM code
recorded in MDS item I0020B. To do so, refer to the PDPM Clinical Categories to ICD-10
Diagnosis Codes mapping (available at www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/PDPM.html), which maps a resident’s primary diagnosis as recorded in MDS
item I0020B to the 10 PDPM primary diagnosis clinical categories.
I0020B diagnosis: ____________________
Default primary diagnosis clinical category: ____________________

STEP #1A

Some ICD-10-CM codes can map to a different clinical category from the default depending on a
resident’s prior inpatient procedure history. For these codes, a resident may be categorized into a
surgical clinical category if the resident received a surgical procedure during the prior inpatient
stay that relates to the primary reason for the Part A SNF stay as indicated by item J2100. If the
PDPM clinical category mapping indicates that the resident’s primary diagnosis code is eligible
for one of the two orthopedic surgery categories (major joint replacement or spinal surgery, and
orthopedic surgery (except major joint replacement or spinal surgery)), then proceed to Step 1A;
if eligible for the non-orthopedic surgery category, then proceed to Step 1C. Otherwise, proceed
to Step 1D to finalize the primary diagnosis clinical category assignment.

Determine whether the resident received a major joint replacement or spinal surgery during the
prior inpatient stay using item J2100. If any of the procedures indicated in items J2300, J2310,
J2320, J2330, J2400, J2410, or J2420 was performed during the prior inpatient stay, then the
resident is categorized into the major joint replacement or spinal surgery clinical category. If
none of these procedures was performed, the resident did not receive major joint replacement or
spinal surgery during the prior inpatient stay for purposes of determining the PDPM
classification.

Resident Eligible for Surgical Clinical Category and Received Major Joint Replacement or
Spinal Surgery? (Yes/No) _____
If the resident received Major Joint Replacement or Spinal Surgery, then the primary diagnosis
clinical category is Major Joint Replacement or Spinal Surgery. Proceed to Step 1D to finalize
the primary diagnosis clinical category assignment. Otherwise, proceed to Step 1B.

October 2024

Page 6-14

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #1B
Determine whether the resident received orthopedic surgery (except major joint replacement or
spinal surgery) during the prior inpatient stay using item J2100. If any of the procedures
indicated in items J2500, J2510, J2520, or J2530 was performed during the prior inpatient stay,
then the resident is categorized into the Orthopedic Surgery (Except Major Joint Replacement or
Spinal Surgery) clinical category. If none of these procedures was performed, the resident did not
receive orthopedic surgery (except major joint replacement or spinal surgery) during the prior
inpatient stay for purposes of determining the PDPM classification.
Resident Eligible for Surgical Clinical Category and Received Orthopedic Surgery (Except
Major Joint Replacement or Spinal Surgery)? (Yes/No) _____

If the resident received Orthopedic Surgery (Except Major Joint Replacement or Spinal Surgery),
then the primary diagnosis clinical category is Orthopedic Surgery (Except Major Joint
Replacement or Spinal Surgery). Otherwise, the resident stays in the default primary diagnosis
clinical category in Step 1. Proceed to Step 1D to finalize the primary diagnosis clinical category
assignment.
STEP #1C

Determine whether the resident received a significant non-orthopedic surgical procedure during
the prior inpatient stay using item J2100. If any of the procedures indicated in items J2600,
J2610, J2620, J2700, J2710, J2800, J2810, J2900, J2910, J2920, J2930, or J2940 was performed
during the prior inpatient stay, then the resident is categorized into the non-orthopedic surgery
clinical category. If none of these procedures was performed, the resident did not receive a
significant non-orthopedic surgical procedure during the prior inpatient stay for purposes of
determining the PDPM classification.
Resident Eligible for Surgical Clinical Category and Received Significant Non-Orthopedic
Surgical Procedure? (Yes/No) _____

STEP #1D

If the resident received a significant Non-Orthopedic Surgical Procedure, then the primary
diagnosis clinical category is Non-Orthopedic Surgery. Otherwise, the resident stays in the
default primary diagnosis clinical category in Step 1. Proceed to Step 1D to finalize the primary
diagnosis clinical category assignment.

To finalize the primary diagnosis clinical category assignment, if the resident is not eligible for a
different clinical category from the default, then select the default clinical category assigned to
the primary diagnosis as recorded in MDS item I0020B in Step 1. If the resident is eligible for a
different clinical category from the default, select the eligible surgical clinical category as
determined in Steps 1A, 1B, or 1C.

Primary diagnosis clinical category: ____________________

October 2024

Page 6-15

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #2
Next, determine the resident’s PT clinical category based on the mapping shown below.
Table 7: PT Clinical Category

STEP #3

PT Clinical Category
Major Joint Replacement or Spinal Surgery
Other Orthopedic
Non-Orthopedic Surgery
Medical Management
Medical Management
Medical Management
Other Orthopedic
Acute Neurologic
Medical Management
Medical Management
PT Clinical Category: ____________________

Primary Diagnosis Clinical Category
Major Joint Replacement or Spinal Surgery
Orthopedic Surgery (Except Major Joint
Replacement or Spinal Surgery)
Non-Orthopedic Surgery
Acute Infections
Cardiovascular and Coagulations
Pulmonary
Non-Surgical Orthopedic/Musculoskeletal
Acute Neurologic
Cancer
Medical Management

Calculate the resident’s Function Score for PT payment. Use the following table to determine the
Function Score for Eating Admission Performance (GG0130A1), Oral Hygiene Admission
Performance (GG0130B1), Toileting Hygiene Admission Performance (GG0130C1), Sit to
Lying Admission Performance (GG0170B1), Lying to Sitting on Side of Bed Admission
Performance (GG0170C1), Sit to Stand Admission Performance (GG0170D1), Chair/Bed-toChair Transfer Admission Performance (GG0170E1), and Toilet Transfer Admission
Performance (GG0170F1).

It should be noted that, in the case of an IPA, the items used for calculation of the resident’s
PDPM functional score are the Interim Performance items (GG0XXXX5), rather than the
Admission Performance items (GG0XXXX1). For example, rather than GG0130B1, which is
used on the 5-Day to assess the resident’s Oral Hygiene Admission Performance, the IPA uses
item GG0130B5 in order to measure the resident’s Oral Hygiene Interim Performance.

Determine if the resident can walk using item GG0170I1. If the resident cannot walk 10 feet
(GG0170I1 = 07, 09, 10, or 88), then the Function Score for Walk 50 Feet with Two Turns
(GG0170J1) and Walk 150 Feet (GG0170K1) is 0. If the resident can walk (GG0170I1 = 06, 05,
04, 03, 02, 01), then determine the Function Score for Walk 50 Feet with Two Turns
(GG0170J1) and Walk 150 Feet (GG0170K1) using the following table.

October 2024

Page 6-16

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

Table 8: Function Score for PT Payment
Admission or Interim Performance
(Column 1 or 5) =
05, 06
04
03
02
01, 07, 09, 10, 88, missing

Function Score =
4
3
2
1
0

Enter the Function Score for each item:
Eating

Eating Function Score: _____

Oral Hygiene

Oral Hygiene Function Score: _____

Toileting Hygiene

Bed Mobility

Toileting Hygiene Function Score: _____

Sit to Lying Function Score: _____

Lying to Sitting on Side of Bed Function Score: _____
Transfer

Sit to Stand Function Score: _____

Chair/Bed-to-Chair Function Score: _____
Toilet Transfer Function Score: _____
Walking

Walk 50 Feet with Two Turns Function Score: _____
Walk 150 Feet Function Score: _____

The next step is to calculate the average function scores for the two bed mobility items, the
three transfer items, and the two walking items as follows. For the Average Bed Mobility
Function Score, calculate the sum of the Function Scores for Sit to Lying and Lying to Sitting
on Side of Bed and divide this sum by 2. For the Average Transfer Function Score, calculate
the sum of the Function Scores for Sit to Stand, Chair/Bed-to-Chair, and Toilet Transfer, and
October 2024

Page 6-17

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

divide this sum by 3. For the Average Walking Function Score, calculate the sum of the
Function Scores for Walk 50 Feet with Two Turns and Walk 150 Feet, and divide this sum by
2. Enter the Average Bed Mobility, Average Transfer Function, and Average Walking Function
Scores below.
Average Bed Mobility Function Score: _____
Average Transfer Function Score: _____
Average Walking Function Score: _____

Calculate the sum of the following Function Scores: Eating Function Score, Oral Hygiene
Function Score, Toileting Hygiene Function Score, Average Bed Mobility Function Score,
Average Transfer Function Score, and Average Walking Function Score. Finally, round this sum
to the nearest integer. This is the PDPM Function Score for PT Payment. The PDPM Function
Score for PT Payment ranges from 0 through 24.
PT FUNCTION SCORE: _____

STEP #4

Using the responses from Steps 2 and 3 above, determine the resident’s PT group using the table
below.
Table 9: PT Case-Mix Groups

Section GG
Function Score
0-5
6-9
10-23
24
0-5
6-9
10-23
24
0-5
6-9
10-23
24
0-5
6-9
10-23
24

PT Case-Mix
Group
TA
TB
TC
TD
TE
TF
TG
TH
TI
TJ
TK
TL
TM
TN
TO
TP

PDPM PT Classification: _____

October 2024

Page 6-18

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

PDPM Payment Component: OT
*Note: The steps for calculating the resident’s PDPM classification for the OT component
follow the same logic used for calculating the resident’s PDPM classification for the PT
component, described above.
STEP #1
Determine the resident’s primary diagnosis clinical category using the ICD-10-CM code
recorded in MDS item I0020B. To do so, refer to the PDPM Clinical Categories to ICD-10
Diagnosis Codes mapping (available at www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/PDPM.html), which maps a resident’s primary diagnosis as recorded in MDS
item I0020B to the 10 PDPM primary diagnosis clinical categories.

I0020B diagnosis: ____________________

Default primary diagnosis clinical category: ____________________

STEP #1A

October 2024

Page 6-19

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #1D

Primary diagnosis clinical category: ____________________

October 2024

Page 6-20

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #2
Next, determine the resident’s OT clinical category based on the mapping shown below.
Table 10: OT Clinical Category

STEP #3

OT Clinical Category
Major Joint Replacement or Spinal Surgery
Other Orthopedic
Non-Orthopedic Surgery
Medical Management
Medical Management
Medical Management
Other Orthopedic
Acute Neurologic
Medical Management
Medical Management
OT Clinical Category: ____________________

Calculate the resident’s Function Score for OT payment. Use the following table to determine
the Function Score for Eating Admission Performance (GG0130A1), Oral Hygiene Admission
Performance (GG0130B1), Toileting Hygiene Admission Performance (GG0130C1), Sit to
Lying Admission Performance (GG0170B1), Lying to Sitting on Side of Bed Admission
Performance (GG0170C1), Sit to Stand Admission Performance (GG0170D1), Chair/Bed-toChair Transfer Admission Performance (GG0170E1), and Toilet Transfer Admission
Performance (GG0170F1).

October 2024

Page 6-21

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

Table 11: Function Score for OT Payment
Admission or Interim Performance
(Column 1 or 5) =
05, 06
04
03
02
01, 07, 09, 10, 88, missing

Function Score =
4
3
2
1
0

Enter the Function Score for each item:
Eating

Eating Function Score: _____

Oral Hygiene

Oral Hygiene Function Score: _____

Toileting Hygiene

Bed Mobility

Toileting Hygiene Function Score: _____

Sit to Lying Function Score: _____

Lying to Sitting on Side of Bed Function Score: _____
Transfer

Sit to Stand Function Score: _____

Chair/Bed-to-Chair Function Score: _____
Toilet Transfer Function Score: _____
Walking

Walk 50 Feet with Two Turns Function Score: _____
Walk 150 Feet Function Score: _____

Page 6-22

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

Calculate the sum of the following Function Scores: Eating Function Score, Oral Hygiene
Function Score, Toileting Hygiene Function Score, Average Bed Mobility Function Score,
Average Transfer Function Score, and Average Walking Function Score. Finally, round this sum
to the nearest integer. This is the PDPM Function Score for OT Payment. The PDPM Function
Score for OT Payment ranges from 0 through 24.
OT FUNCTION SCORE: _____

STEP #4

Using the responses from Steps 2 and 3 above, determine the resident’s OT group using the table
below.
Table 12: OT Case-Mix Groups

Section GG
Function Score
0-5
6-9
10-23
24
0-5
6-9
10-23
24
0-5
6-9
10-23
24
0-5
6-9
10-23
24

OT Case-Mix
Group
TA
TB
TC
TD
TE
TF
TG
TH
TI
TJ
TK
TL
TM
TN
TO
TP

PDPM OT Classification: _____

October 2024

Page 6-23

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

PDPM Payment Component: SLP
*Note: The primary diagnosis clinical category used for the SLP component is the same as
the clinical category used for the PT and OT components.
STEP #1
Determine the resident’s primary diagnosis clinical category using the ICD-10-CM code
recorded in MDS item I0020B. To do so, refer to the PDPM Clinical Categories to ICD-10
Diagnosis Codes mapping (available at www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/PDPM.html), which maps a resident’s primary diagnosis as recorded in MDS
item I0020B to the 10 PDPM primary diagnosis clinical categories.
I0020B diagnosis: ____________________

Default primary diagnosis clinical category: ____________________

STEP #1A

October 2024

Page 6-24

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #1D

Primary diagnosis clinical category: ____________________

October 2024

Page 6-25

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #2
Next, determine the resident’s SLP clinical category based on the mapping shown below.
Table 13: SLP Clinical Category

STEP #3

SLP Clinical Category
Non-Neurologic
Non-Neurologic
Non-Neurologic
Non-Neurologic
Non-Neurologic
Non-Neurologic
Non-Neurologic
Acute Neurologic
Non-Neurologic
Non-Neurologic
SLP Clinical Category: ____________________

Determine whether the resident has one or more SLP-related comorbidities. To do so, examine
the services and conditions in the table below. If any of these items is indicated as present, the
resident has an SLP-related comorbidity. For conditions and services that are recorded in item
I8000 of the MDS, check if the corresponding ICD-10-CM codes are coded in item I8000 using
the mapping available at www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/PDPM.html.
Table 14: SLP-Related Comorbidities

O0110F1b

Description
Aphasia
CVA, TIA, or Stroke
Hemiplegia or Hemiparesis
Traumatic Brain Injury
Laryngeal Cancer
Apraxia
Dysphagia
ALS
Oral Cancers
Speech and Language Deficits
Tracheostomy Care While a Resident
Invasive Mechanical Ventilator or Respirator
While a Resident

MDS Item
I4300
I4500
I4900
I5500
I8000
I8000
I8000
I8000
I8000
I8000
O0110E1b

Presence of one or more SLP-related comorbidities? (Yes/No) _____
October 2024

Page 6-26

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #4
Determine whether the resident has a cognitive impairment. Calculate the resident’s PDPM
cognitive level, as described previously. If the PDPM cognitive level is cognitively intact, then
the resident does not have a cognitive impairment. Otherwise, if the resident is assessed as
mildly, moderately, or severely impaired, then the resident classifies as cognitively impaired.
Presence of Cognitive Impairment? (Yes/No) _____
STEP #5
Determine how many of the following conditions are present:
a. Based on Step 2, the resident is classified in the Acute Neurologic clinical category.

b. Based on Step 3, the resident has one or more SLP-related comorbidities.

c. Based on Step 4, the resident has a cognitive impairment.
Number of conditions present: _____

STEP #6

Determine whether the resident has a swallowing disorder using item K0100. If any of the
conditions indicated in items K0100A through K0100D is present, then the resident has a
swallowing disorder. If none of these conditions is present, the resident does not have a
swallowing disorder for purposes of this calculation.
Presence of Swallowing Disorder? (Yes/No) _____

STEP #7

Determine whether the resident has a mechanically altered diet. If K0520C3 (mechanically
altered diet while a resident) is checked, then the resident has a mechanically altered diet.

Presence of Mechanically Altered Diet? (Yes/No) _____
STEP #8

Determine how many of the following conditions are present based on Steps 6 and 7:

a. The resident has neither a swallowing disorder nor a mechanically altered diet.
b. The resident has either a swallowing disorder or a mechanically altered diet.
c. The resident has both a swallowing disorder and a mechanically altered diet.
Presence of Mechanically Altered Diet or Swallowing Disorder? (Neither/Either/Both): _____

October 2024

Page 6-27

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #9
Determine the resident’s SLP group using the responses from Steps 1-8 and the table below.
Table 15: SLP Case-Mix Groups

Presence of Acute Neurologic Condition, SLPRelated Comorbidity, or Cognitive Impairment
None
None
None
Any one
Any one
Any one
Any two
Any two
Any two
All three
All three
All three

Mechanically
Altered Diet or
Swallowing
Disorder
Neither
Either
Both
Neither
Either
Both
Neither
Either
Both
Neither
Either
Both

SLP Case-Mix
Group
SA
SB
SC
SD
SE
SF
SG
SH
SI
SJ
SK
SL

PDPM SLP Classification: _____

ft
October 2024

Page 6-28

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

PDPM Payment Component: NTA
STEP #1
Determine whether resident has one or more NTA-related comorbidities.
1. Determine whether the resident has HIV/AIDS. HIV/AIDS is not reported on the MDS but is
recorded on the SNF claim (ICD-10-CM code B20).
Resident has HIV/AIDS? (Yes/No) _____

2. Determine whether the resident meets the criteria for the comorbidity: “Parenteral/IV
Feeding – High Intensity” or the comorbidity: “Parenteral/IV Feeding – Low Intensity.” To
do so, first determine if the resident received parenteral/IV feeding during the last 7 days
while a resident of the SNF using item K0520A3. If the resident did not receive parenteral/IV
feeding during the last 7 days while a resident, then the resident does not meet the criteria for
Parenteral/IV Feeding – High Intensity or Parenteral/IV Feeding – Low Intensity.

If the resident did receive parenteral/IV feeding during the last 7 days while a resident, then
use item K0710A to determine if the proportion of total calories the resident received through
parenteral or tube feeding was 51% or more while a resident (K0710A2 = 3). If K0710A2 =
3, then the resident meets the criteria for Parenteral/IV Feeding – High Intensity. If the
proportion of total calories the resident received through parenteral or tube feeding was 2650% (K0710A2 = 2) and average fluid intake per day by IV or tube feeding was 501 cc per
day or more while a resident (K0710B2 = 2), then the resident qualifies for Parenteral/IV
Feeding – Low Intensity.
Presence of Parenteral/IV Feeding – High Intensity? (Yes/No) _____
Presence of Parenteral/IV Feeding – Low Intensity? (Yes/No) _____

3. Determine whether the resident has any additional NTA-related comorbidities. To do this,
examine the conditions and services in the table below, of which all except HIV/AIDS are
recorded on the MDS. HIV/AIDS is recorded on the SNF claim. For conditions and services
that are recorded in item I8000 of the MDS, check if the corresponding ICD-10-CM codes
are coded in item I8000 using the mapping available at www.cms.gov/Medicare/MedicareFee-for-Service-Payment/SNFPPS/PDPM.html.

October 2024

Page 6-29

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

Table 16: NTA Comorbidity Score Calculation
HIV/AIDS

Condition/Extensive Service

Parenteral IV Feeding: Level High
Special Treatments/Programs: Intravenous
Medication Post-admit Code
Special Treatments/Programs: Invasive Mechanical
Ventilator or Respirator Post-admit Code
Parenteral IV Feeding: Level Low

Points
8

O0110H1b

O0110F1b

K0520A3,
K0710A2,
K0710B2
I8000

3
3

O0110I1b

I8000
I5200
I8000

2
2
2

I6200

I8000

I8000
I2500
I2900
I8000
I8000
I8000
I8000
I8000

2
2
2
1
1
1
1
1

Lung Transplant Status
Special Treatments/Programs: Transfusion Postadmit Code
Major Organ Transplant Status, Except Lung
Active Diagnoses: Multiple Sclerosis Code
Opportunistic Infections
Active Diagnoses: Asthma COPD Chronic Lung
Disease Code
Bone/Joint/Muscle Infections/Necrosis - Except:
Aseptic Necrosis of Bone
Chronic Myeloid Leukemia
Wound Infection Code
Active Diagnoses: Diabetes Mellitus (DM) Code
Endocarditis
Immune Disorders
End-Stage Liver Disease
Narcolepsy and Cataplexy
Cystic Fibrosis
Special Treatments/Programs: Tracheostomy Care
Post-admit Code
Active Diagnoses: Multi-Drug Resistant Organism
(MDRO) Code
Special Treatments/Programs: Isolation Post-admit
Code
Specified Hereditary Metabolic/Immune Disorders
Morbid Obesity
Special Treatments/Programs: Radiation Post-admit
Code
Stage 4 Unhealed Pressure Ulcer Currently Present1
Psoriatic Arthropathy and Systemic Sclerosis
Chronic Pancreatitis
Proliferative Diabetic Retinopathy and Vitreous
Hemorrhage

MDS Item
N/A (SNF claim)
K0520A3,
K0710A2

October 2024

O0110E1b

I1700

O0110M1b

I8000
I8000

1
1

O0110B1b

M0300D1
I8000
I8000

1
1
1

I8000

Page 6-30

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

MDS Item

Points

M1040A, M1040B,
M1040C

I8000

H0100D

I1300
I8000

1
1

O0110D1b

I8000
I8000

1
1

I8000

K0520B3

I8000
I8000
I5600

1
1
1

I8000

I8000
H0100C
I8000

1
1
1

I8000

Condition/Extensive Service
Other Foot Skin Problems: Foot Infection Code,
Diabetic Foot Ulcer Code, Other Open Lesion on
Foot Code
Complications of Specified Implanted Device or
Graft
Bladder and Bowel Appliances: Intermittent
Catheterization
Inflammatory Bowel Disease
Aseptic Necrosis of Bone
Special Treatments/Programs: Suctioning Postadmit Code
Cardio-Respiratory Failure and Shock
Myelodysplastic Syndromes and Myelofibrosis
Systemic Lupus Erythematosus, Other Connective
Tissue Disorders, and Inflammatory
Spondylopathies
Diabetic Retinopathy - Except: Proliferative
Diabetic Retinopathy and Vitreous Hemorrhage
Nutritional Approaches While a Resident: Feeding
Tube
Severe Skin Burn or Condition
Intractable Epilepsy
Active Diagnoses: Malnutrition Code
Disorders of Immunity - Except: RxCC97: Immune
Disorders
Cirrhosis of Liver
Bladder and Bowel Appliances: Ostomy
Respiratory Arrest
Pulmonary Fibrosis and Other Chronic Lung
Disorders

If the number of Stage 4 Unhealed Pressure Ulcers is recorded as greater than 0, it will add one point to the NTA
comorbidity score calculation. Only the presence, not the count, of Stage 4 Unhealed Pressure Ulcers affects the
PDPM NTA comorbidity score calculation.

STEP #2

Calculate the resident’s total NTA score using the table above. To calculate the total NTA score,
sum the points corresponding to each condition or service present. If none of these conditions or
services is present, the resident’s score is 0.

NTA Score: _____

October 2024

Page 6-31

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #3
Determine the resident’s NTA group using the table below.
Table 17: NTA Case-Mix Groups
NTA Score Range
12+
9-11
6-8
3-5
1-2
0

NTA Case-Mix Group
NA
NB
NC
ND
NE
NF

PDPM NTA Classification: _____

October 2024

Page 6-32

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

PDPM Payment Component: Nursing
STEP #1
Calculate the resident’s Function Score for nursing payment. Use the following table to
determine the Function Score for Eating Admission Performance (GG0130A1), Toileting
Hygiene Admission Performance (GG0130C1), Sit to Lying Admission Performance
(GG0170B1), Lying to Sitting on Side of Bed Admission Performance (GG0170C1), Sit to Stand
Admission Performance (GG0170D1), Chair/Bed-to-Chair Transfer Admission Performance
(GG0170E1), and Toilet Transfer Admission Performance (GG0170F1).
Table 18: Function Score for Nursing Payment

Admission Performance (Column 1) =
05, 06
04
03
02
01, 07, 09, 10, 88, missing

Function Score =
4
3
2
1
0

Enter the Function Score for each item:

Eating

Eating Function Score: _____
Toileting Hygiene

Toileting Hygiene Function Score: _____
Bed Mobility

Sit to Lying Function Score: _____

Lying to Sitting on Side of Bed Function Score: _____
Transfer
Sit to Stand Function Score: _____

Chair/Bed-to-Chair Function Score: _____
Toilet Transfer Function Score: _____

October 2024

Page 6-33

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

Next, calculate the average score for the two bed mobility items and the three transfer items as
follows: Average the scores for Sit to Lying and Lying to Sitting on Side of Bed. 1 Average the
scores for Sit to Stand, Chair/Bed-to-Chair and Toilet Transfer. 2 Enter the average bed mobility
and transfer scores below.
Average Bed Mobility Function Score: _____
Average Transfer Function Score: _____
Calculate the sum of the following scores: Eating Function Score, Toileting Hygiene Function
Score, Average Bed Mobility Score, and Average Transfer Score. Finally, round this sum to the
nearest integer. This is the PDPM Function Score for nursing payment. The PDPM Function
Score for nursing payment ranges from 0 through 16.
PDPM NURSING FUNCTION SCORE: _____

D
STEP #2

Determine the resident’s nursing case-mix group using the hierarchical classification below.
Nursing classification under PDPM employs the hierarchical classification method. Hierarchical
classification is used in some payment systems, in staffing analysis, and in many research
projects. In the hierarchical approach, start at the top and work down through the PDPM nursing
classification model steps discussed below; the assigned classification is the first group for which
the resident qualifies. In other words, start with the Extensive Services groups at the top of the
PDPM nursing classification model. Then go down through the groups in hierarchical order:
Extensive Services, Special Care High, Special Care Low, Clinically Complex, Behavioral
Symptoms and Cognitive Performance, and Reduced Physical Function. When you find the first
of the 25 individual PDPM nursing groups for which the resident qualifies, assign that group as
the PDPM nursing classification.

1 Calculate the sum of the Function Scores for Sit to Lying and Lying to Sitting on Side of Bed. Divide this sum by

2. This is the Average Bed Mobility Function Score.

2 Calculate the sum of the Function Scores for Sit to Stand, Chair/Bed-to-Chair, and Toilet Transfer. Divide by 3.

This is the Average Transfer Function Score.

October 2024

Page 6-34

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

CATEGORY: EXTENSIVE SERVICES
The classification groups in this category are based on various services provided. Use the
following instructions to begin the calculation:
STEP #1
Determine whether the resident is coded for one of the following treatments or services:
O0110E1b
O0110F1b
O0110M1b

Tracheostomy care while a resident
Invasive mechanical ventilator or respirator while a resident
Isolation or quarantine for active infectious disease while a
resident

If the resident does not receive one of these treatments or services, skip to the Special Care
High Category now.
STEP #2

STEP #3

If at least one of these treatments or services is coded and the resident has a total PDPM Nursing
Function Score of 14 or less, they classify in the Extensive Services category. Move to Step #3.
If the resident’s PDPM Nursing Function Score is 15 or 16, they classify as Clinically
Complex. Skip to the Clinically Complex Category, Step #2.

The resident classifies in the Extensive Services category according to the following chart:

*while a resident

PDPM Nursing Classification
ES3
ES2

Extensive Service Conditions
Tracheostomy care* and ventilator/respirator*
Tracheostomy care* or ventilator/respirator*
Isolation or quarantine for active infectious
disease*
without tracheostomy care*
without ventilator/respirator*

ES1

PDPM Nursing Classification: _____

If the resident does not classify in the Extensive Services Category, proceed to the Special
Care High Category.

October 2024

Page 6-35

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

CATEGORY: SPECIAL CARE HIGH
The classification groups in this category are based on certain resident conditions or services.
Use the following instructions:
STEP #1
Determine whether the resident is coded for one of the following conditions or services:
Comatose and completely dependent or activity did not occur
at admission (GG0130A1, GG0130C1, GG0170B1,
GG0170C1, GG0170D1, GG0170E1, and GG0170F1 all equal
01, 09, or 88)

I2100

Septicemia

I2900, N0350A, B

Diabetes with both of the following:
Insulin injections (N0350A) for all 7 days
Insulin order changes on 2 or more days (N0350B)

I5100, Nursing Function Score

Quadriplegia with Nursing Function Score <= 11

I6200, J1100C

Chronic obstructive pulmonary disease and shortness of breath
when lying flat

B0100, Section GG items

J1550A, others

Fever and one of the following:
I2000 Pneumonia
J1550B Vomiting
K0300 Weight loss (1 or 2)
K0520B2 or K0520B3 Feeding tube*

K0520A2 or K0520A3

Parenteral/IV feedings

O0400D2

Respiratory therapy for all 7 days

If the resident does not have one of these conditions, skip to the Special Care Low Category
now.
STEP #2

If at least one of the special care conditions above is coded and the resident has a total PDPM
Nursing Function Score of 14 or less, they classify as Special Care High. Move to Step #3. If
the resident's PDPM Nursing Function Score is 15 or 16, they classify as Clinically
Complex. Skip to the Clinically Complex Category, Step #2.

October 2024

Page 6-36

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #3
Evaluate for depression. Signs and symptoms of depression are used as a third-level split for the
Special Care High category. Residents with signs and symptoms of depression are identified by
the Patient Mood Interview (PHQ-2 to 9©) or the Staff Assessment of Patient Mood (PHQ-9OV©). Instructions for completing the PHQ-2 to 9© are in Chapter 3, Section D. Item D0100 is a
gateway question to determine when the Patient Mood Interview (D0100 is coded 1, Yes) or the
Staff Assessment of Patient Mood is to be conducted (D0100 is coded 0, No). Refer to Appendix
E for cases in which the PHQ-2 to 9© or PHQ-9-OV© is complete but all questions are not
answered. For the PHQ-2 to 9©, if either D0150A2 or D0150B2 is coded 2 or 3, continue asking
the questions below, otherwise end the PHQ interview. Assessors should proceed to D0700,
Social Isolation in the case of resident refusal or unwillingness to participate. The following
items comprise the PHQ-2 to 9© and PHQ-9-OV© for the Patient and Staff assessments,
respectively:

D
Staff
D0500A
D0500B
D0500C
D0500D
D0500E
D0500F

D0150G

D0500G

D0150H

D0500H

D0150I

D0500I

D0500J

Description
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or have let
yourself down or your family down
Trouble concentrating on things, such as reading the newspaper or
watching television
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
Thoughts that you would be better off dead, or of hurting yourself in
some way
Being short-tempered, easily annoyed

Resident
D0150A
D0150B
D0150C
D0150D
D0150E
D0150F

These items are used to calculate a Total Severity Score for the resident interview at item D0160
and for the staff assessment at item D0600. The resident qualifies as depressed for PDPM
classification in either of the two following cases:
The D0160 Total Severity Score is greater than or equal to 10 but not 99,
or

The D0600 Total Severity Score is greater than or equal to 10.
Resident Qualifies as Depressed Yes _____ No _____

October 2024

Page 6-37

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #4
Select the Special Care High classification based on the PDPM Nursing Function Score and
the presence or absence of depression according to this table:
Nursing Function Score
0-5
0-5
6-14
6-14

Depressed?
Yes
No
Yes
No

PDPM Nursing Classification
HDE2
HDE1
HBC2
HBC1
PDPM Nursing Classification: _____

D
October 2024

Page 6-38

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

CATEGORY: SPECIAL CARE LOW
The classification groups in this category are based on certain resident conditions or services.
Use the following instructions:
STEP #1
Determine whether the resident is coded for one of the following conditions or services:
Cerebral palsy, with Nursing Function Score <=11
Multiple sclerosis, with Nursing Function Score <=11
Parkinson’s disease, with Nursing Function Score <=11
Respiratory failure and oxygen therapy while a resident
Feeding tube*
Two or more stage 2 pressure ulcers with two or more selected
skin treatments**
Any stage 3 or 4 pressure ulcer or any unstageable pressure
ulcer due to slough and/or eschar with two or more selected
skin treatments**
Two or more venous/arterial ulcers with two or more selected
skin treatments**
1 stage 2 pressure ulcer and 1 venous/arterial ulcer with 2 or
more selected skin treatments**
Foot infection, diabetic foot ulcer or other open lesion of foot
with application of dressings to the feet
Radiation treatment while a resident
Dialysis treatment while a resident

I4400, Nursing Function Score
I5200, Nursing Function Score
I5300, Nursing Function Score
I6300, O0110C1b
K0520B2 or K0520B3
M0300B1
M0300C1, D1, F1

M1030

M0300B1, M1030

M1040A, B, C; M1200I
O0110B1b
O0110J1b

*Tube feeding classification requirements:
(1) K0710A3 is 51% or more of total calories OR
(2) K0710A3 is 26% to 50% of total calories and K0710B3 is 501 cc or more per day fluid enteral intake in the
last 7 days.
**Selected skin treatments:
M1200A, B Pressure relieving chair and/or bed
M1200C Turning/repositioning program
M1200D Nutrition or hydration intervention
M1200E Pressure ulcer/injury care
M1200G Application of nonsurgical dressings (not to feet)
M1200H Application of ointments/medications (not to feet)
#Count as one treatment even if both provided

If the resident does not have one of these conditions, skip to the Clinically Complex
Category now.

October 2024

Page 6-39

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #2
If at least one of the special care conditions above is coded and the resident has a total PDPM
Nursing Function Score of 14 or less, they classify as Special Care Low. Move to Step #3. If the
resident's PDPM Nursing Function Score is 15 or 16, they classify as Clinically Complex.
Skip to the Clinically Complex Category, Step #2.
STEP #3

Evaluate for depression. Signs and symptoms of depression are used as a third-level split for the
Special Care Low category. Residents with signs and symptoms of depression are identified by
the Patient Mood Interview (PHQ-2 to 9©) or the Staff Assessment of Patient Mood (PHQ-9OV©). Instructions for completing the PHQ-2 to 9© are in Chapter 3, Section D. Item D0100 is a
gateway question to determine when the Patient Mood Interview (D0100 is coded 1, Yes) or the
Staff Assessment of Patient Mood is to be conducted (D0100 is coded 0, No). Refer to Appendix
E for cases in which the PHQ-2 to 9© or PHQ-9-OV© is complete but all questions are not
answered. For the PHQ-2 to 9©, if either D0150A2 or D0150B2 is coded 2 or 3, continue asking
the questions below, otherwise end the PHQ interview. Assessors should proceed to D0700,
Social Isolation in the case of resident refusal or unwillingness to participate. The following
items comprise the PHQ-2 to 9© and PHQ-9-OV© for the Patient and Staff assessments,
respectively:
Staff
D0500A
D0500B
D0500C
D0500D
D0500E
D0500F

D0150G

D0500G

D0150H

D0500H

D0150I

D0500I

D0500J

October 2024

Resident
D0150A
D0150B
D0150C
D0150D
D0150E
D0150F

Page 6-40

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

Select the Special Care Low classification based on the PDPM Nursing Function Score and
the presence or absence of depression according to this table:
Depressed?
Yes
No
Yes
No

PDPM Nursing Classification
LDE2
LDE1
LBC2
LBC1

Nursing Function Score
0-5
0-5
6-14
6-14

PDPM Nursing Classification: _____

ft
October 2024

Page 6-41

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

CATEGORY: CLINICALLY COMPLEX
The classification groups in this category are based on certain resident conditions or services.
Use the following instructions:
STEP #1
Determine whether the resident is coded for one of the following conditions or services:
Table 19: Clinically Complex Conditions or Services
MDS Item
I2000
I4900, Nursing Function Score

Pneumonia
Hemiplegia/hemiparesis with Nursing Function Score <= 11
Open lesions (other than ulcers, rashes, and cuts) or surgical
wounds with any selected skin treatments*
Burns (second or third degree)
Chemotherapy while a resident
Oxygen therapy while a resident
IV Medications while a resident
Transfusions while a resident

M1040D, E

Condition or Service

M1040F
O0110A1b
O0110C1b
O0110H1b
O0110I1b

*Selected Skin Treatments: M1200F Surgical wound care, M1200G Application of nonsurgical dressing (other than
to feet), M1200H Application of ointments/medications (other than to feet)

If the resident does not have one of these conditions, skip to the Behavioral Symptoms and
Cognitive Performance Category now.
STEP #2

Evaluate for depression. Signs and symptoms of depression are used as a third-level split for the
Clinically Complex category. Residents with signs and symptoms of depression are identified by
the Patient Mood Interview (PHQ-2 to 9©) or the Staff Assessment of Patient Mood (PHQ-9OV©). Instructions for completing the PHQ-2 to 9© are in Chapter 3, Section D. Item D0100 is a
gateway question to determine when the Patient Mood Interview (D0100 is coded 1, Yes) or the
Staff Assessment of Patient Mood is to be conducted (D0100 is coded 0, No). Refer to Appendix
E for cases in which the PHQ-2 to 9© or PHQ-9-OV© is complete but all questions are not
answered. For the PHQ-2 to 9©, if either D0150A2 or D0150B2 is coded 2 or 3, continue asking
the questions below, otherwise end the PHQ interview. Assessors should proceed to D0700,
Social Isolation in the case of resident refusal or unwillingness to participate. The following
items comprise the PHQ-2 to 9© and PHQ-9-OV© for the Patient and Staff assessments,
respectively:

October 2024

Page 6-42

CMS’s RAI Version 3.0 Manual

Resident
D0150A
D0150B
D0150C
D0150D
D0150E
D0150F

Staff
D0500A
D0500B
D0500C
D0500D
D0500E
D0500F

D0150G

D0500G

D0150H

D0500H

D0150I

D0500I

CH 6: Medicare SNF PPS

D0500J

These items are used to calculate a Total Severity Score for the resident interview at item D0160
and for the staff assessment at item D0600. A higher Total Severity Score is associated with
more symptoms of depression. For the resident interview, a Total Severity Score of 99 indicates
that the interview was not successful.
The resident qualifies as depressed for PDPM classification in either of the two following cases:
The D0160 Total Severity Score is greater than or equal to 10 but not 99,
or

The D0600 Total Severity Score is greater than or equal to 10.

Resident Qualifies as Depressed Yes _____ No _____

STEP #3

Select the Clinically Complex classification based on the PDPM Nursing Function Score
and the presence or absence of depression according to this table:
Nursing Function Score
0-5
0-5
6-14
15-16
6-14
15-16

Depressed?
Yes
No
Yes
Yes
No
No

PDPM Nursing Classification
CDE2
CDE1
CBC2
CA2
CBC1
CA1

PDPM Nursing Classification: _____

October 2024

Page 6-43

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

CATEGORY: BEHAVIORAL SYMPTOMS AND
COGNITIVE PERFORMANCE
Classification in this category is based on the presence of certain behavioral symptoms or the
resident’s cognitive performance. Use the following instructions:
STEP #1
Determine the resident’s PDPM Nursing Function Score. If the resident's PDPM Nursing
Function Score is 11 or greater, go to Step #2.
If the PDPM Nursing Function Score is less than 11, skip to the Reduced Physical Function
Category now.

STEP #2

If the resident interview using the Brief Interview for Mental Status (BIMS) was not
conducted (indicated by a value of “0” for item C0100), skip the remainder of this step and
proceed to Step #3 to check staff assessment for cognitive impairment.

C0200
C0300
C0400

Determine the resident’s cognitive status based on resident interview using the BIMS.
Instructions for completing the BIMS are in Chapter 3, Section C. The BIMS items involve the
following:
Repetition of three words
Temporal orientation
Recall

Item C0500 provides a BIMS Summary Score for these items and indicates the resident’s
cognitive performance, with a score of 15 indicating the best cognitive performance and 0
indicating the worst performance. If the resident interview is not successful, then the BIMS
Summary Score will equal 99.

If the resident’s Summary Score is less than or equal to 9, they classify in the Behavioral
Symptoms and Cognitive Performance category. Skip to Step #5.

If the resident’s Summary Score is greater than 9 but not 99, proceed to Step #4 to check
behavioral symptoms.

If the resident’s Summary Score is 99 (resident interview not successful) or the Summary
Score is blank (resident interview not attempted and skipped) or the Summary Score has a
dash value (not assessed), proceed to Step #3 to check staff assessment for cognitive
impairment.

October 2024

Page 6-44

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #3
Determine the resident’s cognitive status based on the staff assessment rather than on resident
interview.
Check if one of the three following conditions exists:
1.

B0100

C1000

B0700, C0700, C1000

Coma (B0100 = 1) and completely dependent or activity did not
occur at admission (GG0130A1, GG0130C1, GG0170B1,
GG0170C1, GG0170D1, GG0170E1, and GG0170F1 all equal 01,
09, or 88)
Severely impaired cognitive skills for daily decision making
(C1000 = 3)
Two or more of the following impairment indicators are present:
B0700 > 0 Usually, sometimes, or rarely/never understood
C0700 = 1 Short-term memory problem
C1000 > 0 Impaired cognitive skills for daily decision making
and
One or more of the following severe impairment indicators are
present:
B0700 >= 2 Sometimes or rarely/never makes self understood
C1000 >= 2 Moderately or severely impaired cognitive skills for
daily decision making

If the resident meets one of the three above conditions, then they classify in Behavioral
Symptoms and Cognitive Performance. Skip to Step #5. If they do not meet any of the three
conditions, proceed to Step #4.
STEP #4

Determine whether the resident presents with one of the following behavioral symptoms:

E0100A
E0100B
E0200A
E0200B
E0200C
E0800
E0900

Hallucinations
Delusions
Physical behavioral symptoms directed toward others (2 or 3)
Verbal behavioral symptoms directed toward others (2 or 3)
Other behavioral symptoms not directed toward others (2 or 3)
Rejection of care (2 or 3)
Wandering (2 or 3)

If the resident presents with one of the symptoms above, then they classify in Behavioral
Symptoms and Cognitive Performance. Proceed to Step #5. If they do not present with
behavioral symptoms, skip to the Reduced Physical Function Category.

October 2024

Page 6-45

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

STEP #5
Determine Restorative Nursing Count
Count the number of the following services provided for 15 or more minutes a day for 6 or more
of the last 7 days:
Urinary toileting program and/or bowel toileting program
Passive and/or active range of motion
Splint or brace assistance
Bed mobility and/or walking training
Transfer training
Dressing and/or grooming training
Eating and/or swallowing training
Amputation/prostheses care
Communication training

H0200C, H0500**
O0500A, B**
O0500C
O0500D, F**
O0500E
O0500G
O0500H
O0500I
O0500J

**Count as one service even if both provided

STEP #6

Restorative Nursing Count: _____

Select the final PDPM Classification by using the total PDPM Nursing Function Score and
the Restorative Nursing Count.
Nursing Function Score
11-16
11-16

Restorative Nursing Count PDPM Nursing Classification
2 or more
BAB2
0 or 1
BAB1

PDPM Nursing Classification: _____

October 2024

Page 6-46

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

CATEGORY: REDUCED PHYSICAL FUNCTION
STEP #1
Residents who do not meet the conditions of any of the previous categories, including those who
would meet the criteria for the Behavioral Symptoms and Cognitive Performance category but
have a PDPM Nursing Function Score less than 11, are placed in this category.
STEP #2
Determine Restorative Nursing Count
Count the number of the following services provided for 15 or more minutes a day for 6 or more
of the last 7 days:

Urinary toileting program and/or bowel toileting program
Passive and/or active range of motion
Splint or brace assistance
Bed mobility and/or walking training
Transfer training
Dressing and/or grooming training
Eating and/or swallowing training
Amputation/prostheses care
Communication training

H0200C, H0500**
O0500A, B**
O0500C
O0500D, F**
O0500E
O0500G
O0500H
O0500I
O0500J

**Count as one service even if both provided

Restorative Nursing Count: _____

STEP #3

Select the PDPM Classification by using the PDPM Nursing Function Score and the
Restorative Nursing Count.
Nursing Function Score
0-5
0-5
6-14
15-16
6-14
15-16

Restorative Nursing Count PDPM Nursing Classification
2 or more
PDE2
0 or 1
PDE1
2 or more
PBC2
2 or more
PA2
0 or 1
PBC1
0 or 1
PA1

PDPM Nursing Classification: _____

October 2024

Page 6-47

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

Calculation of Variable Per Diem Payment Adjustment
PDPM incorporates variable per diem payment adjustments to account for changes in resource
use over the course of a stay for three payment components: PT, OT, and NTA. To calculate the
per diem rate for these components, multiply the component base rate by the case-mix index
associated with the resident’s case-mix group and the adjustment factor based on the day of the
stay, as shown in the following equation:
Component Per Diem Payment = Component Base Rate x Resident Group CMI x Component
Adjustment Factor
The adjustment factors for the PT and OT components can be found in the table below.
Table 20: PT and OT Variable Per Diem Adjustment Factors
PT and OT Adjustment Factor
1.00
0.98
0.96
0.94
0.92
0.90
0.88
0.86
0.84
0.82
0.80
0.78
0.76

Day in Stay
1-20
21-27
28-34
35-41
42-48
49-55
56-62
63-69
70-76
77-83
84-90
91-97
98-100

The adjustment factors for the NTA component can be found in the table below.

Table 21: NTA Variable Per Diem Adjustment Factors
Day in Stay
1-3
4-100

October 2024

NTA Adjustment Factor
3.00
1.00

Page 6-48

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

Calculation of Total Case-Mix Adjusted
PDPM Per Diem Rate
The total case-mix adjusted PDPM per diem rate equals the sum of each of the five case-mix
adjusted components and the non-case-mix adjusted rate component. To calculate the total casemix adjusted per diem rate, add all component per diem rates calculated in prior steps together,
along with the non-case-mix rate component, as shown in the following equation:
Total Case-Mix Adjusted Per Diem Payment = (PT Component Per Diem Rate * PT Variable
Per Diem Adjustment Factor) + (OT Component Per Diem Rate * OT Variable Per Diem
Adjustment Factor) + SLP Component Per Diem Rate + (NTA Component Per Diem Rate * NTA
Variable Per Diem Adjustment Factor) + Nursing Component Per Diem Rate + Non-Case-Mix
Component Per Diem Rate

D
October 2024

Page 6-49

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

6.7 SNF PPS Policies
Requirements and policies for SNF PPS are described in greater detail in Chapter 8 of the
Medicare Benefit Policy Manual (https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c08pdf.pdf). There are some situations that the
SNF may encounter that may impact Medicare Part A SNF coverage for a resident, affect the
PPS assessment schedule, or impact the reimbursement received by the SNF.

Delay in Requiring and Receiving Skilled Services (30-Day Transfer)

There are instances in which the resident does not require SNF level of care services when
initially admitted to the SNF. When the resident requires and receives SNF level of care services
within 30 days from the hospital discharge, Day 1 for the PPS assessment schedule is the day on
which SNF level of care services begin. For example, if a resident is discharged from the hospital
on August 1 and the SNF determines on August 30 that the resident requires skilled service for a
condition that was treated during the qualifying hospital stay, then the SNF would start the PPS
assessment schedule with a 5-Day PPS assessment, with August 30 as Day 1 for scheduling
purposes. However, if the resident requires and receives a SNF level of care 31 or more days
after the hospital discharge, the resident does not qualify for a SNF Part A stay (see Medical
Appropriateness Exception below).

Medical Appropriateness Exception (Deferred Treatment)

Interrupted Stay

An elapsed period of more than 30 days is permitted for starting SNF Part A services when a
resident’s condition makes it inappropriate to begin an active course of treatment in a SNF
immediately after a qualifying hospital stay discharge. It is applicable only where, under
accepted medical practice, the established pattern of treatment for a particular condition indicates
that a covered level of SNF care will be required within a predeterminable time frame, and it is
medically predictable at the time of hospital discharge that the resident will require SNF level of
care within a predetermined time period (for more detailed information see Chapter 8 of the
Medicare Benefit Policy Manual). For example, a resident is admitted to the SNF after a
qualifying hospital stay for an open reduction and internal fixation of a hip. It is determined upon
hospital discharge that the resident is not ready for weight-bearing activity but will most likely
be ready in 4-6 weeks. The physician writes an order to start therapy when the resident is able to
tolerate weight bearing. Once the resident is able to start therapy, the Medicare Part A stay
begins, and the 5-Day assessment will be performed. Day 1 of the stay will be the first day on
which the resident starts therapy services.

An “interrupted” SNF stay is defined as one in which a resident is discharged from SNF care and
subsequently readmitted to the same SNF (not a different SNF) within 3 days or less after the
discharge (the “interruption window”).
The interruption window is a 3-day period, starting with the calendar day of Part A discharge and
including the 2 immediately following calendar days, ending at midnight. In other words, the
resident must return to the same SNF by 11:59 p.m. at the end of the third calendar day. The
October 2024

Page 6-50

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

interruption window begins on the first non-covered day following a Part A-covered stay and
ends at 11:59 p.m. on the third consecutive non-covered day following a Part A-covered stay.
If both conditions are met, the subsequent stay is considered a continuation of the previous
Medicare Part A stay for the purposes of both the variable per diem schedule and the assessment
schedule. The variable per diem schedule continues from the day of the previous discharge. For
example, if the resident was discharged on Day 7, payment rates resume at Day 7 upon
readmission. The assessment schedule also continues from the day of the previous discharge.
Thus, no new 5-Day assessment is required upon the subsequent readmission, although the
optional IPA may be completed at clinician’s discretion.

If a resident is readmitted to the same SNF more than 3 consecutive calendar days after
discharge, OR in any instance when the resident is admitted to a different SNF (regardless of the
length of time between stays), then the Interrupted Stay Policy does not apply, and the
subsequent stay is considered a new stay. In such cases, the variable per diem schedule resets to
Day 1 payment rates, and the assessment schedule also resets to Day 1, necessitating the
completion of a new 5-Day assessment.

Example 1: Resident A is admitted to the SNF on 11/07/19. They are admitted to a hospital on
11/20/19. They return to the same SNF on 11/25/19. Because Resident A is readmitted to the
same SNF more than three calendar days after discharge, this would be considered a new stay.
The assessment schedule would be reset to Day 1, beginning with a new 5-Day assessment, and
the variable per diem schedule would begin from Day 1.
Example 2: Resident B is admitted to the SNF on 11/07/19. They are admitted to the hospital on
11/20/19. They are admitted to a different SNF on 11/22/19. Because Resident B is admitted to a
different SNF, this would be considered a new stay. The assessment schedule would be reset,
beginning with a new 5-Day assessment, and the variable per diem schedule would begin from
Day 1.

Example 3: Resident C is admitted to the SNF on 11/07/19. They are admitted to a hospital on
11/20/19. They return to the same SNF on 11/22/19. Because Resident C is admitted to the same
SNF within three days from the point of discharge, this would be considered a continuation of
the previous stay. No 5-Day assessment would be required upon readmission, though the IPA
would be an option. Additionally, the variable per diem would continue from Day 14 (Day of
Discharge).

Resident Discharged from Part A Skilled Services and Returns to SNF
Part A Skilled Level Services
In the situation in which a resident is discharged from SNF Medicare Part A services and later
requires SNF Part A skilled level of care services, and it is not an instance of an interrupted stay
(as described above), the resident may be eligible for Medicare Part A SNF coverage if the
following criteria are met:
1. Less than 30 days have elapsed since the last day on which SNF level of care services were
required and received,

October 2024

Page 6-51

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

2. SNF-level services required by the resident are for a condition that was treated during the
qualifying hospital stay or for a condition that arose while receiving care in the SNF for a
condition for which the beneficiary was previously treated in the hospital,
3. Services must be reasonable and necessary,
4. Services can only be provided on an inpatient basis,
5. Resident must require and receive the services on a daily basis, and
6. Resident has remaining days in the SNF benefit period.
For greater detail, refer to the Medicare Benefit Policy Manual, Chapter 8.

6.8 Non-compliance with the SNF PPS Assessment
Schedule

To receive payment under the SNF PPS, the SNF must complete scheduled and unscheduled
assessments as described in Chapter 2.

According to 42 CFR 413.343, an assessment that does not have an ARD within the prescribed
ARD window will be paid at the default rate for the number of days the ARD is out of
compliance. Frequent late assessment scheduling practices or missing assessments may result in
additional review. The default rate (ZZZZZ) takes the place of the otherwise applicable Federal
rate. It is equal to the sum of the rate paid for the case-mix group reflecting the lowest acuity
level under each PDPM component, and would generally be lower than the Medicare rate
payable if the SNF had submitted an assessment in accordance with the prescribed assessment
schedule.

Late Assessment

If the SNF fails to set the ARD within the defined ARD window for a PPS assessment, and the
resident is still on Part A, the SNF must complete a late assessment. The ARD can be no earlier
than the day the error was identified.

The SNF will bill the default rate for the number of days that the assessment is out of
compliance. This is equal to the number of days between the day following the last day of the
available ARD window and the late ARD (including the late ARD). The SNF would then bill
the Health Insurance Prospective Payment System (HIPPS) code established by the late
assessment for the remaining period of time that the assessment would have controlled
payment. For example, a 5-Day assessment with an ARD of Day 11 is out of compliance for 3
days and therefore would be paid at the default rate for Days 1 through 3 and the HIPPS code
from the late 5-Day assessment for the remainder of the Part A stay, unless an IPA is completed.
In the case of a late assessment, the variable per diem schedule still begins on Day 1 of the stay
and not with the late assessment ARD and default billing will be assessed prior to billing based
on the late 5-Day assessment.

October 2024

Page 6-52

CMS’s RAI Version 3.0 Manual

CH 6: Medicare SNF PPS

Missed Assessment
If the SNF fails to set the ARD of a PPS assessment prior to the end of the last day of the ARD
window, and the resident is no longer a SNF Part A resident, and as a result a PPS assessment
does not exist in iQIES for the payment period, the provider may not usually bill for days when
an assessment does not exist in iQIES. When a PPS assessment does not exist in iQIES, there is
not a HIPPS code the provider may bill. In order to bill for Medicare SNF Part A services, the
provider must submit a valid PPS assessment that is accepted into iQIES. The provider must bill
the HIPPS code that is verified by the system. If the resident was already discharged from
Medicare Part A when this is discovered, a PPS assessment may not be performed.
However, there are instances when the SNF may bill the default code when a PPS assessment
does not exist in iQIES. These exceptions are:
1. The stay is less than 8 days within a spell of illness,

2. The SNF is notified on an untimely basis of or is unaware of a Medicare Secondary Payer
denial,
3. The SNF is notified on an untimely basis of a beneficiary’s enrollment in Medicare Part A,
4. The SNF is notified on an untimely basis of the revocation of a payment ban,
5. The beneficiary requests a demand bill, or

6. The SNF is notified on an untimely basis or is unaware of a beneficiary’s disenrollment from
a Medicare Advantage plan.

ARD Outside the Medicare Part A SNF Benefit

A SNF may not use a date outside the SNF Part A Medicare Benefit (i.e., 100 days) as the ARD
for a PPS assessment. For example, the resident returns to the SNF on December 11 following a
hospital stay, requires and receives SNF skilled services (and meets all other required coverage
criteria), and has 3 days left in their SNF benefit period. The SNF must set the ARD for the PPS
assessment on December 11, 12, or 13 to bill for the HIPPS code associated with the assessment.

ft
October 2024

Page 6-53

CMS’s RAI Version 3.0 Manual

Appendix A: Glossary and Common Acronyms

APPENDIX A: GLOSSARY AND COMMON ACRONYMS
Glossary
Term

Abbreviation

Definition
Comprehension of direct person-to-person communication
whether spoken, written, or in sign language or Braille.
Includes the resident’s ability to process and understand
language.

Active Assisted
Range of Motion

A type of active range of motion in which assistance is
provided by an outside force, either manually or
mechanically because the prime mover muscles need
assistance to complete the motion. This type of range of
motion may be used when muscles are weak or when joint
movement causes discomfort; or for example, if the
resident is able to move their limbs but requires help to
perform entire movement.

Ability to
Understand
Others

An active discharge plan means a plan that is being
currently implemented. In other words, the resident’s care
plan has current goals to make specific arrangements for
discharge, staff are taking active steps to accomplish
discharge, and there is a target discharge date for the near
future. If there is not an active discharge plan, residents
should be asked if they want to talk to someone about
community living and then referred to the Local Contact
Agency (LCA) accordingly. Furthermore, referrals to the
LCA are recommended as part of many residents’
discharge plans. Such referrals are a helpful source of
information for residents and facilities in informing the
discharge planning process.

Active Disease
Diagnosis

An illness or condition that is currently causing or
contributing to a resident's complications and/or
functional, cognitive, medical and psychiatric symptoms
or impairments.

Active Range of
Motion

Movement within the unrestricted range of motion for a
segment, which is produced by active contraction of the
muscles crossing that joint is completed without assistance
by the resident. This type of range of motion occurs when
a resident can move their limbs without assistance.

October 2024

Active Discharge
Plan

Appendix A-1

CMS’s RAI Version 3.0 Manual

Term
Activities of Daily
Living

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition

ADLs

Activities of daily living are those needed for self-care and
mobility and include activities such as bathing, dressing,
grooming, oral care, ambulation, toileting, eating,
transferring, and communicating. Select self-care and
mobility items from Section GG are utilized to classify a
resident into the PT, OT, and nursing components for
PDPM.
Alteration in mental status (e.g., orientation, inattention,
organization of thought, level of consciousness,
psychomotor behavior, change in cognition) that was new
or worse for this resident, usually over hours to days.

ADL Aspects

Components of ADL activities. These are listed next to
each ADL in the item set. For example, the aspects of
GG0130A (Eating) are using suitable utensils to bring
food and/or liquid to the mouth and swallowing food
and/or liquid once the meal is placed before the resident.

Adverse
Consequence

An unpleasant symptom or event that is caused by or
associated with a medication, impairment or decline in an
individual’s physical condition, mental, functional or
psychosocial status. It may include various types of
adverse drug reactions (ADR) and interactions (e.g.,
medication-medication, medication-food, and medicationdisease).

Acute Change in
Mental Status

Adverse Drug
Reaction

ADR

ADR is a form of adverse consequence. It may be either a
secondary effect of a medication that is usually
undesirable and different from the therapeutic effect of the
medication, or any response to a medication that is
noxious and unintended and occurs in doses for
prophylaxis, diagnosis or treatment. The term “side effect”
is often used interchangeably with ADR; however, side
effects are but one of five ADR categories, the others
being hypersensitivity, idiosyncratic response, toxic
reactions, and adverse medication interactions. A side
effect is an expected, well-known reaction that occurs with
a predictable frequency and may or may not constitute an
adverse consequence.

Assessment ID

A sequential numeric identifier assigned to each record
submitted to iQIES.

Assessment Period

See Observation Period.

October 2024

Appendix A-2

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Assessment
Reference Date

ARD

Definition
The specific end-point for the look-back periods in the
MDS assessment process.
The period of time defined by Medicare regulations that
specifies when the ARD must be set.

Assisted Living

A noninstitutional community residential setting that
includes services of the following types: home health
services, homemaker/personal care services, or meal
services.

Audiology
Services

Audiology services include the testing of hearing and
balance; recommending assistive listening equipment;
managing hearing screening programs; providing
education regarding the effects of noise on hearing and the
prevention of hearing loss; managing cochlear implants;
and providing counseling and aural rehabilitation.
Audiologist is defined in regulation (42 CFR 484).

Autism

Baseline

Assessment
Window

A developmental disorder that is characterized by
impaired social interaction, problems with verbal and
nonverbal communication, and unusual, repetitive, or
severely limited activities and interests.

An individual's usual, customary, initial, or most common
(depending on the item) range or level of something; for
example, behavior, laboratory values, mood, endurance,
function, vital signs, etc. "Baseline" information is often
used as a basis for comparing findings or results over time.

Bladder
Rehabilitation/
Bladder Retraining

A behavioral technique that requires the resident to resist
or inhibit the sensation of urgency (the strong desire to
urinate), to postpone or delay voiding, and to urinate
according to a timetable rather than to the urge to void.

Board and Care

A noninstitutional community residential setting that
includes services of the following types: home health
services, homemaker/personal care services, or meal
services.

Body Mass Index

October 2024

BMI

Number calculated from a person's weight and height.
BMI is a reliable indicator of body fat. BMI is used as a
screening tool to identify possible weight problems for
adults.

Appendix A-3

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Brief Interview
for Mental Status

BIMS

Definition
The BIMS is a brief screener that aids in detecting
cognitive impairment. It does not assess all possible
aspects of cognitive impairment.

Broken Tooth

A tooth with a crack, chip, or other loss of structural
integrity.

Browser

A program that allows access to the Internet or a private
intranet site. A browser with 128-bit encryption is
necessary to access the Centers for Medicare & Medicaid
Services (CMS) intranet to submit data or report retrieval.
CAA

Care Area Triggers

CAT

The review of one or more of the twenty conditions,
symptoms, and other areas of concern that are commonly
identified or suggested by MDS findings. Care areas are
triggered by responses on the MDS item set.

Care Area
Assessment

A set of items and responses from the MDS that are
indicators of particular issues and conditions that affect
nursing facility residents.

Case Mix Index

CMI

Weight or numeric score assigned to each Resource
Utilization Group (RUG-III, RUG IV) that reflects the
relative resources predicted to provide care to a resident.
The higher the case mix weight, the greater the resource
requirements for the resident.
A payment system that measures the intensity of care and
services required for each resident and translates these
measures into the amount of reimbursement given to the
facility for care of a resident. Payment is linked to the
intensity of resource use.

Cavity

A tooth with a hole due to decay or other erosion.

Centers for
Medicare &
Medicaid Services

CMS

Check and
Change
CMS Certification
Number

October 2024

Case Mix
Reimbursement
System

CMS is the Federal agency that administers the Medicare,
Medicaid, and Child Health Insurance Programs.
Involves checking the resident’s dry/wet status at regular
intervals and using incontinence devices and products.

CCN

Replaces the term “Medicare Provider Number” in survey
and certification, and assessment-related activities.

Appendix A-4

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Code of Federal
Regulations

CFR

Definition
A codification of the general and permanent rules
published in the Federal Register by the Executive
departments and agencies of the Federal Government.

Colostomy

A surgical procedure that brings the end of the large
intestine through the abdominal wall.

Comatose (Coma)

Pathological state in which neither arousal (wakefulness,
alertness) nor awareness exists. The person is
unresponsive and cannot be aroused; they may or may not
open their eyes, does not speak, and does not move their
extremities on command or in response to noxious stimuli
(e.g., pain).

D
Comprehensive
Assessment

Constipation

Continence

CAM

A condition of more than short duration where someone
has fewer than three bowel movements a week or stools
that are usually hard, dry, and difficult and/or painful to
eliminate.
Any void that occurs voluntarily, or as the result of
prompted toileting, assisted toileting, or scheduled
toileting.

CAH

Critical Access
Hospital

October 2024

An instrument that screens for overall cognitive
impairment as well as features to distinguish delirium or
reversible confusion from other types of cognitive
impairments.

Confusion
Assessment
Method

Requires completion of the MDS and review of CAAs,
followed by development and/or review of the
comprehensive care plan.

A Medicare-participating hospital located in a rural area or
an area that is treated as rural and that meets all of the
criteria established by CMS for designation as a CAH.
Additional information on CAHs is available at
https://www.cms.gov/medicare/provider-enrollment-andcertification/certificationandcomplianc/cahs.html.

Appendix A-5

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition
Includes: choosing clothing; knowing when to go to
scheduled meals; using environmental cues to organize
and plan (e.g., clocks, calendars, posted event notices); in
the absence of environmental cues, seeking information
appropriately (i.e. not repetitively) from others in order to
plan the day; using awareness of one’s own strengths and
limitations to regulate the day’s events (e.g., asks for help
when necessary); acknowledging need to use appropriate
assistive equipment such as a walker.

Delirium

Acute onset or worsening of impaired brain function
resulting in cognitive and behavioral symptoms such as
worsening confusion, disordered expression of thoughts,
frequent fluctuation in level of consciousness, and
hallucinations.

Daily Decision
Making

Delusion

A fixed, false belief not shared by others that the resident
holds even in the face of evidence to the contrary.

Disorganized
Thinking

LCA

Each state has community contact agencies that can
provide individuals with information about community
living options and available community-based supports
and services. These local contact agencies may be a single
entry point agency, an Aging/Disabled Resource Center,
an Area Agency on Aging, a Center for Independent
Living, or other state designated entities.

Designated Local
Contact Agency

Having thoughts that are fragmented or not logically
connected.

Dose

Total amount/strength/concentration of a medication
given at one time or over a period of time. The individual
dose is the amount/strength/concentration received at
each administration. The amount received over a 24-hour
period may be referred to as the “daily dose.”

Down Syndrome

A common genetic disorder in which a child is born with
47 rather than 46 chromosomes, resulting in
developmental delays, intellectual disability, low muscle
tone, and other possible effects.

Dually Certified
Facilities

Nursing facilities that participate in both the Medicare
and Medicaid programs.

October 2024

Appendix A-6

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Duplicate Record
Error

Definition
A fatal record error that results from a resubmission of a
record previously accepted into the CMS MDS database.
A duplicate record is identified as having the same target
date, reason for assessment, resident, and facility. This is
the only fatal record error that does not require correction
and resubmission.

EHR

An electronic version of a resident’s medical history that
is maintained by the provider over time. Sometimes
referred to as an electronic medical record (EMR).

Electronic Medical
Record

EMR

See Electronic Health Record.

Electronic Health
Record

The initial date of admission/entry to the facility, or the
date on which the resident most recently re-entered the
facility after being discharged (whether or not the return
was anticipated).

Epilepsy

A chronic neurological disorder that is characterized by
recurrent unprovoked seizures, as a result of abnormal
neuronal activity in the brain.

Entry Date

External Condom
Catheter
Facility ID

Device attached to the shaft of the penis like a condom
and connected to a drainage bag.

FAC_ID

The facility identification number is assigned to each
facility. The FAC_ID must be placed in the individual
MDS and tracking form records. This normally is
completed as a function within the facility’s MDS data
entry software.

Fall

Unintentional change in position coming to rest on the
ground or onto the next lower surface (e.g., onto a bed,
chair, or bedside mat), but not as a result of an
overwhelming external force.

Fatal File Error

An error in the MDS file format that causes the entire file
to be rejected. The individual records are not validated nor
stored in the database. The facility must contact its
software support to resolve the problem with the
submission file.

October 2024

Appendix A-7

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition
An error in MDS record that is severe enough to result in
record rejection. A fatal record is not saved in the CMS
database. The facility must correct the error that caused
the rejection and resubmit a corrected original record.

Fecal Impaction

A mass of dry, hard stool that can develop in the rectum
due to chronic constipation. Watery stool from higher in
the bowel or irritation from the impaction may move
around the mass and leak out, causing soiling, often a sign
of a fecal impaction.

Federal Register

The official daily publication for rules, proposed rules,
and notices of Federal agencies and organizations, as well
as Executive Orders and other Presidential Documents. It
is a publication of the National Archives and Records
Administration and is available by subscription and
online.

Fatal Record Error

Feeding Tube

Fever

Presence of any type of tube that can deliver
food/nutritional substances/fluids directly into the
gastrointestinal system. Examples include, but are not
limited to: nasogastric tubes, gastrostomy tubes,
jejunostomy tubes, percutaneous endoscopic gastrotomy
(PEG) tubes.

FVR

First Time in This
Facility
Fiscal
Intermediary

October 2024

A report generated after the successful submission of
MDS 3.0 assessment data. This report lists all of the
residents for whom assessments have been submitted in a
particular submission batch and displays all errors and/or
warnings that occurred during the validation process. An
FVR is a facility’s documentation for successful file
submission. An individual record listed on the FVR
marked as “accepted” is documentation for successful
record submission.

Final Validation
Report

A fever is present when the resident’s temperature (°F) is
2.4 degrees greater than the baseline temperature.

Newly admitted resident who has not been admitted to this
facility before.
FI

In the past, an organization designated by CMS to process
Medicare claims for payment that are submitted by a
nursing facility. Fiscal intermediaries (FIs) are now called
Medicare Administrative Contractors (MACs).

Appendix A-8

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition

F-Tag

Numerical designations for criteria reviewed during the
nursing facility survey.

Functional
Limitation in
Range of Motion

Limited ability to move a joint that interferes with daily
functioning (particularly with activities of daily living) or
places the resident at risk of injury.

Gradual Dose
Reduction

GDR

Group Home

Step-wise tapering of a dose to determine whether or not
symptoms, conditions, or risks can be managed by a lower
dose or whether or not the dose or medication can be
discontinued.

A noninstitutional community residential setting that
includes services of the following types: home health
services, homemaker/personal care services, or meal
services.

Habit Training/
Scheduled
Voiding

Hallucination

A behavior technique that calls for scheduled toileting at
regular intervals on a planned basis to match the resident’s
voiding habits or needs.
A perception in a conscious and awake state, of something
in the absence of external stimuli. May be auditory or
visual or involve smells, tastes, or touch.

HIE

An organization that oversees and governs the exchange
of health-related information among organizations
according to nationally recognized standards. HIEs can
function at the federal, state and local level.

Healthcare
Common
Procedure Coding
System

HCPCS

A uniform coding system that describes medical services,
procedures, products, and supplies. These codes are used
primarily for billing.

Health Insurance
Portability and
Accountability
Act of 1996

HIPAA

Federal law that gives the Department of Health and
Human Services (DHHS) the authority to mandate
regulations that govern privacy, security, and electronic
transactions standards for health care information.

October 2024

Health Information
Exchange

Appendix A-9

CMS’s RAI Version 3.0 Manual

Term
Health Insurance
Prospective
Payment System
Code

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition

HIPPS
Code

The Health Insurance Prospective Payment System code is
comprised of the PDPM case mix code, which is
calculated from the assessment data. The first four
positions of the HIPPS code contain the PDPM
classification codes for each PDPM component to be
billed for Medicare reimbursement, followed by an
indicator of the type of assessment that was completed.
The degree to which individuals have the capacity to
obtain, process, and understand basic health information
and services needed to make appropriate health decisions.

Hierarchy

The ordering of groups within the RUG Classification
system is a hierarchy. The RUG hierarchy begins with
groups with the highest resource use and descends to those
groups with the lowest resource use. The RUG-IV
Classification system has eight hierarchical levels or
categories: Rehabilitation Plus Extensive Services,
Rehabilitation, Extensive Services, Special Care High,
Special Care Low, Clinically Complex, Behavioral
Symptoms and Cognitive Performance, and Reduced
Physical Function.

Health Literacy

A program for terminally ill persons where an array of
services is provided for the palliation and management of
terminal illness and related conditions. The hospice must
be licensed by the state as a hospice provider and/or
certified under the Medicare program as a hospice
provider.

Ileostomy

A stoma that has been constructed by bringing the end or
loop of small intestine (the ileum) out onto the surface of
the skin.

Inactivation

A type of correction allowed under the MDS Correction
Policy. When an invalid record has been accepted into the
CMS database, a correction record is submitted with
inactivation selected as the type of correction. An
inactivation will remove the invalid record from the
database.

Inattention

Reduced ability to maintain attention to external stimuli
and to appropriately shift attention to new external stimuli.

October 2024

Hospice Services

Appendix A-10

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition

Indication

The identified, documented clinical rationale for
administering a medication that is based upon a
physician’s (or prescriber’s) assessment of a resident’s
condition and therapeutic goals.

Indwelling
Catheter

A catheter that is maintained within the bladder for the
purpose of continuous drainage of urine.

Interdisciplinary
Team

IDT

Intermittent
Catheterization

A team that includes staff members from multiple
disciplines such as nursing, therapy, physicians, and other
advanced practitioners.

Insertion and removal of a catheter through the urethra
into the bladder for bladder drainage.

ICD-CM

Official system of assigning codes to diagnoses and
procedures associated with hospital utilization in the
United States. The ICD-CM contains a numerical list of
the disease code numbers in tabular form, an alphabetical
index to the disease entries, and a classification system for
surgical, diagnostic, and therapeutic procedures.

International
Classification
of Diseases –
Clinical
Modification

Internet Quality
Improvement and
Evaluation System

iQIES

The umbrella system that encompasses the MDS system
and other provider-specific assessment collection systems,
as well as survey and certification data collection and
storage. SNF/NF providers not utilizing proprietary
software can complete and submit the MDS records in
iQIES, as well as obtain MDS-related reports.
A system’s ability to exchange electronic health
information with, and use electronic information from,
other systems without special effort on the part of the user.
Interoperability is further specified as health systems’
ability to electronically send health information to, receive
health information from, find health information in,
integrate health information into, or health information
from other electronic systems outside of their
organizations.

Interrupted Stay

Interrupted Stay is a Medicare Part A SNF stay in which a
resident is discharged from SNF care (i.e., the resident is
discharged from a Medicare Part A-covered stay) and
subsequently resumes SNF care in the same SNF for a
Medicare Part A-covered stay during the interruption
window.

October 2024

Interoperability

Appendix A-11

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Interruption
Window

Definition

The interruption window is a 3-day period, starting with
the calendar day of discharge and including the 2
immediately following calendar days. In other words, if a
resident in a Medicare Part A SNF stay is discharged from
Part A, the resident must resume Part A services, or return
to the same SNF (if physically discharged) to resume Part
A services, by 11:59 p.m. at the end of the third calendar
day after their Part A-covered stay ended. The interruption
window begins with the first non-covered day following a
Part A-covered stay and ends at 11:59 p.m. on the third
consecutive non-covered day following a Part A-covered
SNF stay. If these conditions are met, the subsequent stay
is considered a continuation of the previous Medicare Part
A-covered stay for the purposes of both the variable per
diem schedule and PPS assessment completion.

Invalid Record

As defined by the MDS Correction Policy, a record that
was accepted into iQIES that should not have been
submitted. Invalid records are defined as: a test record
submitted as production, a record for an event that did not
occur, a record with the wrong resident identified or the
wrong reason for assessment, or submission of an
inappropriate non-required record.

ISC

A code based upon combinations of reasons for
assessment (A0310 items) that determines which items are
active on a particular type of MDS assessment or tracking
record.

Leave of Absence

LOA

Leave of Absence (LOA), which does not require
completion of either a Discharge assessment or an Entry
tracking record, occurs when a resident has a:

Item Set Code

•
•
•

Temporary home visit of at least one night; or
Therapeutic leave of at least one night; or
Hospital observation stay less than 24 hours and
the hospital does not admit the resident.

Legal Name

Resident’s name as it appears on the Medicare card. If the
resident is not enrolled in the Medicare program, use the
resident’s name as it appears on a government-issued
document (i.e., driver’s license, birth certificate, social
security card).

October 2024

Appendix A-12

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Level of
Consciousness

Definition
Alert: startles easily to any sound or touch.
Drowsy/Lethargic: repeatedly dozes off when you are
asking questions but responds to voice or touch.
Stuporous: very difficult to arouse and keep aroused for
the interview.
Comatose: cannot be aroused despite shaking and
shouting.
See Observation Period.

Major Surgery

Generally, major surgery refers to a procedure that meets
the following criteria:

Look-Back Period

1.
2.

Able to express or communicate requests, needs, opinions,
and to conduct social conversation in their primary
language, whether in speech, writing, sign language,
gestures, or a combination of these. Deficits in ability to
make one’s self understood (expressive communication
deficits) can include reduced voice volume and difficulty
in producing sounds, or difficulty in finding the right
word, making sentences, writing, and/or gesturing.

Makes Self
Understood

The resident was an inpatient in an acute care hospital
for at least 1 day in the 100 days prior to admission to
the skilled nursing facility (SNF), and
The surgery carried some degree of risk to the
resident’s life or the potential for severe disability.

The date at which the RN assessment coordinator attests
that all portions of the MDS have been completed. This is
the date recorded at Z0500B.

Mechanically
Altered Diet

A diet specifically prepared to alter the texture or
consistency of food in order to facilitate oral intake.
Examples include soft solids, pureed foods, ground meat,
and thickened liquids.

Medicaid

A Federal and State program subject to the provisions of
Title XIX of the Social Security Act that pays for specific
kinds of medical care and treatment for low-income
families.

October 2024

MDS Completion
Date

Appendix A-13

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Medicare

Definition
A health insurance program administered by CMS under
provisions of Title XVIII of the Social Security Act for
people aged 65 and over, for those who have permanent
kidney failure, and for certain people with disabilities.
Medicare Part A: The part of Medicare that covers
inpatient hospital services and services furnished by other
institutional health care providers, such as nursing
facilities, home health agencies, and hospices.
Medicare Part B: The part of Medicare that covers
services of doctors, suppliers of medical items and
services, and various types of outpatient services.

MAC

An organization designated by CMS to process Medicare
claims for payment that are submitted by a nursing
facility. MACs were previously called Fiscal
Intermediaries (FIs).

Medicare
Administrative
Contractor

Skilled Nursing Facility stays billable to Medicare Part A.
Does not include stays billable to other payers (e.g.,
Medicare Advantage plans).

Medicare Number

An identifier assigned to an individual for participation in
national health insurance program. The Medicare Health
Insurance identifier is different from the resident’s Social
Security Number (SSN) and may contain both letters and
numbers.

Medication
Interaction

The impact of medication or other substance (such as
nutritional supplements including herbal products, food, or
substances used in diagnostic studies) upon another
medication. The interactions may alter absorption,
distribution, metabolism, or elimination. These
interactions may decrease the effectiveness of the
medication or increase the potential for adverse
consequences.

Minimum Data
Set

October 2024

MDS

Medicare-Covered
Stay

A core set of screening, clinical assessment, and
functional status elements, including common definitions
and coding categories that form the foundation of the
comprehensive assessment for all residents of long-term
care facilities certified to participate in Medicare and
Medicaid and for patients receiving SNF services in noncritical access hospitals with a swing bed agreement.

Appendix A-14

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition
A type of correction allowed under the MDS Correction
Policy. A modification is required when a valid MDS
record has been accepted by the CMS MDS database, but
the information in the record contains errors. The
modification will correct the record in the CMS database.
A modification is not done when a record has been
rejected.

Monitoring

The ongoing collection and analysis of information (such
as observations and diagnostic test results) and
comparison to baseline and current data in order to
ascertain the individual’s response to treatment and care,
including progress or lack of progress toward a goal.
Monitoring can detect any improvements, complications
or adverse consequences of the condition or of the
treatments; and support decisions about adding,
modifying, continuing, or discontinuing, any
interventions.

Modification

This is a Medicare Part A covered stay that has started on
or after the most recent admission/entry or reentry to the
nursing facility.

Music Therapy

Music therapy is an intervention that uses music to address
physical, emotional, cognitive, and social needs of
individuals of all ages. Music therapy interventions can be
designed to promote wellness, manage stress, alleviate
pain, express feelings, enhance memory, improve
communication, and promote physical rehabilitation. In
order for music therapy to be coded on the MDS, the
service must be provided or directly supervised by a
qualified staff.

Most Recent
Medicare Stay

National Drug
Code

NDC

A unique 10-digit number assigned to each drug product
listed under Section 510 of the Federal Food, Drug and
Cosmetic Act. The NDC code identifies the vendor, drug
name, dosage, and form of the drug.

National Provider
Identifier

NPI

A unique federal number that identifies providers of health
care services. The NPI applies to the SNF/NFs for all of
its residents.

Nephrostomy
Tube

October 2024

A catheter inserted through the skin into the kidney or its
collecting system.

Appendix A-15

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition

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, nerve block, stretching and strengthening
exercises, chiropractic, electrical stimulation,
radiotherapy, ultrasound, and acupuncture.

Nonpharmacological
Intervention

Approaches that do not involve the use of medication to
address a medical condition.

Nursing Facility

A facility that is primarily engaged in providing skilled
nursing care and related services to individuals who
require medical or nursing care or rehabilitation services
for the rehabilitation of injured, disabled, or sick persons,
or on a regular basis, health related care services above the
level of custodial care to other than mentally retarded
individuals.
Nursing Monitoring includes clinical monitoring by a
licensed nurse (e.g. serial blood pressure evaluations,
medication management, etc.).

Nursing
Monitoring

Interventions related to diet, nutrients, and hydration that
are provided to prevent or manage specific skin conditions
(e.g., wheat-free diet to prevent dermatitis, increased
calorie diets to meet basic standards for daily energy
requirements, vitamin or mineral supplements for
specifically identified deficiencies.)

Observation Period

The time period over which an MDS assessment captures
a resident’s condition or status. A day begins at 12:00 a.m.
and ends at 11:59 p.m.; the observation period must also
cover this time period. An MDS assessment captures only
occurrences during the observation period. In other words,
if it did not occur during the observation period, it is not
coded on the MDS. Also referred to as Look-Back Period
or Assessment Period.

October 2024

Nutrition or
Hydration
Intervention to
Manage Skin
Problems

Appendix A-16

CMS’s RAI Version 3.0 Manual

Term
Occupational
Therapy

Appendix A: Glossary and Common Acronyms

Definition

Services that are provided or directly supervised by a
licensed occupational therapist. A qualified occupational
therapy assistant may provide therapy but not supervise
others (aides or volunteers) giving therapy. Includes
services provided by a qualified occupational therapy
assistant who is employed by (or under contract to) the
nursing facility only if they are under the direction of a
licensed occupational therapist. Occupational therapist and
occupational therapy assistant are defined in regulations
(42 CFR 484.4). Occupational therapy interventions
address deficits in physical, cognitive, psychosocial,
sensory, and other aspects of performance in order to
support engagement in everyday life activities that affect
health, well-being, and quality of life.

Abbreviation

Omnibus Budget
Reconciliation Act
of 1987

OBRA ’87

Law that enacted reforms in nursing facility care and
provides the statutory authority for the MDS. The goal is
to ensure that residents of nursing facilities receive quality
care that will help them to attain or maintain the highest
practicable, physical, mental, and psychosocial well-being.

On Admission

On admission is defined as: as close to the actual time of
admission as possible.

Oral Lesions

An abnormal area of tissue on the lips, gums, tongue,
palate, cheek lining, or throat. This may include
ulceration, plaques or patches (e.g. candidiasis), tumors or
masses, and color changes (red, white, yellow, or
darkened).

Pain Medication
Regimen

Pharmacological agent(s) prescribed to relieve or prevent
the recurrence of pain. Include all medications used for
pain management by any route and any frequency during
the look-back period.

Passive Range of
Motion

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; no effort is required from
them.

Patient Health
Questionnaire

October 2024

PHQ-2 to 9©

A validated interview that screens for symptoms of
depression. It provides a standardized severity score and a
rating for evidence of a depressive disorder.

Appendix A-17

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Definition

Patient Driven
Payment Model

PDPM

The Patient Driven Payment Model (PDPM) is a new
case-mix classification system for classifying skilled
nursing facility (SNF) residents in a Medicare Part A
covered stay into payment groups under the SNF
Prospective Payment System. Effective beginning October
1, 2019, PDPM replaced the Federal case-mix
classification system, the Resource Utilization Group,
Version IV (RUG-IV).

Persistent
Vegetative State

PVS

PVS is an enduring situation in which an individual has
failed to demonstrate meaningful cortical function but can
sustain basic body functions supported by noncortical
brain activity.

Abbreviation

Physical Therapy

Services that are provided or directly supervised by a
licensed physical therapist. A qualified physical therapy
assistant 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 and activity limitations and
participation restrictions, promote and maintain optimal
fitness, physical function, and quality of life, and reduce
risk as it relates to movement and health. Following an
evaluation of an individual with impairments, activity
limitations, and participation restrictions or other healthrelated conditions, the physical therapist designs an
individualized plan of physical therapy 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 adaptive devices and equipment,
physical agents, and electrotherapeutic modalities.

Physician
Prescribed Weightloss Regimen

October 2024

A weight reduction plan ordered by the resident’s
physician with the care plan goal of weight reduction.
May employ a calorie-restricted diet or other weight-loss
diets and exercise. Also includes planned diuresis. It is
important that weight loss is intentional.

Appendix A-18

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition
A secure online website that gives providers, residents,
and others 24-hour access to personal health information
from anywhere with an Internet connection.

Private Home/
Apartment

A noninstitutional community residential setting that can
include houses, condominiums, or apartments in the
community whether owned by the resident or another
person, as well as retirement communities and
independent housing for the elderly.

Program
Transmittal

Transmittal pages summarize the instructions to providers,
emphasizing what has been changed, added, or clarified.
They provide background information that would be
useful in implementing the instructions. Program
Transmittals can be found at the following Web site:
https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/index.html

Portal

Prompted Voiding

Prospective
Payment System

Psychomotor
Retardation

October 2024

PPS

A payment system, developed for Medicare skilled
nursing facilities, which pays facilities an all-inclusive rate
for all Medicare Part A beneficiary services. Payment is
determined by a case mix classification system that
categorizes patients by the type and intensity of resources
used.
The treatment of mental and emotional disorders through
the use of psychological techniques designed to encourage
communication of conflicts and insight into problems,
with the goal being relief of symptoms, changes in
behavior leading to improved social and vocational
functioning, and personality growth. Psychological
therapy may be provided by a psychiatrist, psychologist,
clinical social worker, or clinical nurse specialist in mental
health as allowable under applicable state laws.

Psychological
Therapy

Prompted voiding is a behavioral intervention to maintain
or regain urinary continence and may include timed verbal
reminders and positive feedback for successful toileting.

Visibly slowed level of activity or mental processing in
residents who are alert. Psychomotor retardation should be
differentiated from altered level of consciousness (i.e.
stupor) and lethargy.

Appendix A-19

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Definition

Quality
Improvement
Network

QIN

The Quality Improvement Organization (QIO) Program’s
14 Quality Innovation Network-QIOs (QIN-QIOs) bring
Medicare beneficiaries, providers, and communities
together in data-driven initiatives that increase patient
safety, make communities healthier, better coordinate
post-hospital care, and improve clinical quality. By
serving regions of two to six states each, QIN-QIOs are
able to help best practices for better care spread more
quickly, while still accommodating local conditions and
cultural factors.

Quality
Improvement
Organization

QIO

A program administered by CMS that is designed to
monitor and improve utilization and quality of care for
Medicare beneficiaries. The program consists of a national
network of QIOs responsible for each U.S. State, territory,
and the District of Columbia. Their mission is to ensure
the quality, effectiveness, efficiency, and economy of
health care services provided to Medicare beneficiaries.

Quality Measure

Abbreviation

Recreational
Therapy

Information derived from MDS data, that provides a
numeric value to quality indicators. These data are
available to the public as part of the Nursing Home
Quality Initiative (NHQI) and SNF Quality Reporting
Program (QRP) and are intended to provide objective
measures for consumers to make informed decisions about
the quality of care in SNF/NFs.

Services that are provided or directly supervised by a
qualified recreational therapist who holds a national
certification in recreational therapy, also referred to as a
Certified Therapeutic Recreation Specialist.” Recreational
therapy includes, but is not limited to, providing treatment
services and recreation activities to individuals using a
variety of techniques, including arts and crafts, animals,
sports, games, dance and movement, drama, music, and
community outings. Recreation therapists treat and help
maintain the physical, mental, and emotional well-being of
their clients by seeking to reduce depression, stress, and
anxiety; recover basic motor functioning and reasoning
abilities; build confidence; and socialize effectively.
Recreational therapists should not be confused with
recreation workers, who organize recreational activities
primarily for enjoyment.

October 2024

Appendix A-20

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Re-entry

Definition
When a resident returns to a facility following a temporary
discharge (return anticipated) and returns within 30 days
of the discharge.

Registered Nurse
Assessment
Coordinator

RNAC

Rehabilitation
Therapy

An individual licensed as a registered nurse by the State
Board of Nursing and employed by a nursing facility and
is responsible for coordinating and certifying completion
of the resident assessment instrument.

Special health care services or programs that help a person
regain physical, mental, and/or cognitive (thinking and
learning) abilities that have been lost or impaired as a
result of disease, injury, or treatment. These services or
programs can include, for example, physical therapy,
occupational therapy, speech therapy, and cardiac and
pulmonary therapies.

Religion

Resource Use

Belief in and reverence for a supernatural power or powers
regarded as creator and governor of the universe. Can be
expressed in practice of rituals associated with various
religious faiths, attendance and participation in religious
services, or in private prayer or religious study.

Resource
Utilization Group,
Version IV

The measure of the wage-weighted minutes of care used to
develop the RUG classification system.

RUG-IV

A category-based classification system in which nursing
facility residents classify into one of 66, 57, or 47 RUGIV groups. Residents in each group utilize similar
quantities and patterns of resources. Assignment of a
resident to a RUG-IV group is based on certain item
responses on the MDS 3.0. Some states utilize the RUGIV system for Medicaid payment in nursing facilities.

October 2024

Appendix A-21

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Respiratory
Therapy

Definition

Services that are provided by a qualified professional
(respiratory therapists, respiratory nurse). Respiratory
therapy services are for the assessment, treatment, and
monitoring of patients with deficiencies or abnormalities
of pulmonary function. Respiratory therapy services
include coughing, deep breathing, nebulizer treatments,
assessing breath sounds and mechanical ventilation, etc.,
which must be provided by a respiratory therapist or
trained respiratory nurse. A respiratory nurse must be
proficient in the modalities listed above either through
formal nursing or specific training and may deliver these
modalities as allowed under the state Nurse Practice Act
and under applicable state laws.
Short-term, temporary care provided to residents to allow
family members to take a break from the daily routine of
care giving.

Significant Error

An error in an assessment where the resident’s clinical
status is not accurately represented (i.e. miscoded) on the
erroneous assessment and the error has not been corrected
via submission of a more recent assessment.

Respite

Skilled Nursing
Facility

SNF

A facility that is primarily engaged in providing skilled
nursing care and related services to individuals who
require medical or nursing care or rehabilitation services
of injured, disabled, or sick persons.
Practices, habits, and environmental factors that promote
and/or improve sleep patterns.

Social Isolation

An actual or perceived lack of contact with other people,
such as living alone or residing in a remote area.

Social Security
Number

A tracking number assigned to an individual by the U.S.
Federal government for taxation, benefits, and
identification purposes.

October 2024

Sleep Hygiene

Appendix A-22

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Speech-Language
Pathology and
Audiology
Services

Definition

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.

SOM

A manual provided by CMS that provides information
regarding the how the State comes into compliance with
Medicare and Medicaid requirements for survey and
certification of all entities and appendices that provides
regulatory requirements and related guidance.

State Operations
Manual

Medicaid Provider Number established by a state.

State Resident
Assessment
Instrument (RAI)
Coordinator

A state agency person who provides information regarding
RAI requirements and MDS coding instructions (See
Appendix B).

Stress Incontinence

Episodes of a small amount of urine leakage only
associated with physical movement or activity such as
coughing, sneezing, laughing, lifting heavy objects, or
exercise.

Submission
Confirmation

The initial feedback generated by iQIES after an MDS
data file is electronically submitted. This message
acknowledges receipt of the submission file but does not
examine the file for any warnings and/or errors. Warnings
and/or errors are provided on the Final Validation Report.

October 2024

State Provider
Number

Appendix A-23

CMS’s RAI Version 3.0 Manual

Term
Submission
Requirement

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition

SUB_REQ

A field in the MDS electronic record (A0410) that
identifies the authority for data collection. CMS has
authority to collect assessments for all residents
(regardless of their payer source) who reside in Medicareand/or Medicaid-certified units. States may or may not
have regulatory authority to collect assessments for
residents in non-certified units.
An indwelling catheter that is placed into the bladder
through the abdominal wall above the pubic symphysis.

Swing Bed

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.

Suprapubic
Catheter

System of Records

Standards for collection and processing of personal
information as defined by the Privacy Act of 1974.
In general, the ability to place oneself in correct time. For
BIMS, it is the ability to indicate correct date in current
surroundings.

Temporal
Orientation

SOR

A therapeutic diet is a diet intervention prescribed by a
physician or other authorized nonphysician practitioner
that provides food or nutrients via oral, enteral, and
parenteral routes as part of treatment of disease or clinical
condition, to modify, eliminate, decrease, or increase
identified micro- and macronutrients in the diet (Academy
of Nutrition and Dietetics, 2020).

Tooth Fragment

A remnant of a tooth.

Total Severity
Score

A summary of the Patient Health Questionnaire frequency
scores that indicates the extent of potential depression
symptoms. The score does not diagnose a mood disorder
but provides a standard of communication between
clinicians and mental health specialists.

October 2024

Therapeutic Diet

Appendix A-24

CMS’s RAI Version 3.0 Manual

Term

Appendix A: Glossary and Common Acronyms

Abbreviation

Definition
Settings that provide longer-term residential services
offering professional support, education, and a stable
living environment for individuals transitioning from
situations such as homelessness, alcohol use disorder, and
substance use disorder. Such settings afford safe living
accommodations and services to support a successful
transition to self-sufficient living.

Up to Date (for
COVID-19 Vaccine)

For the definition of “up to date,” providers should refer
to the CDC webpage “Stay Up to Date with COVID-19
Vaccines” at https://www.cdc.gov/coronavirus/2019ncov/vaccines/stay-up-to-date.html.

Urostomy

A stoma for the urinary system, intended to bypass the
bladder or urethra.

Usual Performance

The environment or situations encountered at a facility can
have an impact on a resident’s functional status.
Observing the resident’s interactions with others in
different locations and circumstances is important for a
comprehensive understanding of the resident’s functional
status. 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 or worst
performance, but rather, record the resident’s usual
performance.

Utilization
Guidelines

Transitional Living

Instructions concerning when and how to use the RAI.
These include instructions for completion of the RAI as
well as structured frameworks for synthesizing MDS and
other clinical information.

Vomiting

The forceful expulsion of stomach contents through the
mouth or nose.

Z Codes

ICD-10-CM provides codes to deal with encounters for
circumstances other than a disease or injury. The Factors
Influencing Health Status and Contact with Health Services
codes (Z00–Z99) are provided to deal with occasions when
circumstances other than a disease or injury are recorded as
diagnosis or problems.

October 2024

Appendix A-25

CMS’s RAI Version 3.0 Manual

Appendix A: Glossary and Common Acronyms

Common Acronyms
Acronym
ADLs
ADR
AHEs
ARD
BBA-97
BBRA
BEA
BIMS
BIPA

October 2024

BLS
BMI
CAA
CAH
CAM
CAT
CBSA
CFR
CLIA
CMI
CMS
CNN
COTA
CPI
CPI-U
CPS
CPT
CR
CWF
DME
DMERC
DOS
ECI
EHR
EMR

Definition
Activities of Daily Living
Adverse Drug Reaction
Average Hourly Earnings
Assessment Reference Date
Balanced Budget Act of 1997
Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999
(U.S) Bureau of Economic Analysis
Brief Interview for Mental Status
Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act
(BIPA) of 2000
(U.S.) Bureau of Labor Statistics
Body mass index
Care Area Assessment
Critical Access Hospital
Confusion Assessment Method
Care Area Trigger
Core-Based Statistical Area
Code of Federal Regulations
Clinical Laboratory Improvements Amendments (1998)
Case Mix Index
Centers for Medicare & Medicaid Services
CMS Certification Number
Certified Occupational Therapist Assistant
Consumer Price Index
Consumer Price Index for All Urban Consumers
Cognitive Performance Scale (MDS)
(Physicians) Current Procedural Terminology
Change Request
Common Working File
Durable Medical Equipment
Durable Medical Equipment Regional Carrier
Dates of Service
Employment Cost Index
Electronic Health Record
Electronic Medical Record

Appendix A-26

CMS’s RAI Version 3.0 Manual

Definition
End Stage Renal Disease
Facility ID (for MDS submission)
Focused Medical Review
Final Rule
Final Validation Report (MDS submission)
Fiscal Year
Healthcare Common Procedure Coding System
Health Information Exchange
Health Insurance Portability and Accountability Act of 1996
Health Insurance PPS (Rate Codes)
International Classification of Diseases
International Classification of Diseases, Clinical Modification
Interdisciplinary Team
Interim Final Rule with Comment
Internet-Only Manual
Internet Quality Improvement and Evaluation System
Interim Payment Assessment
Item Set Code
Leave of Absence
Medicare Administrative Contractor
Minimum Data Set
Medicare Provider Analysis and Review (File)
Medicare Intermediary Manual
Magnetic Resonance Imaging
National Supplier Clearinghouse
National Drug Code
Network Data Mover
Nursing Facility
Nursing Home
National Provider Identifier
National Supplier Clearinghouse
Non-Therapy Ancillary
Omnibus Budget Reconciliation Act of 1987
Office of Management and Budget
Occupational Therapy/Therapist
Personal Care Expenditures

October 2024

Acronym
ESRD
FAC_ID
FMR
FR
FVR
FY
HCPCS
HIE
HIPAA
HIPPS
ICD
ICD-CM
IDT
IFC
IOM
iQIES
IPA
ISC
LOA
MAC
MDS
MEDPAR
MIM
MRI
NCS
NDC
NDM
NF
NH
NPI
NSC
NTA
OBRA
OMB
OT
PCE

Appendix A: Glossary and Common Acronyms

Appendix A-27

CMS’s RAI Version 3.0 Manual

Definition
Patient Driven Payment Model
Patient Health Questionnaire
PHQ-9© Observational Version
Program Integrity Manual
Point of Service
Producer Price Index
Prospective Payment System
Provider Reimbursement Manual
Physical Therapy/Therapist
Physical Therapist Assistant
Medicare General Information, Eligibility, and Entitlement IOM
Medicare Benefit IOM
Medicare Claims Processing IOM
Medicare State Operation IOM
Medicare Program Integrity IOM
State Medicaid IOM
Persistent Vegetative State
Quality Indicator
Quality Measure
Quality Improvement Organization
Resident Assessment Instrument
Registered Nurse Assessment Coordinator
Resource Utilization Group
Swing Bed Prospective Payment System
Significant Change in Status Assessment
Skilled Nursing Facility
Skilled Nursing Facility Prospective Payment System
Skilled Nursing Facility Quality Reporting Program
Speech Language Pathology Services
State Operations Manual
Systems of Records
Social Security Number
Staff Time Measure
Submission Requirement
Total Parenteral Nutrition

October 2024

Acronym
PDPM
PHQ-2 to 9©
PHQ-9-OV©
PIM
POS
PPI
PPS
PRM
PT
PTA
Pub.100-1
Pub.100-2
Pub.100-4
Pub.100-7
Pub.100-8
Pub.100-12
PVS
QI
QM
QIO
RAI
RNAC
RUG
SB-PPS
SCSA
SNF
SNF PPS
SNF QRP
SLP (or ST)
SOM
SOR
SSN
STM
SUB_REQ
TPN

Appendix A: Glossary and Common Acronyms

Appendix A-28

CMS’s RAI Version 3.0 Manual

Appendix B: RAI/MDS Contacts

APPENDIX B: STATE AGENCY AND CMS LOCATIONS
RAI/MDS CONTACTS
Appendix B: State Agency and CMS Locations RAI/MDS Contacts is located in the
“Downloads” section on CMS’s MDS 3.0 RAI Manual Web page:
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html

D
October 2024

Appendix B-1

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources

APPENDIX C
CARE AREA ASSESSMENT (CAA) RESOURCES

October 2024

Appendix C-1

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources

Chapter 4 of this manual provides information on specific care areas triggered and the CAA
process. This appendix contains both specific and general resources that nursing homes may
choose to use to further assess care areas triggered from the MDS 3.0 Resident Assessment
Instrument (RAI). The resources include the care area specific tools beginning in this section and
the general resource list at the end of this appendix.
It is important to note that the resources provided in this appendix are provided solely as a
courtesy for use by nursing homes, should they choose to, in completing the RAI CAA process.
It is also important to reiterate that CMS does not mandate, nor does it endorse, the use of
any particular resource(s), including those provided in this appendix. However, nursing
homes should ensure that the resource(s) used are current, evidence-based or expert-endorsed
research and clinical practice guidelines/resources.

DISCLAIMER: The list of resources in this appendix is neither prescriptive nor allinclusive. References to non-U.S. Department of Health and Human Services (HHS)
sources or sites on the Internet are provided as a service and do not constitute or imply
endorsement of these organizations or their programs by CMS or HHS. CMS is not
responsible for the content of pages found at these sites. URL addresses were current as of
the date of this publication.

October 2024

Appendix C-2

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources

CARE AREA SPECIFIC RESOURCES
The specific resources or tools contained on the next several pages are provided by care area.
The general instructions for using them include:
Step 1: After completing the MDS, review all MDS items and responses to determine if any care
areas have been triggered.
Step 2: For any triggered care area(s), conduct a thorough assessment of the resident using the
care area-specific resources.
Step 3: Check the box in the left column if the item is present for this resident. Some of this
information will be on the MDS - some will not.

Step 4: In the right column the facility can provide a summary of supporting documentation
regarding the basis or reason for checking a particular item or items. This could include the
location and date of that information, symptoms, possible causal and contributing factor(s) for
item(s) checked, etc.
Step 5: Obtain and consider input from resident and/or family/resident’s representative regarding
the care area.

Step 6: Analyze the findings in the context of their relationship to the care area and standards of
practice. This should include a review of indicators and supporting documentation, including
symptoms and causal and contributing factors, related to this care area. Draw conclusions about
the causal/contributing factors and effect(s) on the resident, and document these conclusions in
the Analysis of Findings section.
Step 7: Decide whether referral to other disciplines is warranted and document this decision.

Step 8: In the Care Plan Considerations section, document whether a care plan for the triggered
care area will be developed and the reason(s) why or why not.

Step 9: Information in the Supporting Documentation column can be used to populate the
Location and Date of CAA Documentation column in Section V, Item V0200A (CAA Results) –
for e.g. “See Delirium CAA 4/30/11, H&P dated 4/18/11.”
NOTE: An optional Signature/Date line has been added to each checklist. This was added if the
facility wants to document the staff member who completed the checklist and date completed.
DISCLAIMER: The checklists of care area specific resources in this appendix are not
mandated, prescriptive, or all-inclusive and are provided as a service to facilities. They do
not constitute or imply endorsement by CMS or HHS.

October 2024

Appendix C-3

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources

TABLE OF CONTENTS
1.

Delirium ..............................................................................................................................C-5

Cognitive Loss/Dementia..................................................................................................C-10

Visual Function .................................................................................................................C-14

Communication .................................................................................................................C-17

Activities of Daily Living (ADLs) – Functional/Rehabilitation Potential........................C-21

Urinary Incontinence and Indwelling Catheter .................................................................C-25

Psychosocial Well-Being ..................................................................................................C-29

Mood State ........................................................................................................................C-33

Behavioral Symptoms .......................................................................................................C-36

10.

Activities ...........................................................................................................................C-42

11.

Fall(s) ................................................................................................................................C-46

12.

Nutritional Status ..............................................................................................................C-51

13.

Feeding Tube(s) ................................................................................................................C-56

14.

Dehydration/Fluid Maintenance .......................................................................................C-59

15.

Dental Care .......................................................................................................................C-63

16.

Pressure Ulcer/Injury ........................................................................................................C-66

17.

Psychotropic Medication Use ...........................................................................................C-70

18.

Physical Restraints ............................................................................................................C-75

19.

Pain ...................................................................................................................................C-79

20.

Return to Community Referral .........................................................................................C-83

Care Area General Resources ....................................................................................................C-85

October 2024

Appendix C-4

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
1. Delirium

DELIRIUM

Review of Indicators of Delirium



□

□
□


□
□

October 2024

Supporting Documentation
Blank

□
□
□
□
□
□
□

□

□
□
□
□
□

Changes in vital signs compared to baseline
Temperatures 2.40F higher than baseline or a
temperature of 100.40F (380C) on admission
prior to establishment of baseline. (J1550A)
Pulse rate less than 60 or greater than 100 beats
per minute
Respiratory rate over 25 breaths per minute or
less than 16 per minute (J1100)
Hypotension or a significant decrease in blood
pressure: (I0800)
• Systolic blood pressure of less than 90 mm
Hg, OR
• Decline of 20 mm Hg or greater in systolic
blood pressure from person’s usual baseline,
OR
• Decline of 10 mm Hg or greater in diastolic
blood pressure from person’s usual baseline,
OR
Hypertension - a systolic blood pressure above
160 mm Hg, OR a diastolic blood pressure
above 95 mm Hg (I0700)
Abnormal laboratory values
• Electrolytes, such as sodium
• Kidney function
• Liver function
• Blood sugar
• Thyroid function
• Arterial blood gases
• Other
Pain
• Pain CAA triggered (J0100, J0200) [review
findings for relationship to delirium
(C1310)]
• Pain frequency, intensity, and characteristics
(time of onset, duration, quality) (J0410,
J0600, J0800, J0850) indicate possible
relationship to delirium (C1310)
• Adverse effect of pain on function (J0510,
J0520, J0530) may be related to delirium
(C1310)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

Supporting Documentation
Blank

Appendix C-5

CMS’s RAI Version 3.0 Manual



□

Diseases and conditions
(diagnosis/signs/symptoms)
• Circulatory/Heart
 Anemia (I0200)
 Cardiac dysrhythmias (I0300)
 Angina, Myocardial Infarction (MI)
(I0400)
 Atherosclerotic Heart Disease (ASHD)
(I0400)
 Congestive Heart Failure (CHF)
pulmonary edema (I0600)
 Cerebrovascular Accident (CVA) (I4500)
 Transient Ischemic Attack (TIA) (I4500)
• Respiratory
 Asthma (I6200)
 Emphysema/Chronic Obstructive
Pulmonary Disease (COPD) (I6200)
 Shortness of breath (J1100)
 Ventilator or respirator (O0110F1)
 Respiratory Failure (I6300)
• Infectious
 Infections (I1700–I2500, M1040A)
 Isolation or quarantine for active
infectious disease (O0110M1)
• Metabolic
 Diabetes (I2900)
 Thyroid disease (I3400)
 Hyponatremia (I3100)
• Gastrointestinal bleed
• Renal disease (I1500), Dialysis (O0110J1–3)
• Hospice care (O0110K1)
• Terminal condition (J1400)
• Cancer (I0100, O0110A1–10, O0110B1)
• Dehydration (J1550C, clinical record)
Signs of Infection
• Fever (J1550A)
• Cloudy or foul smelling urine
• Congested lungs or cough
• Dyspnea (J1100)
• Diarrhea
• Abdominal pain
• Purulent wound drainage
• Erythema (redness) around an incision

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

□
□



□
□
□
□
□
□
□
□

October 2024

□
□
□
□
□
□

□

Appendix C: CAA Resources
1. Delirium

Supporting Documentation
Blank

Appendix C-6

CMS’s RAI Version 3.0 Manual



□
□
□

Indicators of Dehydration
• Dehydration CAA triggered, indicating
signs or symptoms of dehydration are
present (J1550C)
• Recent decrease in urine volume or more
concentrated urine than usual (Intake and
Output)
• Recent decrease in eating habits – skipping
meals or leaving food uneaten, weight loss
(K0300)
• Nausea, vomiting (J1550B), diarrhea, or
blood loss
• Receiving intravenous drugs (O0110H1)
• Receiving diuretics or drugs that may cause
electrolyte imbalance (N0415G1)
Functional Status
• Recent decline in functional abilities status
(GG0130, GG0170) (may be related to
delirium) (C1310)
• Increased risk for falls (J1700–J1900) (may
be related to delirium) (see Falls CAA)
Medications (that may contribute to delirium)
• New medication(s) or dosage increase(s)
• Medications with anticholinergic properties
(for example, some antipsychotics
(N0415A), antidepressants (N0415C),
antiparkinsonians, antihistamines)
• Opioids (N0415H)
• Benzodiazepines, especially long-acting
agents (N0415B)
• Analgesics, cardiac and GI medications,
anti-inflammatory drugs
• Recent abrupt discontinuation, omission, or
decrease in dose of a short or long acting
benzodiazepines (N0415B)
• Medication interactions (pharmacist review
may be required)
• Resident taking more than one medication
from a particular class
• Possible medication toxicity, especially if
the person is dehydrated (J1550C) or has
renal insufficiency (I1500). Check serum
medication levels



□
□


□
□

□
□
□

October 2024

Supporting Documentation
Blank

□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

□
□
□

Appendix C: CAA Resources
1. Delirium

Appendix C-7

CMS’s RAI Version 3.0 Manual



□
□
□
□

Appendix C: CAA Resources
1. Delirium



□

Supporting Documentation
Blank

Associated or progressive signs and
symptoms
• Sleep disturbances (for example, up and
awake at night/asleep during the day)
(D0150C, D0500C, J0510)
• Agitation and inappropriate movements
(for example, unsafe climbing out of bed or
chair, pulling out tubes) (E0500)
• Hypoactivity (for example, low or lack of
motor activity, lethargy or sluggish
responses) (D0150D, D0500D)
• Perceptual disturbances such as
hallucinations (E0100A) and delusions
(E0100B)
Other Considerations
Psychosocial
• Recent change in mood; sad or anxious (for
example, crying, social withdrawal)
(D0150, D0160, D0500, D0600)
• Recent change in social situation (for
example, isolation, recent loss of family
member or friend)
• Use of restraints (P0100)
Physical or environmental factors
• Hearing or vision impairment (B0200,
B1000) - may have an impact on ability to
process information (directions, reminders,
environmental cues)
• Lack of frequent reorientation, reassurance,
reminders to help make sense of things
• Recent change in environment (for
example, a room or unit change, new
admission, or return from hospital) (A1700)
• Interference with resident’s ability to get
enough sleep (for example, light, noise,
frequent disruptions)
• Noisy or chaotic environment (for example,
calling out, loud music, constant
commotion, frequent caregiver changes)

Supporting Documentation
(Basis/reason for checking the item, including
the location, date, and source (if applicable)
of that information)
Blank

Blank

October 2024

Appendix C-8

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
1. Delirium

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Review indicators and supporting
documentation, and draw conclusions.
Document:
• Description of the problem;
• Causes and contributing factors; and
• Risk factors related to the care area.

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/
will not be developed.

Blank

ra
Referral(s) to another discipline(s) is warranted (to whom and why): ______________________
______________________________________________________________________________
Information regarding the CAA transferred to the CAA Summary (Section V of the MDS):
□ Yes □ No
Signature/Title:___________________________________ Date:_________________________

October 2024

Appendix C-9

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
2. Cognitive Loss/Dementia

COGNITIVE LOSS/DEMENTIA

Review of Indicators of Cognitive Loss/Dementia



□



□
□

□
□
□
□

October 2024

Supporting Documentation
Blank

□

Supporting Documentation
Blank

□
□
□
□
□
□
□

Reversible causes of cognitive loss
• Delirium (C1310) CAA triggered
(Immediate follow-up required. Perform
the Delirium CAA to determine possible
causes, contributing factors, etc., and go
directly to care planning for those issues.
Then continue below.)
Neurological factors
• Intellectual disability/Developmental
Disability (A1550)
• Alzheimer’s Disease or other dementias
(I4200, I4800)
• Parkinson’s Disease (I5300)
• Traumatic brain injury (I5500)
• Brain tumor
• Normal pressure hydrocephalus
• Other (I8000)
Observable characteristics and extent of
this resident’s cognitive loss
• Analyze component of Brief Interview for
Mental Status (BIMS) (C0200–C0500)
(V0100D)
• If unable to complete BIMS, analyze
components of Staff Assessment for
Mental Status (C0700, C0800, C0900,
C1000)
• Identify components of Delirium
assessment (C1310) that are present and
not new onset or worsening
• Confusion, disorientation, forgetfulness
(C0200, C0300, C0400, C0500, C0700,
C0800, C0900, C1310)
• Decreased ability to make self-understood
(B0700) or to understand others (B0800)
• Impulsivity
• Other

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

Appendix C-10

CMS’s RAI Version 3.0 Manual



□
□



Mood and behavior
• Mood State (D0160, D0600) CAA
triggered. Analysis of Findings indicates
possible impact on cognition – important
to consider when drawing conclusions
about cognitive loss
• Behavioral Symptoms (E0200) CAA
triggered: Analysis of Findings points to
cause(s), contributing factors, etc. –
important to consider when drawing
conclusions about cognitive loss
Medical problems that can impact cognition
• Constipation (H0600), fecal impaction,
diarrhea
• Diabetes (I2900)
• Thyroid Disorder (I3400)
• Congestive heart failure (I0600)/other
cardiac diseases (I0300, I0400)
• Respiratory problems (I6200, I6300,
I2000, I2200, I8000)/decreased oxygen
saturation
• Cancer (I0100)
• Liver disease (I1100, I2400, I8000)
• Renal failure (I1500)
• Psychiatric or mood disorder (I5700–
I6100)
• Electrolyte imbalance
• Poor nutrition (I5600) or hydration status
(J1550C)
• End of life (J1400, O0110K1)
• Alcoholism (I8000)
• Failure to thrive (I8000)
Pain and its relationship to cognitive loss
and behavior
• Indications that pain is present (J0100,
J0300–J0600, J0800, J0850)
• Pain CAA triggered. Determine
relationship between pain and cognitive
status via observation and assessment.



□
□

October 2024

Supporting Documentation
Blank

□
□
□
□
□
□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

□
□
□
□
□

Appendix C: CAA Resources
2. Cognitive Loss/Dementia

Supporting Documentation
Blank

Appendix C-11

CMS’s RAI Version 3.0 Manual



□

Appendix C: CAA Resources
2. Cognitive Loss/Dementia

□
□
□
□


□
□
□
□

□
□

October 2024

□

Supporting Documentation
Blank

Functional status and its relationship to
cognitive loss
• Functional Abilities (Section GG)
 Functional Abilities Care Area
triggered (GG0130, GG0170).
Analysis of Findings provides
important information about
relationship of functional decline to
cognitive loss (C0500, C0700, C0800,
C0900, C1000, V0100D)
 Resident has potential for more
independence with cueing, restorative
nursing program, and/or task
segmentation or other programs
• Decline in continence (H0300, H0400)
• Impaired daily decision-making (C1000)
• Participates better in small group
programs (F0800P)
• Staff and/or resident believe resident is
capable of doing more
Other Considerations
• Cognitive decline occurred slowly over
time (V0100D)
• Unexplainable behavior may be attempt at
communication about pain, toileting
needs, uncomfortable position, etc.
• Use of physical restraints (P0100)
• Hearing or vision impairment (B0200,
B0300, B1000, B1200) - may have an
impact on ability to process information
(directions, reminders, environmental
cues)
• Lack of frequent reorientation,
reassurance, reminders to help make sense
of things (C0900, C1310)
• Interference with the resident’s ability to
get enough sleep (noise, light, etc.)
(D0150, D0500C, J0510)
• Noisy or chaotic environment (for
example, calling out, loud music, constant
commotion, frequent caregiver changes)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

Appendix C-12

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
2. Cognitive Loss/Dementia

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Review indicators and supporting
documentation, and draw conclusions.
Document:
• Description of the problem;
• Causes and contributing factors; and
• Risk factors related to the care area.

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan
will/ will not be developed.

Blank

October 2024

Appendix C-13

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
3. Visual Function

VISUAL FUNCTION

Review of Indicators of Visual Function



□
□
□
□
□
□

October 2024

Blank

□
□

Supporting Documentation

□
□
□
□
□
□
□
□
□
□
□

Diseases and conditions of the eye
(diagnosis OR signs/symptoms present)
• Cataracts, Glaucoma, or Macular
Degeneration (I6500)
• Diabetic retinopathy (I2900)
• Blindness (B1000)
• Decreased visual acuity (B1000, B1200)
• Visual field deficit (B1200)
• Eye pain
• Blurred vision
• Double vision
• Sudden loss of vision
• Itching/burning eye
• Indications of eye infection
Diseases and conditions that can cause
visual disturbances
• Cerebrovascular accident or transient
ischemic attack (I4500)
• Alzheimer’s Disease and other dementias
(I4200, I4800)
• Myasthenia gravis (I8000)
• Multiple sclerosis (I5200)
• Cerebral palsy (I4400)
• Mood ((I5800, I5900, I5950, I6000,
I6100, D0160 or D0600) or anxiety
disorder (I5700)
• Traumatic brain injury (I5500)
• Other (I8000)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

Appendix C-14

CMS’s RAI Version 3.0 Manual



□

Functional limitations related to vision
problems
• Peripheral vision or other visual problem
that impedes ability to eat, walk, or interact
with others (B1000)
• Ability to recognize staff limited by vision
problem (B1000)
• Difficulty negotiating the environment due
to vision problem (B1000)
• Balance problems exacerbated by vision
problem (B1000, B1200)
• Participation in self-care limited by vision
problem (B1000)
• Difficulty seeing television, reading
material of interest, or participating in
activities of interest because of vision
problem (B1000)
• Increased risk for falls due to vision
problems or due to bifocals or trifocals
(B1200)
Environment
• Is resident’s environment adapted to their
unique needs, such as availability of large
print books, high wattage reading lamp,
night light, etc.?
• Are there aspects the facility’s environment
that should be altered to enhance vision,
such as low-glare floors, low glare tables
and surfaces, large print signs marking
rooms, etc.?
Medications that can impair vision
(consultant pharmacist review of medication
regimen can be very helpful)
• Opioids (N0415H)
• Antipsychotics (N0415A)
• Antidepressants (N0415C)
• Anticholinergics
• Hypnotics (N0415D)
• Other
Use of visual appliances (B1200)
• Reading glasses
• Distance glasses
• Contact lenses
• Magnifying glass

□


□
□

□
□
□
□
□
□


□
□
□
□

October 2024

Supporting Documentation

Blank



Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

□
□
□
□
□

Appendix C: CAA Resources
3. Visual Function

Supporting Documentation
Blank

Appendix C-15

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
3. Visual Function

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Review indicators and supporting
documentation, and draw conclusions.
Document:
• Description of the problem;
• Causes and contributing factors; and
• Risk factors related to the care area.
Blank

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-16

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
4. Communication

COMMUNICATION

Review of Indicators of Communication



□
□
□
□


October 2024

Supporting Documentation
Blank

□
□
□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□

Diseases and conditions that may be related
to communication problems
• Alzheimer’s Disease or other dementias
(I4200, I4800, I8000)
• Aphasia (I4300) following a
cerebrovascular accident (I4500)
• Parkinson’s disease (I5300)
• Mental health problems (I5700–I6100)
• Conditions that can cause voice production
deficits, such as
 Asthma (I6200)
 Emphysema/COPD (I6200)
 Cancer (I0100)
 Poor-fitting dentures (L0200)
• Transitory conditions, such as
 Delirium (C1310)
 Infection (I1700–I2500, M1040A)
 Acute illness (I8000)
• Other (I8000, clinical record)
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)
• Aspirin
• Other

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-17

CMS’s RAI Version 3.0 Manual



Characteristics of the communication
impairment
• Expressive communication (B0700)
 Speaks different language (A1110A–
B)
 Disruption in ability to speak (B0600)
 Problem with voice production, low
volume (B0600)
 Word-finding problems
 Difficulty putting sentence together
(B0700, C1310C)
 Problem describing objects and events
(B0700)
 Pronouncing words incorrectly
(B0600)
 Stuttering (B0700)
 Hoarse or distorted voice
• Receptive communication (B0800)
 Does not understand English
(A1110A–B)
 Hearing impairment (B0200, B0300,
B0800)
 Speech discrimination problems
 Decreased vocabulary comprehension
(A1110B)
 Difficulty reading and interpreting
facial expressions
• Communication is more successful with
some individuals than with others. Identify
and build on the successful approaches
• Limited opportunities for communication
due to social isolation or need for
communication devices
• Communication problem may be mistaken
as cognitive impairment

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

□

October 2024

□

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

Appendix C: CAA Resources
4. Communication

Appendix C-18

CMS’s RAI Version 3.0 Manual



□
□
□
□
□

Appendix C: CAA Resources
4. Communication

Confounding problems that may need to be
resolved before communication will improve
• Decline in cognitive status and BIMS
decline (C0500, V0100D)
• Mood problem, increase in PHQ-2 to 9© or
PHQ-9-OV© score (D0160, D0600,
V0100E)
• Increased dependence in functional
abilities (changes in GG0130, GG0170)
• Deterioration in respiratory status
• Oral motor function problems, such as
swallowing, clarity of voice production
(B0600, K0100)
Use of communication devices



•
•
•
•
•
•
•
•

Hearing aid (B0300)
Written communication
Sign language (A1100A)
Braille (A1100A)
Signs, gestures, sounds
Communication board
Electronic assistive devices
Other

Supporting Documentation
Blank

□
□
□
□
□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

October 2024

Appendix C-19

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
4. Communication

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-20

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
5. Activities of Daily Living

5.
ACTIVITIES OF DAILY LIVING (ADLs) –
FUNCTIONAL/REHABILITATION POTENTIAL
Review of Indicators of ADLs – Functional/Rehabilitation Potential



□
□
□
□
□
□

October 2024

□
□
□
□
□
□
□
□
□
□
□

□
□
□
□
□

Possible underlying problems that may affect
function. Some may be reversible.
• Delirium (C1310) (Delirium CAA)
• Acute episode or flare-up of chronic
condition
• Changing cognitive status (C0100) (see
Cognitive Loss CAA)
• Mood decline (D0160, D0600) (see Mood
State CAA)
• Daily behavioral symptoms/decline in
behavior (E0200) (see Behavioral
Symptoms CAA)
• Use of physical restraints (P0100) (see
Physical Restraints CAA)
• Pneumonia (I2000)
• Fall (J1700–J1900) (see Falls CAA)
• Hip fracture (I3900)
• Recent hospitalization (A1700, A1805)
• Fluctuating functional abilities (GG0130,
GG0170)
• Nutritional problems (K0520A, K0520B)
(see Nutrition CAA)
• Pain (J0300, J0800) (see Pain CAA)
• Dizziness
• Communication problems (B0200, B0700,
B0800) (see Communication CAA)
• Vision problems (B1000) (see Vision CAA)
Abnormal laboratory values
• Electrolytes
• Complete blood count
• Blood sugar
• Thyroid function
• Arterial blood gases
• Other

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Supporting Documentation
Blank

Appendix C-21

CMS’s RAI Version 3.0 Manual



□
□
□


□

Medications that can contribute to functional
decline
• Psychoactive medications (N0415A–D)
• Opioids (N0415H)
• Other medications – ask consultant
pharmacist to review medication regimen
to identify these medications
Limiting factors resulting in need for
assistance with self-care or mobility
• Mental errors such as sequencing
problems, incomplete performance, or
anxiety limitations
• Physical limitations such as weakness
(GG0130, GG0170), limited range of
motion (GG0115), poor coordination, poor
balance, visual impairment (B1000), or
pain (J0300, J0800)
• Facility conditions such as policies, rules,
or physical layout
Problems resident is at risk for because of
functional decline
• Falls (J1700–J1900)
• Weight loss (K0300)
• Unidentified pain (J0800)
• Social isolation
• Restraint use (P0100)
• Depression (D0150, D0160, D0500,
D0600)
• Complications of immobility, such as
 Pressure ulcer/injury (M0210, M0300)
 Muscular atrophy
 Contractures (GG0115)
 Incontinence (H0300, H0400)
 Urinary (I2300) and respiratory
(I2000, I2200, I8000) infections

□


□
□
□
□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Supporting Documentation

Blank

□

Appendix C: CAA Resources
5. Activities of Daily Living

Supporting Documentation
Blank

October 2024

Appendix C-22

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
5. Activities of Daily Living

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

ra
Referral(s) to another discipline(s) is warranted (to whom and why): ______________________
______________________________________________________________________________
Information regarding the CAA transferred to the CAA Summary (Section V of the MDS):
□ Yes □ No
Signature/Title: ___________________________________ Date: ________________________

October 2024

Appendix C-23

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
5. Activities of Daily Living

Where rehabilitation goals are envisioned, use of the ADL Supplement will help care planners to
focus on those areas that might be improved, allowing them to choose from among a number of
basic tasks in designated areas. Part 1 of the supplement can assist in the evaluation of all
residents that trigger this care area. Part 2 of the supplement can be helpful for residents with
rehabilitation potential (ADL Triggers A), to help plan a treatment program.
ADL SUPPLEMENT
(Attaining maximum possible Independence)
PART 1: ADL Problem
Evaluation
INSTRUCTIONS:
For those triggered In areas physical help provided,
indicate reason(s) for this help.

DRESSING

Mental Errors:
blank
Sequencing problems,
incomplete performance, anxiety
limitations, etc.

BATHING

blank

TOILETING

blank

LOCOMOTION

blank

TRANSFER

EATING

blank

Physical Limitations:
Weakness, limited range of
motion, poor coordination, visual
impairment, pain, etc.

Facility Conditions:
Policies, rules, physical layout,
etc.

PART 2: Possible ADL Goals
INSTRUCTIONS:
For those considered for
rehabilitation or decline
prevention treatment -

October 2024

Goes to tub/
shower

Goes to toilet
(include
commode/
urinal at night)

Walks in
room/
nearby

Positions self
in preparation

Opens/
pours/
unwraps/
cuts etc.

Grasps/puts on
upper
lower body

Turns on
water/ adjusts
temperature

Removes/
opens clothes
in preparation

Walks on
unit

Approaches
chair/bed

Grasps
utensils and
cups

Manages snaps,
zippers, etc.

Lathers body
(except back)

Transfers/
positions self

Walks
throughout
building (uses
elevator)

Prepares
chair/bed
(locks pad,
moves covers)

Scoops/
spears food
(uses fingers
when
necessary)

Puts on in correct
Rinses body
order

Eliminates into
toilet

Walks
outdoors

Transfers
(stands/sits/
lifts/turns)

Chews,
drinks,
swallows

Grasps, removes
each item

Dries with
towel

Tears/uses
paper to clean
self

Walks on
uneven
surfaces

Repositions/
arranges self

Repeats until
food
consumed

Replaces clothes
properly

Other

Flushes

Other

Uses napkins,
cleans self

Other

blank

Adjusts
clothes,
washes hands

blank

Other

Locates/ selects/
obtains clothes

Indicate specific type of ADL
activity that might require:
1. Maintenance to prevent
decline.
2. Treatment to achieve
highest practical selfsufficiency (selecting ADL
abilities that are just above
those the resident can now
perform or participate in).

If wheelchair,
check:

Appendix C-24

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
6. Urinary Incontinence and Indwelling Catheter

URINARY INCONTINENCE AND INDWELLING CATHETER

Review of Indicators of Urinary Incontinence and Indwelling Catheter



□
□
□
□

October 2024

Supporting Documentation

Blank

□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□
□
□
□

Modifiable factors contributing to transitory
urinary incontinence
• Delirium (C1310) (see Delirium CAA)
• Urinary Tract Infection (I2300)
• Postmenopausal atrophic vaginitis (I8000)
• Medications (see below)
• Psychological or psychiatric problems
(I5700–I6100)
• Constipation/impaction (H0600)
• Caffeine use
• Excessive fluid intake
• Pain (J0300, J0800)
• Environmental factors
 Restricted mobility (GG0170) (see
Functional Abilities CAA)
 Lack of access to a toilet
 Other environmental barriers (such as
pads or briefs)
 Restraints (P0100)
Other factors that contribute to incontinence
or catheter use
• Excessive or inadequate urine output
• Urinary urgency AND need for assistance
in toileting (GG0130, GG0170)
• Bladder cancer (I0100) or stones (I8000)
• Spinal cord or brain lesions (I8000)
• Tabes dorsalis (I8000)
• Neurogenic bladder (I1550)
Laboratory tests
• High serum calcium
• High blood glucose
• Low B12
• High BUN or creatinine

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

Blank

Supporting Documentation

Appendix C-25

CMS’s RAI Version 3.0 Manual



□
□
□
□
□
□
□
□


Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

Diseases and conditions
• Benign prostatic hypertrophy (I1400)
• Congestive Heart Failure (CHF),
pulmonary edema (I0600)
• Cerebrovascular Accident (CVA) (I4500)
• Transient Ischemic Attack (TIA) (I4500)
• Diabetes (I2900)
• Depression (I5800)
• Parkinson’s disease (I5300)
• Prostate cancer (I0100)
Supporting Documentation
Type of incontinence
• Stress (occurs with coughing, sneezing,
Blank
laughing, lifting heavy objects, etc.)
• Urge (overactive or spastic bladder)
• Mixed (stress incontinence with urgency)
• Overflow (due to blocked urethra or weak
bladder muscles)
• Transient (temporary/occasional related to a
potentially improvable/reversible cause)
• Functional (can’t get to toilet in time due to
physical disability, external obstacles, or
problems thinking or communicating)
Medications (from medication administration
record and preadmission records if new
Supporting Documentation
admission; review by consultant pharmacist)
• Diuretics (N0415G)– can cause urge
Blank
incontinence
• Sedatives, hypnotics (N0415B, N0415D)
• Anticholinergics – can lead to overflow
incontinence
 Parkinson’s medications (except
Sinemet and Deprenyl)
 Disopyramide
 Antispasmodics
 Antihistamines
 Antipsychotics (N0415A)
 Antidepressants (N0415C)
 Opioids (N0415H)
• Drugs that stimulate or block sympathetic
nervous system
• Calcium channel blockers



□
□
□

□
□
□
□
□
□

Appendix C: CAA Resources
6. Urinary Incontinence and Indwelling Catheter

□
□

October 2024

Appendix C-26

CMS’s RAI Version 3.0 Manual



□
□
□
□
□

Appendix C: CAA Resources
6. Urinary Incontinence and Indwelling Catheter

Use of indwelling catheter (H0100 is
checked): (Presence of situation in which
catheter use may be appropriate intervention
after consideration of risks/benefits and after
efforts to avoid catheter use have been
unsuccessful
• Coma (B0100)
• Terminal illness (J1400, O0110K1)
• Stage 3 or 4 pressure ulcer in area affected
by incontinence (M0300C, M0300D)
• Need for exact measurement of urine
output
• History of inability to void after catheter
removal

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

D
October 2024

Appendix C-27

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
6. Urinary Incontinence and Indwelling Catheter

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-28

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
7. Psychosocial Well-Being

PSYCHOSOCIAL WELL-BEING

Review of Indicators of Psychosocial Well-Being



□

□
□
□
□
□


□
□

October 2024

Blank

Supporting Documentation

□

□
□

Modifiable factors for relationship
problems
• Resident says or indicates they feel lonely
(D0700)
 Recent decline in social involvement
and associated loneliness can be sign of
acute health complications and
depression
• Resident indicates they feel distressed
because of decline in social activities
• Over the past few years, resident has
experienced absence of daily exchanges
with relatives and friends
• Resident is uneasy dealing with others
• Resident has conflicts with family, friends,
roommate, other residents, or staff
• Resident appears preoccupied with the past
and unwilling to respond to needs of the
present
• Resident seems unable or reluctant to begin
to establish a social role in the facility; may
be grieving lost status or roles
• Recent change in family situation or social
network, such as death of a close family
member or friend
Customary lifestyle (Section F)
• Was lifestyle more satisfactory to the
resident prior to admission to the nursing
home?
• Are current psychosocial/relationship
problems consistent with resident’s longstanding lifestyle or is this relatively new
for the resident?
• Has facility care plan to date been as
consistent as possible with resident’s prior
lifestyle, preferences, and routines?

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-29

CMS’s RAI Version 3.0 Manual



□
□
□
□
□
□


Diseases and conditions that may impede
ability to interact with others
• Delirium (C1310, Delirium CAA)
• Intellectual disability /developmental
disability (A1550)
• Alzheimer’s disease (I4200)
• Aphasia (I4300)
• Other dementia (I4800)
• Depression (I5800)
Health status factors that may inhibit social
involvement
• Decline in functional abilities (GG0130,
GG0170)
• Health problem, such as falls (J1700–
J1900), pain (J0300, J0800), fatigue, etc.
• Mood (D0150, D0160, D0500, D0600) or
behavior (E0200) problem that impacts
interpersonal relationships or that arises
because of social isolation (see Mood State
and Behavioral Symptoms CAAs)
• Change in communication (B0700,
B0800), vision (B1000), hearing (B0200),
cognition (C0100, C0600)
• Medications with side effects that interfere
with social interactions, such as
incontinence, diarrhea, delirium, or
sleepiness
Environmental factors that may inhibit
social involvement
• Use of physical restraints (P0100)
• Change in residence leading to loss of
autonomy and reduced self-esteem
(A1700)
• Change in room assignment or dining
location or table mates
• Living situation limits informal social
interaction, such as isolation precautions
(O0110M1)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Supporting Documentation
Blank

□
□



□
□

October 2024

Supporting Documentation

Blank

□
□

□
□
□

Appendix C: CAA Resources
7. Psychosocial Well-Being

Appendix C-30

CMS’s RAI Version 3.0 Manual



□
□
□
□

Strengths to build upon (from resident,
family, staff interviews and clinical record)
• Activities in which resident appears
especially at ease interacting with others
• Certain situations appeal to resident more
than others, such as small groups or 1:1
interactions rather than large groups
• Certain individuals who seem to bring out
a more positive, optimistic side of the
resident
• Positive traits that distinguished the
resident as an individual prior to their
illness
• What gave the resident a sense of
satisfaction earlier in their life?

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

□

Appendix C: CAA Resources
7. Psychosocial Well-Being

October 2024

Appendix C-31

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
7. Psychosocial Well-Being

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-32

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
8. Mood State

MOOD STATE

Review of Indicators of Mood



□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

□



□
□

October 2024

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

Psychosocial changes
• Personal loss
• Recent move into or within the nursing
home (A1700)
• Recent change in relationships, such as
illness or loss of a relative or friend
• Recent change in health perception, such
as perception of being seriously ill or too
ill to return home (Q0310–Q0610)
• Clinical or functional change that may
affect the resident’s dignity, such as new or
worsening incontinence, communication,
or decline
Clinical issues that can cause or contribute to
Supporting Documentation
a mood problem
Blank
• Relapse of an underlying mental health
problem (I5700–I6100)
• Psychiatric disorder (anxiety, depression,
manic depression, schizophrenia, posttraumatic stress disorder) (I5700–I6100)
• Alzheimer’s disease (I4200)
• Delirium (C1310)
• Delusions (E0100B)
• Hallucinations (E0100A)
• Communication problems (B0700, B0800)
• Decline in Functional Abilities (GG0130,
GG0170)
• Infection (I1700–I2500, I8000, M1040A)
• Pain (J0300 or J0800)
• Cardiac disease (I0200–I0900)
• Thyroid abnormality (I3400)
• Dehydration (J1550C)
• Metabolic disorder (I2900–I3400)
• Neurological disease (I4200–I5500)
• Recent cerebrovascular accident (I4500)
• Dementia, cognitive decline (I4800)
• Cancer (I0100)
• Other (I8000)

Appendix C-33

CMS’s RAI Version 3.0 Manual



Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank



October 2024

Blank

Supporting Documentation

□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

Appendix C: CAA Resources
8. Mood State

Appendix C-34

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
8. Mood State

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-35

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
9. Behavioral Symptoms

BEHAVIORAL SYMPTOMS

Review of Indicators of Behavioral Symptoms



□
□

□
□
□


□

October 2024

□

Seriousness of the behavioral symptoms
• Resident is immediate threat to self –
IMMEDIATE INTERVENTION
REQUIRED (D0150I1, D0500I1)
• Resident is immediate threat to others –
IMMEDIATE INTERVENTION
REQUIRED
• Physical behavioral symptoms directed
toward others (e.g., hitting, kicking,
pushing, scratching, grabbing, abusing
others sexually) (E0200A)
• Verbal behaviors directed toward others
(e.g., threatening, screaming at, or cursing
at others) (E0200B)
• Other behavior symptoms not directed
toward others (e.g., hitting or scratching
self, pacing, rummaging, public sexual
acts, disrobing in public, throwing or
smearing food or bodily waste, or
verbal/vocal symptoms like screaming,
disruptive sounds) (E0200C)
• Behavior significantly interferes with the
resident’s care (E0500B)
• Behavior significantly interferes with the
resident’s participation in activities or
social interaction (E0500C)
• Behavior significantly intrudes on the
privacy or activity of others (E0600B,
E1000B)
• Behavior significantly disrupts care or
living environment (E0600C)
• Resident rejects care that is necessary to
achieve their goals for health and wellbeing (E0800)
• Resident’s behavior status, care rejection,
or wandering has worsened since last
assessment (E1100)
Nature of the behavioral disturbance
(resident interview, if possible)
• Provoked or unprovoked

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Supporting Documentation
Blank

Appendix C-36

CMS’s RAI Version 3.0 Manual



□
□
□
□
□
□
□

Appendix C: CAA Resources
9. Behavioral Symptoms

Seriousness of the behavioral symptoms
• Offensive or defensive
• Purposeful
• Occurs during specific activities, such as
bath or transfers
• Pattern, such as certain times of the day, or
varies over time
• Others in the vicinity are involved
• Reaction to a particular action, such as
being physically moved
• Resident appears to startle easily

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)

D
October 2024

Appendix C-37

CMS’s RAI Version 3.0 Manual



□
□
□
□
□

Appendix C: CAA Resources
9. Behavioral Symptoms

□
□
□



□

October 2024

Supporting Documentation

Blank

□
□
□
□
□
□
□
□
□
□
□

Medication side effects that can cause
behavioral symptoms
• New medication
• Change in dosage
• Antiparkinsonian medications - may cause
hypersexuality, socially inappropriate
behavior
• Sedatives, centrally active
antihypertensives, some cardiac
medications, anticholinergic agents can
cause paranoid delusions, delirium
• Bronchodilators or other respiratory
medications, which can increase agitation
and cause difficulty sleeping
• Caffeine
• Nicotine
• Medications that impair impulse control,
such as benzodiazepines, sedatives, alcohol
(or any product containing alcohol, such as
some cough medicine)
Illness or conditions that can cause behavior
problems
• Long-standing mental health problem
associated with the behavioral
disturbances, such as schizophrenia,
bipolar disorder, depression, anxiety
disorder, post-traumatic stress disorder
(I5700–I6100)
• New or acute physical health problem or
flare-up of a known chronic condition
(I8000)
• Delusions (E0100B)
• Hallucinations (E0100A)
• Paranoia
• Constipation (H0600)
• Congestive heart failure (I0600)
• Infection (I1700–I2500)
• Head injury (I5500)
• Diabetes (I2900)
• Pain (J0300, J0800)
• Fever (J1550A)
• Dehydration (J1550C, see Dehydration
CAA)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-38

CMS’s RAI Version 3.0 Manual



□
□
□
□
□

Appendix C: CAA Resources
9. Behavioral Symptoms

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

October 2024

Supporting Documentation



Factors that can cause or exacerbate the
behavior
• Frustration due to problem communicating
discomfort or unmet need
• Frustration, agitation due to need to urinate
or have bowel movement
• Fear due to not recognizing caregiver
• Fear due to not recognizing the
environment or misinterpreting the
environment or actions of others
• Major unresolved sources of interpersonal
conflict between the resident and family
members, other residents, or staff (see
Psychosocial Well-Being CAA)
• Recent change, such as new admission
(A1700) or a new unit, assignment of new
care staff, or withdrawal from a treatment
program
• Departure from normal routines
• Sleep disturbance (D0150C, D0500C)
• Noisy, crowded area
• Dimly lit area
• Sensory impairment, such as hearing or
vision problem (B0200, B1000)
• Restraints (P0100)
• Alarm Use (P0200)
• Fatigue (D0150D, D0500D)
• Need for repositioning (M1200C)
Cognitive status problems (also see
Cognitive Loss CAA)
• Delirium (C1310) (see Delirium CAA)
• Dementia (I4800)
• Recent cognitive loss
• Alzheimer’s disease (I4200)
• Effects of cerebrovascular accident (I4500)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Blank

Appendix C-39

CMS’s RAI Version 3.0 Manual



□
□

□

Appendix C: CAA Resources
9. Behavioral Symptoms

Other Considerations
• May be communicating discomfort, fears,
personal needs, preferences, feeling ill
• Persons exhibiting long-standing problem
behaviors related to psychiatric conditions
may place others in danger of physical
assault, intimidation, or embarrassment
and place themselves at increased risk of
being stigmatized, isolated, abused, and
neglected by loved ones or care givers
• The actions and responses of family
members and caregivers can aggravate or
even cause behavioral outbursts

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

October 2024

Appendix C-40

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
9. Behavioral Symptoms

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-41

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
10. Activities

10.

ACTIVITIES

Review of Indicators of Activities



Activity preferences prior to admission
• Passive
• Active
• Outside the home
• Inside the home
• Centered almost entirely on family
activities
• Centered almost entirely on non-family
activities
• Group activities (F0500E, F0800P)
• Solitary activities
• Involved in community service, volunteer
activities
• Athletic
• Non-athletic
Current activity pursuits
• Resident identifies leisure activities of
interest
• Self-directed or done with others and/or
planned by others
• Activities resident pursues when visitors
are present
• Scheduled programs in which resident
participates
• Activities of interest not currently
available or offered to the resident



October 2024

Blank

Supporting Documentation

□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-42

CMS’s RAI Version 3.0 Manual



□
□
□
□

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, O0400) that limit available
time/energy
• Performs tasks slowly due to reduced
energy reserves
Environmental or staffing issues that hinder
participation
• Physical barriers that prevent the resident
from gaining access to the space where the
activity is held
• Need for additional staff responsible for
social activities
• Lack of staff time to involve residents in
current activity programs
• Resident’s fragile nature results in feelings
of intimidation by staff responsible for the
activity

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

□
□
□
□


□

October 2024

Supporting Documentation

Blank

□
□
□

□

Appendix C: CAA Resources
10. Activities

Appendix C-43

CMS’s RAI Version 3.0 Manual



□
□
□


□

Unique skills or knowledge the resident has
that they could pass on to others
• Games
• Complex tasks such as knitting, or
computer skills
• Topic that might interest others
Issues that result in reduced activity
participation
• Resident is new to facility or has been in
facility long enough to become bored with
status quo
• Psychosocial well-being issues, such as
shyness, initiative, and social involvement
• Socially inappropriate behavior (E0200)
• Indicators of psychosis (E0100A–B)
• Feelings of being unwelcome, due to
issues such as those already involved in an
activity drawing boundaries that are
difficult to cross
• Limited opportunities for resident to get to
know others through activities such as
shared dining, afternoon refreshments,
monthly birthday parties, reminiscence
groups
• Available activities do not correspond to
resident’s values, attitudes, expectations
(F0500, F0800)
• Long history of unease in joining with
others

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Supporting Documentation
Blank

□
□
□

□
□
□
□

Appendix C: CAA Resources
10. Activities

October 2024

Appendix C-44

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
10. Activities

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-45

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
11. Fall(s)

11.

FALL(S)

Review of Indicators of Fall Risk
Use information from observations, interviews, the clinical record and the MDS to identify
indicators that pertain to the resident.



History of falling (J1700, J1800, J1900)

• Time of day, exact hour of the fall(s)
• Location of the fall(s), such as bedroom,

bathroom, hallway, stairs, outside, etc.
Related to specific medication
Proximity to most recent meal
Responding to bowel or bladder urgency
Doing usual/unusual activity
Standing still or walking
Reaching up or reaching down
Identify the conclusions about the root
cause(s), contributing factors related to
previous falls
Physical performance limitations: balance,
gait, strength, muscle endurance
• Difficulty maintaining sitting balance
• Need to rock body or push off on arms of
chair when standing up from chair
• Difficulty maintaining standing position
• Impaired balance during transitions
• Gait problem, such as unsteady gait, even
with mobility aid or personal assistance,
slow gait, takes small steps, takes rapid
steps, or lurching gait
• One leg appears shorter than the other
• Musculoskeletal problem, such as
kyphosis, weak hip flexors from extended
bed rest, or shortening of a leg

•
•
•
•
•
•
•



□
□
□
□
□

October 2024

Supporting Documentation

Blank

□
□

□
□
□
□
□
□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-46

CMS’s RAI Version 3.0 Manual



□
□
□
□
□
□
□
□
□

Medications
• Antipsychotics (N0415A)
• Antianxiety agents (N0415B)
• Antidepressants (N0415C)
• Hypnotics (N0415D)
• Cardiovascular medications
• Diuretics (N0415G)
• Opioids (N0415H)
• Neuroleptics
• Other medications that cause lethargy or
confusion
Internal risk factors
• Circulatory/Heart
 Anemia (I0200)
 Cardiac Dysrhythmias (I0300)
 Angina, Myocardial Infarction (MI),
Atherosclerotic Heart Disease (ASHD)
(I0400)
 Congestive Heart Failure (CHF)
pulmonary edema (I0600)
 Cerebrovascular Accident (CVA)
(I4500)
 Transient Ischemic Attack (TIA)
(I4500)
 Postural/Orthostatic hypotension
(I0800)



Appendix C: CAA Resources
11. Fall(s)

□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Blank

Supporting Documentation

(continued)

October 2024

Appendix C-47

CMS’s RAI Version 3.0 Manual



□

Appendix C: CAA Resources
11. Fall(s)

□

October 2024

□

Internal risk factors (continued)
• Neuromuscular/functional
 Cerebral palsy (I4400)
 Loss of arm or leg movement (GG0115)
 Decline in functional status (GG0130,
GG0170)
 Incontinence (H0300, H0400)
 Hemiplegia/Hemiparesis (I4900)
 Parkinson’s disease (I5300)
 Seizure disorder (I5400)
 Paraplegia (I5000)
 Multiple sclerosis (I5200)
 Traumatic brain injury (I5500)
 Syncope
 Chronic or acute condition resulting in
instability
 Peripheral neuropathy
 Muscle weakness
• Orthopedic
 Joint pain
 Arthritis (I3700)
 Osteoporosis (I3800)
 Hip fracture (I3900)
 Missing limb(s) (GG0120D)
• Perceptual
 Visual impairment (B1000)
 Hearing impairment (B0200)
 Dizziness/vertigo
• Psychiatric or cognitive
 Impulsivity or poor safety awareness
 Delirium (C1310)
 Wandering (E0900)
 Agitation behavior (E0200) – describe
the specific verbal or motor activity- e.g.
screaming, babbling, cursing, repetitive
questions, pacing, kicking, scratching,
etc.
 Cognitive impairment (C0500, C0700–
C1000)
 Alzheimer’s disease (I4200)
 Other dementia (I4800)
 Anxiety disorder (I5700)
 Depression (I5800)
 Manic depression (I5900)
 Schizophrenia (I6000)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-48

CMS’s RAI Version 3.0 Manual



□
□
□
□
□
□


Internal risk factors (continued)
Infection (I1700–I2500)
Low levels of physical activity
Pain (J0300, J0800)
Headache
Fatigue, weakness
Vitamin D deficiency
Laboratory tests
• Hypo- or hyperglycemia
• Electrolyte imbalance
• Dehydration (J1550C)
• Hemoglobin and hematocrit
Environmental factors
(from review of facility environment)
• Poor lighting
• Glare
• Patterned carpet
• Poorly arranged furniture
• Uneven surfaces
• Slippery floors
• Obstructed walkway
• Poor fitting or slippery shoes
• Proximity to aggressive resident

•
•
•
•
•
•



□
□
□
□
□
□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Blank

Supporting Documentation

Supporting Documentation
Blank

□
□
□
□

Appendix C: CAA Resources
11. Fall(s)

October 2024

Appendix C-49

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
11. Fall(s)

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-50

CMS’s RAI Version 3.0 Manual

12.

Appendix C: CAA Resources
12. Nutritional Status

NUTRITIONAL STATUS

Review of Indicators of Nutritional Status



□

□
□
□

Current eating pattern – resident leaves
significant proportion of meals, snacks, and
supplements daily for even a few days
• Food offered or available is not consistent
with the resident’s food choices/needs
 Food preferences not consistently
honored
 Resident has allergies or food
intolerance (for example, needs
lactose-free)
 Food not congruent with religious or
cultural needs
 Resident complains about food quality
(for example, not like what spouse
used to prepare, food lacks flavor)
 Resident doesn’t eat processed foods
 Food doesn’t meet other special diet
requirements
• Pattern re: food left uneaten (for example,
usually leaves the meat or vegetables)
• Intervals between meals may be too long or
too short
• Unwilling to accept food supplements or to
eat more than three meals per day

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

October 2024

Appendix C-51

CMS’s RAI Version 3.0 Manual



Functional problems that affect ability to eat
• Swallowing problem (K0100)
• Arthritis (I3700)
• Contractures (GG0115)
• Functional limitation in range of motion
(GG0115)
• Partial or total loss of arm movement
(GG0115)
• Hemiplegia/hemiparesis (I4900, GG0115)
• Quadriplegia/paraplegia (I5100, I5000)
(GG0115)
• Inability to perform self-care or mobility
without significant physical assistance
(GG0130, GG0170)
• Inability to sit up
• Missing limb(s) (GG0120D)
• Vision problems (B1000)
• Decreased ability to smell or taste food
• Need for special diet or altered consistency
which might not appeal to resident
(K0520C, K0520D)
• Recent decline in functional abilities
(GG0130, GG0170)
Cognitive, mental status, and behavior
problems that can interfere with eating
• Review Cognitive Loss CAA
• Alzheimer’s Disease (I4200)
• Other dementia (I4800)
• Intellectual disability/developmental
disability (A1550)
• Paranoid fear that food is poisoned
• Requires frequent/constant cueing
• Disruptive behaviors (E0200)
• Indicators of psychosis (E0100)
• Wandering (E0900)
• Pacing (E0200)
• Throwing food (E0200)
• Resisting care (E0800)
• Very slow eating
• Short attention span
• Poor memory (C0500, C0700–C0900)
• Anxiety problems (I5700)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

□
□
□
□
□
□


October 2024

Supporting Documentation

Blank

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□

Appendix C: CAA Resources
12. Nutritional Status

Appendix C-52

CMS’s RAI Version 3.0 Manual



□
□
□
□
□


Communication problems
• Review Communication CAA
• Comatose (B0100)
• Difficulty making self-understood (B0700)
• Difficulty understanding others (B0800)
• Aphasia (I4300)
Dental/oral problems
• See Dental Care CAA
• Broken or fractured teeth (L0200D)
• Toothache (L0200F)
• Bleeding gums (L0200E)
• Loose dentures, dentures causing sores
(L0200A)
• Lip or mouth lesions (for example, cold
sores, fever blisters, oral abscess)
(L0200C)
• Mouth pain (L0200F)
• Dry mouth
Other diseases and conditions that can
affect appetite or nutritional needs
• Anemia (I0200)
• Arthritis (I3700)
• Burns (M1040F)
• Cancer (I0100)
• Cardiovascular disease (I0300–I0900)
• Cerebrovascular accident (I4500)
• Constipation (H0600)
• Delirium (C1310)
• Depression (I5800)
• Diabetes (I2900)
• Diarrhea
• Gastrointestinal problem (I1100–I1300)
• Hospice care (O0110K1)
• Liver disease (I8000)
• Pain (J0300, J0800)
• Parkinson’s disease (I5300)
• Pressure ulcers/injuries (M0210, M0300)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Blank

Supporting Documentation

□
□


October 2024

Supporting Documentation

Blank

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

□
□
□
□
□
□

Appendix C: CAA Resources
12. Nutritional Status

(continued)

Appendix C-53

CMS’s RAI Version 3.0 Manual



□
□
□
□
□
□
□
□


Other diseases and conditions that can
affect appetite or nutritional needs
(continued)
• Radiation therapy (O0110B1)
• Recent acute illness (I8000)
• Recent surgical procedure (I8000, J2000,
M1200F)
• Renal disease (I1500)
• Respiratory disease (I6200)
• Thyroid problem (I3400)
• Weight loss (K0300)
• Weight gain (K0310)
Abnormal laboratory values
• Electrolytes
• Pre-albumin level
• Plasma transferrin level
• Others
Medications
• Antipsychotics (N0415A)
• Chemotherapy (O0110A1)
• Cardiac medications
• Diuretics (N0415G)
• Anti-inflammatory medications
• Anti-Parkinson’s medications
• Laxatives
• Antacids
• Start of a new medication
Environmental factors
• Sufficient eating assistance
• Availability of adaptive equipment
• Dining environment fosters pleasant social
experience
• Appropriate lighting
• Sufficient personal space during meals
• Proper positioning in wheelchair/chair for
dining



□
□
□
□
□
□
□
□
□


October 2024

Blank

Supporting Documentation

Blank

Supporting Documentation

□
□
□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

□
□
□
□

Appendix C: CAA Resources
12. Nutritional Status

Appendix C-54

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
12. Nutritional Status

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-55

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
13. Feeding Tube(s)

13.

FEEDING TUBE(S)

Review of Indicators of Feeding Tubes



□

□


□

October 2024

Blank

Supporting Documentation

□
□
□
□
□
□
□
□
□
□

□

Reason for tube feeding
• Unable to swallow or to eat food and
unlikely to eat within a few days due to
 Physical problems in chewing or
swallowing (for example, stroke or
Parkinson’s disease) (L0200F, K0100)
 Mental problems (I5700–I6100) (for
example, Alzheimer’s (I4200), Other
Dementia (I4800), depression (I5800))
• Normal caloric intake is substantially
impaired due to endotracheal tube or a
tracheostomy (O0110E1, O0110F1)
• Prevention of meal-induced hypoxemia
(insufficient oxygen to blood), in resident
with COPD (I6200) or other pulmonary
problems that interfere with eating
Complications of tube feeding
• Diagnostic conditions
 Delirium (C1310)
 Repetitive physical movements
 Anxiety (I5700)
 Depression (I5800)
 Lung aspiration, pneumonia (I2000)
 Infection at insertion site (I2500)
 Shortness of breath (J1100)
• Bleeding around insertion site
• Constipation (H0600)
• Abdominal distension or abdominal pain
• Diarrhea or cramping
• Nausea, vomiting (J1550B)
• Tube dislodgement, blockage, leakage
• Bowel perforation
• Dehydration (J1550C) or fluid overload
• Self-extubation
• Use of physical restraints (P0100)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-56

CMS’s RAI Version 3.0 Manual



□
□
□


Psychosocial issues related to tube feeding
• Signs of depression (D0150, D0160,
D0500, D0600, I5800, Mood State CAA)
• Ways to socially engage the resident with a
feeding tube
• Emotional and social support from social
workers, other members of the healthcare
team
Periodic evaluations and consultations
• Weight check at least monthly (K0300,
K0310)
• Lab tests to monitor electrolytes, serum
albumin, hematocrit
• Periodic evaluations by nutritionist or
dietitian
• Periodic evaluation of possibility of
resuming oral feeding
• Regular changing and replacement of PEG
tubes and J-tubes, per physician order and
facility protocol (K0520B)
Factors that may impede removal of
feeding tube
• Comatose (B0100)
• Failure to eat and resists assistance in
eating (E0800)
• Cerebrovascular accident (I4500)
• Gastric ulcers, gastric bleeding, or other
stomach disorder (I1200, I1300)
• Chewing problems unresolvable (L0200F)
• Swallowing problems (K0100)
• Mouth pain (L0200F)
• Anorexia (I8000)
• Lab values indicating compromised
nutritional status
• Significant weight loss (K0300)
• Significant weight gain (K0310)
• Prolonged illness
• Neurological disorder (I4200–I5500)
• Cancer or side effects of cancer treatment
(I0100, O0110A1, O0110B1)
• Advanced dementia (I4800)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Blank

Supporting Documentation



October 2024

Supporting Documentation

Blank

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

□
□
□
□
□

Appendix C: CAA Resources
13. Feeding Tube(s)

Appendix C-57

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
13. Feeding Tube(s)

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-58

CMS’s RAI Version 3.0 Manual

14.

Appendix C: CAA Resources
14. Dehydration/Fluid Maintenance

DEHYDRATION/FLUID MAINTENANCE

Review of Indicators of Dehydration/Fluid Maintenance



Symptoms of dehydration
• Dizziness on sitting or standing
• Confusion or change in mental status
(delirium) (C1310, V0100D)
• Lethargy (C1310D)
• Recent decrease in urine volume or more
concentrated urine than usual
• Decreased skin turgor, dry mucous
membranes (J1550)
• Newly present constipation (H0600), fecal
impaction
• Fever (J1550A)
• Functional decline (GG0130, GG0170)
• Increased risk for falls (J1700–J1900)
• Fluid and electrolyte disturbance
Abnormal laboratory values
• Hemoglobin
• Hematocrit
• Potassium chloride
• Sodium
• Albumin
• Blood urea nitrogen
• Urine specific gravity



□
□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Blank

Supporting Documentation

ft
October 2024

Appendix C-59

CMS’s RAI Version 3.0 Manual



□
□
□
□

Cognitive, communication, and mental
status issues that can interfere with intake
• Depression (I5800, D0160, D0600) or
anxiety (I5700)
• Behavioral disturbance that interferes with
intake (E0200)
• Recent change in mental status (C1310)
• Alzheimer’s or other dementia that
interferes with eating due to short attention
span, resisting assistance, slow
eating/drinking, etc. (I4200, I4800)
• Difficulty making self-understood (B0700)
• Difficulty understanding others (B0800)
Diseases and conditions that predispose to
limitations in maintaining normal fluid
balance
• Infection (I1700–I2500, M1040A)
• Fever (J1550A)
• Diabetes (I2900)
• Congestive heart failure (I0600)
• Swallow problem (K0100)
• Malnutrition (I5600)
• Renal disease (I1500)
• Weight loss (K0300)
• Weight gain (K0310)
• New cerebrovascular accident (I4500)
• Unstable acute or chronic condition
• Nausea or vomiting (J1550B)
• Diarrhea
• Excessive sweating
• Recent surgery (J2000, J2100, I8000)
• Recent decline in functional abilities,
including body control or hand control
problems (GG0115A), inability to sit up,
etc. (GG0130, GG0170)
• Parkinson’s or other neurological disease
that requires unusually long time to eat
(I4200–I5500)
• Abdominal pain, with or without diarrhea,
nausea, or vomiting (clinical record,
(J1550B)



□
□

October 2024

Supporting Documentation
Blank

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

□
□

Appendix C: CAA Resources
14. Dehydration/Fluid Maintenance

(continued)

Appendix C-60

CMS’s RAI Version 3.0 Manual



□
□
□


Diseases and conditions that predispose to
limitations in maintaining normal fluid
balance (continued)
• Newly taking a diuretic or recent increase
in diuretic dose (N0415G)
• Takes excessive doses of a laxative
• Hot weather (increases risk for elderly in
absence of increased fluid intake)
Oral intake
• Recent change in oral intake
• Skips meals or consumes less than 25
percent of meals
• Fluid restriction
• Newly prescribed diet
• Decreased perception of thirst
• Limited fluid-drinking opportunities
• Fluid intake limited to try to control
incontinence
• Dependence on staff for fluid intake
• Excessive output compared to fluid intake

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Blank

Supporting Documentation

□
□
□
□
□
□
□
□
□

Appendix C: CAA Resources
14. Dehydration/Fluid Maintenance

October 2024

Appendix C-61

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
14. Dehydration/Fluid Maintenance

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-62

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
15. Dental Care

15.

DENTAL CARE

Review of Indicators of Oral/Dental Condition/Problem



□
□
□



□
□
□
□
□
□
□


□

October 2024

Blank

Supporting Documentation

□
□

Supporting Documentation

□

Cognitive problems that contribute to
oral/dental problems
• Needs reminders to clean teeth
• Cannot remember steps to complete oral
hygiene (GG0130B)
• Decreased ability to understand others
(B0800) or to perform tasks following
demonstration
• Cognitive deficit (C0500, C0700–C1000)
Functional impairment limiting ability to
perform personal hygiene
• Loss of voluntary arm movement
(GG0115A)
• Impaired hand dexterity (GG0115A)
• Functional limitation in upper extremity
range of motion (GG0115A)
• Decreased mobility (GG0170)
• Resists assistance with activities of daily
living (E0800)
• Lacks motivation or knowledge regarding
adequate oral hygiene, dental care
(GG0130B)
• Requires adaptive equipment for oral
hygiene
Dry mouth causing buildup of oral bacteria
• Dehydration (see Dehydration/Fluid
Maintenance CAA)
• Medications
 Antipsychotics (N0415A)
 Antidepressants (N0415C)
 Antianxiety agents (N0415B)
 Sedatives/hypnotics (N0415D)
 Diuretics (N0415G)
 Antihypertensives
 Antiparkinsonian medications
 Opioids (N0415H)
 Anticonvulsants (N0415K)
 Antihistamines
 Decongestants
 Antiemetics
• Antineoplastics

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-63

CMS’s RAI Version 3.0 Manual



□
□
□
□
□

Appendix C: CAA Resources
15. Dental Care

Diseases and conditions that may be related
to poor oral hygiene, oral infection
• Recurrent pneumonia related to aspiration
of saliva contaminated due to poor oral
hygiene (I2000)
• Unstable diabetes related to oral infection
(I2900)
• Endocarditis related to oral infection
(I8000)
• Sores in mouth related to poor-fitting
dentures (L0200C)
• Poor nutrition (I5600) (see Nutrition CAA)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

D
October 2024

Appendix C-64

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
15. Dental Care

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-65

CMS’s RAI Version 3.0 Manual

16.

Appendix C: CAA Resources
16. Pressure Ulcer/Injury

PRESSURE ULCER/INJURY

Review of Indicators of Pressure Ulcer/Injury



□



□

Blank

Supporting Documentation

□

Existing pressure ulcer/injury (M0210,
M0300)
• Assess location, size, stage, presence and type
of drainage, presence of odors, condition of
surrounding skin
 Note if eschar or slough is present
(M0300F)
 Assess for signs of infection, such as the
presence of a foul odor, increasing pain,
surrounding skin is reddened (erythema)
or warm, or there is a presence of
purulent drainage
 Note whether granulation tissue (required
for healing) is present and the wound is
healing as expected
• If the ulcer/injury does not show signs of
healing despite treatment, consider
complicating factors
 Elevated bacterial level in the absence of
clinical infection
 Presence of exudate, necrotic debris or
slough in the wound, too much granulation tissue, or odor in the wound bed
 Underlying osteomyelitis (bone infection)
Extrinsic risk factors
• Pressure
 Requires staff assistance to move
sufficiently to relieve pressure over any
one site
 Confined to a bed or chair all or most of
the time
 Needs special mattress or seat cushion to
reduce or relieve pressure (M1200A,
M1200B)
 Requires regular schedule of turning
(M1200C)
• Friction and shear
 Slides down in the bed
 Moved by sliding rather than lifting
• Maceration
 Persistently wet, especially from fecal
incontinence, wound drainage, or
perspiration
 Moisture associated skin damage
(M1040H)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

(continued)
October 2024

Appendix C-66

CMS’s RAI Version 3.0 Manual



□
□
□
□


Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank

Intrinsic risk factors
• Immobility (GG0170)
• Altered mental status
 Delirium limits mobility (see Delirium
CAA)
 Cognitive loss (C0500, C0700–C1000)
limits mobility (see Cognitive Loss CAA)
• Incontinence (H0300, H0400, M1040H) (see
Incontinence CAA)
• Poor nutrition (I5600) (see Nutrition CAA)
Medications that increase risk for pressure
Supporting Documentation
ulcer/injury development
Blank
• Antipsychotics (N0415A)
• Antianxiety agents (N0415B)
• Antidepressants (N0415C)
• Hypnotics (N0415D)
• Steroids
• Opioids (N0415H)
Diagnoses and conditions that present
complications or increase risk for pressure
Supporting Documentation
ulcer/injury
Blank
• Delirium (C1310)
• Comatose (B0100)
• Cancer (I0100)
• Peripheral Vascular Disease (I0900)
• Diabetes (I2900)
• Alzheimer’s disease (I4200)
• Cerebrovascular Accident (I4500)
• Other dementia (I4800)
• Hemiplegia/hemiparesis (I4900)
• Paraplegia (I5000), Quadriplegia (I5100)
• Multiple sclerosis (I5200)
• Depression (D0160, D0600, I5800)
• Edema
• Severe pulmonary disease (I6200)
• Sepsis (I2100)
• Terminal illness (J1400, O0110K1)



October 2024

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

□
□
□
□
□
□

Appendix C: CAA Resources
16. Pressure Ulcer/Injury

Appendix C-67

CMS’s RAI Version 3.0 Manual



□

Diagnoses and conditions that present
complications or increase risk for pressure
ulcer/injury (continued)
• Chronic or end-stage renal, liver, or heart
disease (I1500, I1100, I2400, I0400,
I0600)
• Pain (J0300, J0800)
• Dehydration (J1550C, I8000)
• Shortness of breath (J1100)
• Recent weight loss (K0300)
• Recent weight gain (K0310)
• Malnutrition (I5600)
• Decreased sensory perception
• Recent decline in Functional Abilities
(GG0130, GG0170)
Treatments and other factors that cause
complications or increase risk
• Newly admitted or readmitted (A1700)
• History of healed pressure ulcer/injury
• Chemotherapy (O0110A1)
• Radiation therapy (O0110B1)
• Ventilator or respirator (O0110F1)
• Renal dialysis (O0110J1)
• Functional limitation in range of motion
(GG0115)
• Head of bed elevated most or all of the
time
• Physical restraints (P0100)
• Devices that can cause pressure, such as
oxygen (O0110C1) or indwelling catheter
(H0100A) tubing, TED hose, casts, or
splints



□
□
□
□
□
□
□
□
□
□

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Supporting Documentation
Blank

□
□
□
□
□
□
□
□

Appendix C: CAA Resources
16. Pressure Ulcer/Injury

October 2024

Appendix C-68

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
16. Pressure Ulcer/Injury

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-69

CMS’s RAI Version 3.0 Manual

17.

Appendix C: CAA Resources
17. Psychotropic Medication Use

PSYCHOTROPIC MEDICATION USE

Review of Indicators of Psychotropic Drug Use



□
□
□
□


Blank

Supporting Documentation



□
□
□

□
□
□
□
□

Class(es) of medication this resident is taking
• Antipsychotic (N0415A, N0450A)
• Antianxiety (N0415B)
• Antidepressant (N0415C)
• Sedative/Hypnotic (N0415D)
Unnecessary medication evaluation
• Excessive dose, including duplicate
medications
• Excessive duration and/or without gradual
dose reductions (N0450B, N0450C)
• Inadequate monitoring for effectiveness
and/or adverse consequences
• Inadequate or inappropriate indications for
use
• In presence of adverse consequences
related to the medication
Treatable/reversible reasons for use of
psychotropic medication
• Environmental stressors such as excessive
heat, noise, overcrowding, etc.
• Psychosocial stressors such as abuse,
taunting, not following resident’s
customary routine, etc. (F0300–F0800)
• Treatable medical conditions, such as heart
disease (I0200–I0900), diabetes (I2900), or
respiratory disease (I6200, I6300)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Supporting Documentation

Blank

October 2024

Appendix C-70

CMS’s RAI Version 3.0 Manual



□

Adverse consequences of
ANTIDEPRESSANTS exhibited by this
resident
• Worsening of depression and/or suicidal
behavior or thinking (D0150I, D0500I,
V0100E, V0100F)
• Delirium unrelated to medical illness or
severe depression (C1310)
• Hallucinations (E0100A)
• Dizziness
• Nausea
• Diarrhea
• Anxiety (I5700)
• Nervousness, fidgety or restless (D0150H,
D0500H)
• Insomnia
• Somnolence
• Weight gain (K0310)
• Anorexia or increased appetite
• Increased risk for falls (J1700–J1900)
• Seizures (I5400)
• Hypertensive crisis if combined with certain
foods, cheese, wine (MAO inhibitors)
• Anticholinergic (tricyclics), such as
constipation, dry mouth, blurred vision,
urinary retention, etc.
• Postural hypotension (tricyclics)
Adverse consequences of
ANTIPSYCHOTICS exhibited by this
resident
• Anticholinergic effects, such as constipation,
dry mouth, blurred vision, urinary retention,
etc.
• Increase in total cholesterol and triglycerides
• Akathisia (inability to sit still)
• Parkinsonism (any combination of tremors,
postural unsteadiness, muscle rigidity, pillrolling of hands, shuffling gait, etc.)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

□


□
□
□

October 2024

Supporting Documentation

Blank

□

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

Appendix C: CAA Resources
17. Psychotropic Medication Use

(continued)

Appendix C-71

CMS’s RAI Version 3.0 Manual



□
□
□
□
□
□
□

Appendix C: CAA Resources
17. Psychotropic Medication Use

□
□
□
□
□


□

October 2024

Supporting Documentation

Blank

□
□
□
□

Adverse consequences of
ANTIPSYCHOTICS exhibited by this
resident
• Neuroleptic malignant syndrome (high
fever with severe muscular rigidity)
• Blood sugar elevation
• Cardiac arrhythmias (I0300)
• Orthostatic hypotension
• Cerebrovascular accident or transient
ischemic attack (I4500)
• Falls (J1700–J1900)
• Tardive dyskinesia (persistent involuntary
movements such as tongue thrusting, lip
movements, chewing or puckering
movements, abnormal limb movements,
rocking or writhing trunk movements)
• Lethargy (C1310D)
• Excessive sedation
• Depression (D0160, D0600, I5800)
• Hallucinations (E0100A)
• Delirium unrelated to medical illness or
severe depression (C1310)
Adverse consequences of ANXIOLYTICS
exhibited by this resident
• Sedation manifested by short-term memory
loss (C0500, C0700), decline in cognitive
abilities, slurred speech (B0600),
drowsiness, little/no activity involvement
• Delirium unrelated to medical illness or
severe depression (C1310)
• Hallucinations (E0100A)
• Depression (D0160, D0600, I5800)
• Disturbances of balance, gait, positioning
ability (GG0170)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-72

CMS’s RAI Version 3.0 Manual



□

Adverse consequences of
SEDATIVES/HYPNOTICS exhibited by this
resident
• May increase the metabolism of many
medications (for example, anticonvulsants,
antipsychotics), which may lead to decreased
effectiveness and subsequent worsening of
symptoms or decreased control of underlying
illness
• Hypotension (I0800)
• Dizziness, lightheadedness
• “Hangover” effect
• Drowsiness
• Confusion, delirium unrelated to acute illness
or severe depression (C1310)
• Mental depression (I5800, I5900)
• Unusual excitement
• Nervousness
• Headache
• Insomnia
• Nightmares
• Hallucinations (E0100A)
• Falls (J1700–J1900)
Medication-related discomfort requiring
treatment and/or prevention
• Dehydration (J1550C)
• Reduced dietary bulk
• Lack of exercise
• Constipation/fecal impaction (H0600
• Urinary retention
• Dry mouth (interview)
Overall status change for relationship to
psychotropic drug use
• Major differences in a.m./p.m. performance
• Decline in cognition/communication
(V0100D)
• Decline in mood (V0100E, V0100F)
• Decline in behavior (E1100)
• Decline in functional abilities (GG0130,
GG0170)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source
(if applicable) of that information)
Blank



□
□
□
□
□

October 2024

Supporting Documentation

Blank

□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□
□
□

Appendix C: CAA Resources
17. Psychotropic Medication Use

Supporting Documentation

Blank

Appendix C-73

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
17. Psychotropic Medication Use

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-74

CMS’s RAI Version 3.0 Manual

18.

Appendix C: CAA Resources
18. Physical Restraints

PHYSICAL RESTRAINTS

Review of Indicators of Physical Restraints



□



□
□
□
□
□
□
□
□

October 2024

Supporting Documentation

Blank

□
□
□
□
□

□
□
□
□
□
□
□
□
□
□

Evaluation of current restraint use
• Does not meet regulatory definition of
restraint (stop here and check accuracy of
MDS item that triggered this CAA)
• Evidence of informed consent not evident
in chart
• Medical symptom not identified for
treatment via restraints
• Used for staff convenience
• Used for discipline purposes
• Multiple restraints in use
• Non-restraint interventions not attempted
prior to restraining
• Less restrictive devices not attempted
• No regular schedule for removing restraints
• No schedule for frequency by hour of the
day for checking on resident’s well-being
• No plan for reducing/eliminating restraints
Medical conditions/treatments that may
lead to restraint use
• Indwelling catheter (H0100A), external
catheter (H0100B), or ostomy (H0100C)
• Parenteral/IV feeding (K0520A)
• Feeding tube (K0520B)
• Pressure ulcer/injury (M0210, M0300) or
pressure ulcer/injury care (M1200E)
• Other skin ulcers, wounds, skin problems
(M1040) or wound care (M1200F–
M1200I)
• Oxygen therapy (O0110C1)
• Tracheostomy (O0110E1, clinical record)
• Ventilator or respirator (O0110F1)
• IV medications (O0110H1)
• Transfusions (O0110I1)
• Functional decline, decreased mobility
(GG0130, GG0170)
• Alarm use (P0200)
• Other medical problem or equipment
associated with restraint use (clinical
record)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-75

CMS’s RAI Version 3.0 Manual



□
□
□
□

Cognitive impairment/behavioral symptoms
that may lead to restraint use (also see
Cognitive Loss and Behavior CAAs)
• Inattention, easily distracted (C1310B)
• Disorganized thinking (C1310C)
• Fidgety, restless
• Agitation behavior (E0200) – describe the
specific verbal or motor activity- e.g.
screaming, babbling, cursing, repetitive
questions, pacing, kicking, scratching, etc.
• Confusion (C0500, C0700–C1000)
• Psychosis (E0100A, E0100B)
• Physical symptoms directed toward others
(E0200A)
• Verbal behavioral symptoms directed
toward others (E0200B)
• Rejection of care (E0800)
• Wandering (E0900)
• Delirium (C1310), including side effects of
medications
• Alzheimer’s disease (I4200) or other
dementia (I4800)
• Traumatic brain injury (I5500)
• Psychiatric disorder (I5700–I6100)
Risk for falls that may lead to restraint use
(also see Falls CAA)
• Poor safety awareness, impulsivity
• Urinary urgency
• Incontinence of bowel and/or bladder
(H0300, H0400)
• Side effect of medication, such as dizziness,
postural/orthostatic hypotension (I0800),
sedation, etc.
• Insomnia, fatigue (D0150C–D, D0500C–D)
• Need for assistance with mobility
(GG0170)
• Balance problem
• Postural/orthostatic hypotension (I0800)
• Hip or other fracture (I3900, I4000)
• Hemiplegia/hemiparesis (I4900), paraplegia
(I5000), quadriplegia (I5100)
• Other neurological disorder (for example,
Cerebral Palsy (I4400), Multiple Sclerosis
(I5200), Parkinson’s Disease (I5300))
• Respiratory problems (J1100, I6200, I6300)
• History of falls (J1700–J1900)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank



□
□
□
□

□

October 2024

Supporting Documentation

Blank

□
□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□

Appendix C: CAA Resources
18. Physical Restraints

Appendix C-76

CMS’s RAI Version 3.0 Manual



□
□
□
□
□

Adverse reaction to restraint use
• Skin breakdown (M0300, M1030, M1040)
• Incontinence or increased incontinence
(H0300, H0400)
• Moisture associated skin damage
(M1040H)
• Constipation (H0600)
• Increased agitation behavior (E0200,
clinical record) – describe the specific
verbal or motor activity- e.g. screaming,
babbling, cursing, repetitive questions,
pacing, kicking, scratching, etc.
• Depression, withdrawal, diminished
dignity, social isolation (I5800, I5900)
• Loss of muscle mass, contractures,
lessened mobility) and stamina (GG0170,
GG0115)
• Infections, such as UTI or pneumonia
(I1700–I2500)
• Frequent attempts to get out of the
restraints (P0100), falls (J1700–J1900)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

□
□

Appendix C: CAA Resources
18. Physical Restraints

October 2024

Appendix C-77

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
18. Physical Restraints

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-78

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources
19. Pain

19.

PAIN

Review of Indicators of Pain



□
□

□
□
□

□

October 2024

□
□
□

□

Diseases and conditions that may cause pain
(diagnosis OR signs/symptoms present)
• Cancer (I0100)
• Circulatory/heart
 Angina, Myocardial Infarction (MI),
Atherosclerotic Heart Disease (ASHD)
(I0400)
 Deep Vein Thrombosis (I0500)
 Peripheral Vascular Disease (I0900)
• Skin/Wound
 Pressure ulcer/injury (M0210, M0300)
 Venous or arterial ulcers (M1030)
 Other ulcers, wounds, and skin
problems (M1040A–H)
• Infections
 Urinary tract infection (I2300)
 Pneumonia (I2000)
• Neurological (I4200–I5500)
 Head trauma (clinical record)
 Headache
 Neuropathy
 Post-stroke syndrome
• Gastrointestinal
 Gastroesophageal Reflux Disease/Ulcer
(I1200)
 Ulcerative Colitis/Crohn’s
Disease/Inflammatory Bowel Disease
(I1300)
 Constipation (H0600, clinical record,
resident interview)
• Hospice care (O0110K1)
• Terminal condition (J1400)
• Musculoskeletal
 Arthritis (I3700)
 Osteoporosis (I3800)
 Hip fracture (I3900)
 Other fracture (I4000)
 Back problems (I8000)
 Amputation (GG0120D, O0500I)
 Other (I8000)
• Dental problems (L0200)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-79

CMS’s RAI Version 3.0 Manual



□
□
□
□
□

Appendix C: CAA Resources
19. Pain



□
□
□


□
□
□
□


October 2024

Blank

Supporting Documentation

Blank

Supporting Documentation

□
□
□
□
□
□

Supporting Documentation

Characteristics of the pain
• Location
• Type (constant, intermittent, varies over
time, etc.)
• What makes it better
• What makes it worse
• Words that describe it (for example,
aching, soreness, dull, throbbing, crushing)
 Burning, pins and needles, shooting,
numbness (neuropathic)
 Cramping, crushing, throbbing,
stabbing (musculoskeletal)
 Cramping, tightness (visceral)
Frequency and intensity of the pain
(J0410–J0600, J0850)
• How often it occurs
• Time or situation of onset
• How long it lasts
Non-verbal indicators of pain (particularly
important if resident is stoic)
• Facial expression (frowning, grimacing,
etc.) (J0800C)
• Vocal behaviors (sighing, moaning,
groaning, crying, etc.) (J0800A, J0800B)
• Body position (guarding, distorted posture,
restricted limb movement, etc.) (J0800D)
• Restlessness
Pain effect on function
• Disturbs sleep (J0510)
• Decreases appetite
• Adversely affects mood (D0150, D0500)
• Limits participation in rehabilitation
therapy (J0520)
• Limits day-to-day activities (J0530) (social
events, eating in dining room, etc.)
• Limits independence with at least some
functional abilities (GG0130, GG0170)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Appendix C-80

CMS’s RAI Version 3.0 Manual



□
□
□


Associated signs and symptoms
• Agitation or new or increased behavior
problems (E0200) – describe the specific
verbal or motor activity- e.g. screaming,
babbling, cursing, repetitive questions,
pacing, kicking, scratching, etc.
• Delirium (C1310)
• Withdrawal
Other Considerations
• Improper positioning
• Contractures (GG0115)
• Immobility (GG0170)
• Use of restraints (P0100)
• Recent change in pain (characteristics,
frequency, intensity, etc.) (J0410–J0850)
• Insufficient pain relief (J0300–J0850)
• Pain relief occurs, but duration is not
sufficient, resulting in breakthrough pain
(J0300–J0850)

Supporting Documentation
(Basis/reason for checking the item,
including the location, date, and source (if
applicable) of that information)
Blank

Blank

Supporting Documentation

□
□
□
□
□
□
□

Appendix C: CAA Resources
19. Pain

October 2024

Appendix C-81

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
19. Pain

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-82

CMS’s RAI Version 3.0 Manual

20.

Appendix C: CAA Resources
20. Return to Community Referral

RETURN TO COMMUNITY REFERRAL

Review of Return to Community Referral


□
□
□

□
□

□

October 2024

□

Steps in the Process
1. Document in the care plan whether the individual indicated a desire to talk to someone
about the possibility of returning to the community or not (Q0500B).
2. Discuss with the individual and their family to identify potential barriers to transition
planning. The care planning/discharge planning team should have additional discussions
with the individual and family to develop information that will support the individual’s
smooth transition to community living. (Q0110)
3. Other factors to consider regarding the individual’s discharge assessment and planning for
community supports include:
• Cognitive skills for decision making (C1000) and Cognitive deficits (C0500, C0700–
C1000)
• Functional/mobility (GG0130, GG0170) or balance problems
• Need for assistive devices and/or home modifications if considering a discharge home
4. Inform the discharge planning team and other facility staff of the individual’s choice.
5. Look at the previous care plans of this individual to identify their previous responses and
the issues or barriers they expressed. Consider the individual’s overall goals of care and
discharge planning from previous items responses (Q0310 and Q0400A). Has the
individual indicated that their goal is for end-of-life-care (palliative or hospice care)? Or
does the individual expect to return home after rehabilitation in your facility? (Q0310,
Q0400A)
6. Initiate contact with the State-designated local contact agency within approximately 10
business days, and document (Q0610). Follow-up is expected in a “reasonable” amount of
time, 10 business days is a recommendation and not a requirement.
7. If the local contact agency does not contact the individual by telephone or in person
within approximately 10 business days, make another follow-up call to the designated
local contact agency as necessary. The level and type of response needed by a particular
individual is determined on a resident-by-resident basis, so timeframes for response may
vary depending on the needs of the resident and the supports available within the
community.
8. Communicate and collaborate with the State-designated local contact agency on the
discharge process. Identify and address challenges and barriers facing the individual in
their discharge process. Develop solutions to these challenges in the discharge/transition
plan.
9. Communicate findings and concerns with the facility discharge planning team, the
individual’s support circle, the individual’s physician and the local contact agency in
order to facilitate discharge/transition planning.

Appendix C-83

CMS’s RAI Version 3.0 Manual

Blank

Appendix C: CAA Resources
20. Return to Community Referral

Input from resident and/or family/representative regarding the care area.
(Questions/Comments/Concerns/Preferences/Suggestions)

Analysis of Findings

Blank

Care Plan Considerations

Care
Plan
Y/N

Document reason(s) care plan will/ will
not be developed.

Blank Blank

October 2024

Appendix C-84

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources

CARE AREA GENERAL RESOURCES
The general resources contained on this page are not specific to any particular care area. Instead,
they provide a general listing of known clinical practice guidelines and tools that may be used in
completing the RAI CAA process.
NOTE: This list of resources is neither prescriptive nor all-inclusive. References to non-U.S.
Department of Health and Human Services (HHS) sources or sites on the Internet are provided
as a service and do not constitute or imply endorsement of these organizations or their programs
by CMS or HHS. CMS is not responsible for the content of pages found at these sites. URL
addresses were current as of the date of this publication.
•

•
•
•
•
•
•
•

•
•

•

October 2024

•
•

•

Agency for Health Care Research and Quality – Clinical Information, Evidence-Based
Practice: http://www.ahrq.gov/professionals/clinicians-providers/index.html;
Academy of Nutrition and Dietetics – Individualized Nutrition Approaches for Older
Adults in Health Care Communities (PDF Version):
https://www.eatrightpro.org/practice/position-and-practice-papers/positionpapers/individualized-nutrition-approaches-adults-health-care-communities;
Alzheimer’s Association Resources: https://www.alz.org/;
American Geriatrics Society Clinical Practice Guidelines and Tools:
http://www.americangeriatrics.org/publications-tools;
American Medical Directors Association (AMDA) Clinical Practice Guidelines and
Tools: http://www.paltc.org/product-store;
American Society of Consultant Pharmacists Practice Resources:
https://www.ascp.com/page/prc;
Association for Professionals in Infection Control and Epidemiology Practice Resources:
http://www.apic.org/Resources/Overview;
Centers for Disease Control and Prevention: Infection Control in Long-Term Care
Facilities Guidelines: http://www.cdc.gov/longtermcare/prevention/index.html;
CMS Pub. 100-07 State Operations Manual Appendix PP – Guidance to Surveyors for
Long Term Care Facilities (federal regulations noted throughout; resources provided in
endnotes): https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf;
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/;
Improving Nursing Home Culture (CMS Special Study):
http://healthcentricadvisors.org/wp-content/uploads/2015/03/INHC_Final-Report_PtIIV_121505_mam.pdf;
Institute for Safe Medication Practices: http://www.ismp.org/;
Quality Improvement Organization (QIO) Program Nursing Home Resources:
https://qioprogram.org/nursing-home-resources/;

Appendix C-85

CMS’s RAI Version 3.0 Manual

Appendix C: CAA Resources

CARE AREA GENERAL RESOURCES (cont.)
•
•
•

Quality Improvement Organizations: https://qualitynet.cms.gov/;
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/.

D
October 2024

Appendix C-86

CMS’s RAI Version 3.0 Manual

Appendix D: Interviewing to Increase Resident Voice

APPENDIX D: INTERVIEWING TO INCREASE RESIDENT
VOICE IN MDS ASSESSMENTS
All residents capable of any communication should be asked to provide information regarding
what they consider to be the most important facets of their lives. There are several MDS 3.0
sections that require direct interview of the resident as the primary source of information (e.g.,
mood, preferences, pain). Self-report is the single most reliable indicator of these topics. Staff
should actively seek information from the resident regarding these specific topic areas;
however, resident interview/inquiry should become part of a supportive care environment that
helps residents fulfill their choices over aspects of their lives.
In addition, a simple performance-based assessment of cognitive function can quickly clarify a
resident’s cognitive status. The majority of residents, even those with moderate to severe
cognitive impairment, are able to answer some simple questions about these topics.

Even simple scripted interviews like those in MDS 3.0 involve a dynamic, collaborative
process. There are some basic approaches that can make interviews simpler and more effective.
•

Introduce yourself to the resident.

•

Be sure the resident can hear what you are saying.

— Do not mumble or rush. Articulate words clearly.

— Ask the resident if they use or own a hearing aid or other communication device.
— Help them get the aid or device in place before starting the interview.
— The assessor may need to offer an assistive device (headphones).
— If the resident is using a hearing aid or other communication device make sure
that it is operational.
Ask whether the resident would like an interpreter (language or signing) if the
resident does not appear to be fluent in English or continues to have difficulty
understanding. Interpreters are people who translate oral or written language from
one language to another. If an interpreter is used during resident interviews, they
should not attempt to determine the intent behind what is being translated, the
outcome of the interview, or the meaning or significance of the interviewee’s
responses. The resident should determine meaning based solely on their
interpretation of what is being translated.

•

Find a quiet, private area where you are not likely to be interrupted or
overheard. This is important for several reasons:

•

— Background noise should be minimized.
— Some items are personal, and the resident will be more comfortable answering in
private. The interviewer is in a better position to respond to issues that arise.
— Decrease available distractions.

October 2024

Appendix D-1

CMS’s RAI Version 3.0 Manual

•

Appendix D: Interviewing to Increase Resident Voice

•

October 2024

•

Sit where the resident can see you clearly and you can see their expressions.
— Have your face well lighted.
— Minimize glare.
— Ask the resident where you should sit so that they can see you best. Some
residents have decreased central vision or limited ability to turn their heads.
Establish rapport and respect.
— The steps you have already taken to ensure comfort go a long way toward
establishing rapport and demonstrating respect.
— You can also engage the resident in general conversation to help establish
rapport.
— If the resident asks a particular question or makes a request, try to address the
request or question before proceeding with the interview.
Explain the purpose of the questions to the resident.
— Start by introducing the topic and explain that you are going to ask a series of
questions.
— You can tell the resident that these questions are designed to be asked of
everyone to make sure that nothing is missed.
— Highlight what you will ask.
— End by explaining that their answers will help the care team develop a care plan
that is appropriate for the resident.
— Suggested explanations and introductions are included in specific item
instructions.
Say and show the item responses.
— It is helpful to many older adults to both hear and read the response options.
— As you verbally review the response options, show the resident the items written
in large, clear print on a piece of paper or card.
— Residents may respond to questions verbally, by pointing to their answers on the
visual aid or by writing out their answers.
Ask the questions as they appear in the questionnaire.
— Use a nonjudgmental approach to questioning.
— Don’t be afraid of what the resident might say; you are there to hear it.
— Actively listen; these questions can provide insights beyond the direct answer.
Break the question apart if necessary. If the resident has difficulty understanding,
requests clarification, or seems hesitant, you can employ unfolding or disentangling
techniques. (Do not, however, use these techniques for the memory test).
1. Unfolding refers to the use of a general question about the symptom followed by
a sequence of more specific questions if the symptom is reported as present. This
approach walks the resident through the steps needed to think through the
question.

Appendix D-2

CMS’s RAI Version 3.0 Manual

Example: Read the item (or part of the item) to the resident, then ask, “Do you
have this at all?” If yes, then ask, “Do you have it every day?” If no, then ask,
“Did you have it at least half the days in the past 2 weeks?”
2. Disentangling refers to separating items with several parts into manageable
pieces. The type of items that lend themselves to this approach are those that
include a list and phrases such as “and” or “or.” The resident is given a chance to
respond to each piece separately. If a resident responds positively to more than
one component of a complex item, obtain a frequency rating for each positive
response and score that item using the frequency of the component that occurred
most often.
Example: An item asks about “Poor appetite or overeating.” Disentangle this
item by asking, “Poor appetite?”; pause for a response and then ask, “Or
overeating?” If neither part is rated positively by the resident, mark no. If either
or both are rated positively, then mark yes.
Clarify using echoing. If the resident appears to understand but is having difficulty
selecting an answer, try clarifying their response by first echoing what they told you
and then repeating the related response options.
— Echoing means simply restating part of the resident’s response. This is often
extremely helpful during clinical interviews. If the resident provides a related
response but does not use the provided response scale or fails to directly answer
the question, then help clarify the best response by repeating the resident’s own
comment and then asking the related response options again. This interview
approach frequently helps the resident clarify which response option they prefer.
Repeat the response options as needed. Some residents might need to have
response choices repeated for each item on a given list.
Move on to another question if the resident is unable to answer.
— Even if the interview item cannot be completed the time spent is not wasted. The
observation of resident behaviors and attention during the interview attempt
provide important insights into delirium, cognition, mood, etc.
Break up the interview if the resident becomes tired or needs to leave for
rehabilitation, etc.
— Try to complete the current item set and then offer to come back at another time
to complete the remaining interview sections.
— It is particularly important to complete the performance-based cognitive items in
one sitting.
Do not try to talk a resident out of an answer. If the resident expresses strong
emotions, be nonjudgmental, and listen.
Record the resident’s response, not what you believe they should have said.
If the resident becomes deeply sorrowful or agitated, sympathetically respond to
their feelings.
— Allowing emotional expression—even when it is uncomfortable for you as the
interviewer—recognizes its validity and provides cathartic support to residents.

•
•

•
•
•

October 2024

•

Appendix D: Interviewing to Increase Resident Voice

Appendix D-3

CMS’s RAI Version 3.0 Manual

•

Appendix D: Interviewing to Increase Resident Voice

— If the resident remains agitated or overly emotional and does not want to
continue, respond to their needs. This is more important than finishing the
interview at that moment. You can complete this and other sections at a later
point in time.
Resident preferences may be influenced by many factors in a resident’s
physical, psychological and environmental state, and can be challenging to truly
discern.
— Residents should be encouraged to articulate their desires and not be strictly
limited by their physical limitations and perceived environmental restrictions.
— When a resident is unable to communicate information about their preferences, a
family member, close friend, or other representative must be used to complete
preference questions. In this case, it is important to emphasize that this person
should try to answer based on what the resident would prefer. The resident’s
preferences while in the nursing home and the resident’s current responses when
the particular item is offered or provided should form the basis for these
responses.

October 2024

Appendix D-4

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

APPENDIX E: PATIENT HEALTH QUESTIONNAIRE (PHQ)
SCORING RULES AND INSTRUCTION FOR
BIMS (WHEN ADMINISTERED IN WRITING)
Scoring Rules: Resident Mood Interview Total Severity
Score D0160
•

Item D0160 is used to store the total severity score for the Resident Mood Interview.
The score in item D0160 is based upon the sum of the values that are contained in
the following nine items: D0150A2, D0150B2, D0150C2, D0150D2, D0150E2,
D0150F2, D0150G2, D0150H2, D0150I2. These are referred to as the "items in
Column 2", below.

Scoring of items evaluated in D0150A–D0150I is dependent on the completion of
these items following instructions for the PHQ-2 to 9©. Whether or not further
evaluation of a resident’s mood is needed depends on the resident’s responses to the
first two questions (D0150A and D0150B). If both D0150A1 and D0150B1 are
coded 9, OR both D0150A2 and D0150B2 are coded 0 or 1, end the PHQ interview;
otherwise continue. If both D0150A1 and D0150B1 are coded 9, leave D0150A2
and D0150B2 blank, then end the PHQ-2© and leave D0160, Total Severity Score
blank. If both D0150A2 and D0150B2 are coded 0 or 1, then end the PHQ-2© and
enter the total score from D0150A2 and D0150B2 in D0160, Total Severity Score.
For all other scenarios, proceed to ask the remaining seven questions (D0150C to
D0150I of the PHQ-9©) and complete D0160, Total Severity Score.

•

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). 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 nonmissing 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), then omit their values when
computing the sum.

•

If the number of missing items in Column 2 is equal to one, then compute the simple
sum of the eight items in Column 2 that have non-missing values, multiply the sum
by 9/8 (1.125), and place the result rounded to the nearest integer in item D0160.

•

If the number of missing items in Column 2 is equal to two, then compute the simple
sum of the seven items in Column 2 that have non-missing values, multiply the sum
by 9/7 (1.286), and place the result rounded to the nearest integer in item D0160.

•

If the number of missing items in Column 2 is equal to three or more, then item
D0160 must equal [99].

•

October 2024

Appendix E-1

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Scoring Rules: Resident Mood Interview Total Severity
Score: D0160 (cont.)
Example 1: All Items in Column 2 Have Non-missing Values
The following example shows how to score the resident interview when all of the items
in Column 2 have non-missing values:
Item

Value

D0150A2
D0150B2
D0150C2
D0150D2
D0150E2
D0150F2
D0150G2
D0150H2
D0150I2

D0160

1
2
2
0
3
0
1
3
2

In this example, all of the items in Column 2 have non-missing values (i.e., none of the
values are blank). Therefore, the value of D0160 is equal to the simple sum of the values
in Column 2, which is 14.

Example 2: One Missing Value in Column 2

Item

The following example shows how to score the resident interview when one of the items
in Column 2 has a missing value:
D0150A2
D0150B2
D0150C2
D0150D2
D0150E2
D0150F2
D0150G2
D0150H2
D0150I2
D0160

October 2024

Value
1
2
0
3
0
1
3
1

Appendix E-2

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Scoring Rules: Resident Mood Interview Total Severity
Score: D0160 (cont.)
In this example, one of the items in Column 2 (D0150C2) has a missing value (it is
blank) and the other 8 items have non-missing values. D0160 is computed as follows:
1.
2.
3.
4.

Compute the sum of the 8 items with non-missing values. This sum is 11.
Multiply this sum by 1.125. In the example, 11 x 1.125 = 12.375.
Round the result to the nearest integer. In the example, 12.375 rounds to 12.
Place the rounded result in D0160.

Example 3: Two Missing Values in Column 2

The following example shows how to score the resident interview when two of the items
in Column 2 are blank:
Item

1
2
0
3
0
1
1

D0150A2
D0150B2
D0150C2
D0150D2
D0150E2
D0150F2
D0150G2
D0150H2
D0150I2

Value

D0160

In this example, two of the items in Column 2 have missing values: both D0150C2 and
D0150I2 are blank (or skipped). The other seven items have non-missing values. D0160
is computed as follows:
1.
2.
3.
4.

Compute the sum of the 7 items with non-missing values. This sum is 8.
Multiply this sum by 1.286. In the example, 8 x 1.286 = 10.288.
Round the result to the nearest integer. In the example, 10.288 rounds to 10.
Place the rounded result in D0160.

October 2024

Appendix E-3

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Scoring Rules: Resident Mood Interview Total Severity
Score: D0160 (cont.)
Example 4: Three or More Missing Values in Column 2
The following example shows how to score the resident interview when three or more of the
items in Column 2 are blank:
Item

Value

D0150A2
D0150B2
D0150C2
D0150D2
D0150E2
D0150F2
D0150G2
D0150H2
D0150I2

0
3

3
2
99

D0160

1
2

In this example, three of the items in Column 2 have missing values: D0150C2,
D0150F2, and D0150G2 are blank (or skipped). The other 6 items have non-missing
values. Because three or more items have missing values, D0160 is equal to 99.

ft
October 2024

Appendix E-4

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Scoring Rules: Staff Assessment of Resident Mood Total
Severity Score: D0600
Item D0600 is used to store the total severity score for the Staff Assessment of
Resident Mood. The score in item D0600 is based upon the sum of the values that
are contained in the following ten items: D0500A2, D0500B2, D0500C2, D0500D2,
D0500E2, D0500F2, D0500G2, D0500H2, D0500I2, D0500J2. These are referred to
as the "items in Column 2", below.

•

The following rules explain how to compute the score that is placed in item D0600.
These rules consider the "number of missing items in Column 2" which is the
number of items in Column 2 that are equal to dash (an item could be equal to dash if
it could not be assessed – for example, if the resident was unexpectedly discharged
before the assessment could be completed).

•

If all of the items in Column 2 have a value of 0, 1, 2, or 3 (i.e., they all contain nonmissing values), then item D0600 is equal to the simple sum of those values.

•

If any of the items in Column 2 are equal to dash, then omit their values when
computing the sum.

•

If the number of missing items in Column 2 is equal to one, then compute the simple
sum of the nine items in Column 2 that have non-missing values, multiply the sum
by 10/9 (1.111), and place the result rounded to the nearest integer in item D0600.

•

If the number of missing items in Column 2 is equal to two, then compute the simple
sum of the eight items in Column 2 that have non-missing values, multiply the sum
by 10/8 (1.250), and place the result rounded to the nearest integer in item D0600.

•

If the number of missing items in Column 2 is equal to three or more, then enter a
dash in item D0600.

•

October 2024

Appendix E-5

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Scoring Rules: Staff Assessment of Resident Mood Total
Severity Score: D0600 (cont.)
Example 1: All Items in Column 2 Have Non-missing Values
The following example shows how to score the resident interview when all of the items
in Column 2 have non-missing values:
Item

Value

D0500A2
D0500B2
D0500C2
D0500D2
D0500E2
D0500F2
D0500G2
D0500H2
D0500I2
D0500J2

D0600

0
1
2
2
3
0
1
3
2
1

In this example, all of the items in Column 2 have non-missing values (i.e., none of the
values are skipped or equal to dash). Therefore, the value of D0600 is equal to the
simple sum of the values in Column 2, which is 15.

Example 2: One Missing Value in Column 2

The following example shows how to score the resident interview when one of the items
in Column 2 has a missing value:

October 2024

Item

Value

D0500A2
D0500B2
D0500C2
D0500D2
D0500E2
D0500F2
D0500G2
D0500H2
D0500I2
D0500J2

0
1
2
2
—
0
1
3
2
1

D0600

Appendix E-6

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Scoring Rules: Staff Assessment of Resident Mood Total
Severity Score: D0600 (cont.)
In this example, one of the items in Column 2 (D0500E2) has a missing value (it is equal
to dash) and the other 9 items have non-missing values. D0600 is computed as follows:
1. Compute the sum of the 9 items with non-missing values. This sum is 12.
2. Multiply this sum by 1.111 (See bullet 5 on page E-5 for calculation of
multiplier). In the example, the sum of non-missing values is 12. Therefore, the
calculation is: 12 x 1.111 = 13.332.
3. Round the result to the nearest integer. In the example, 13.332 rounds to 13.
4. Place the rounded result in D0600.

Example 3: Two Missing Values in Column 2

The following example shows how to score the resident interview when two of the items
in Column 2 have missing values:
Item

Value
0
1
2
2
—
0

D0500G2

D0500H2
D0500I2
D0500J2

—
2
1

D0600

D0500A2
D0500B2
D0500C2
D0500D2
D0500E2
D0500F2

In this example, two of the items in Column 2 have missing values: D0500E2 and
D0500H2 are equal to dash. The other 8 items have non-missing values. D0600 is
computed as follows:

1. Compute the sum of the 8 items with non-missing values. This sum is 9.
2. Multiply this sum by 1.250 (See bullet 6 on page E-5 for calculation of
multiplier). In the example, the sum of non-missing values is 9. Therefore, the
calculation is: 9 x 1.250 = 11.250.
3. Round the result to the nearest integer. In the example, 11.250 rounds to 11.
4. Place the rounded result in D0600.

October 2024

Appendix E-7

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Scoring Rules: Staff Assessment of Resident Mood Total
Severity Score: D0600 (cont.)
Example 4: Three or More Missing Values in Column 2
The following example shows how to score the resident interview when three or more of
the items in Column 2 have missing values:
Item

Value
0
1
2
2
—
—
1
—
2
1

D0600

—

D0500A2
D0500B2
D0500C2
D0500D2
D0500E2
D0500F2
D0500G2
D0500H2
D0500I2
D0500J2

In this example, three of the items in Column 2 have missing values: D0500E2,
D0500F2, and D0500H2 are equal to dash. Because three or more items have missing
values, enter a dash in D0600 (enter a single dash in the leftmost space of D0600 and
leave the second space blank).

Instructions for BIMS When Administered in Writing

When staff identify that the resident’s primary method of communication is in written
format, the Brief Interview for Mental Status (BIMS) and Category Cues can be
administered in writing. The administration of the BIMS in writing should be limited
only to this circumstance.

1. Interview any resident not screened out by the Should Brief Interview for Mental
Status Be Conducted? item (C0100).
2. Conduct the interview in a private setting, if possible.
3. Residents with visual impairment should be tested using their usual visual aids.
4. Minimize glare by directing light sources away from the resident’s face and from
written materials.
5. Provide a written introduction before starting the interview.
Suggested language: “I would like to ask you some questions, which I will show you
in a moment. We ask everyone these same questions. This will help us provide you
with better care. Some of the questions may seem very easy, while others may be
more difficult. We ask these questions of everyone so we can make sure that our care
will meet your needs.”
October 2024

Appendix E-8

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Instructions for BIMS When Administered in Writing
(cont.)
6. Directly provide the written questions for each item in C0200 through C0400 at one
sitting and in the order provided.
•

For each BIMS question, show the resident a sheet of paper or card with the
instruction for that question from the form clearly written in a large enough font
to be easily seen.

•

The resident may respond to any of the BIMS questions in writing.

•

Show separate sheets or cards for each question or statement.

•

For C0200 items, instructions should be written as:

— I have written 3 words for you to remember. Please read them. Then I will
remove the card and ask you repeat or write down the words as you
remember them.

— Category cues should be provided to the resident in writing after the
resident’s first attempt to answer. Written category cues should state: “sock,
something to wear; blue, a color; bed, a piece of furniture.”

•

For C0300 items, instructions should be written as:

— C0300A: “Please tell me what year it is right now.”
— C0300B: “What month are we in right now?”
— C0300C: “What day of the week is today?”

•

For C0400 items, instructions should be written as:

— “Let’s go back to an earlier question. What were those three words that I
asked you to repeat?”

— If the resident is unable to remember a word, provide Category cues again,
but without using the actual word. Therefore, Category cues for:
○ C0400A should be written as “something to wear,”
○ C0400B should be written as “a color,” and

○ C0500C should be written as “a piece of furniture.”

7. If the resident chooses not to answer a particular item, accept their refusal and move
on to the next questions. For C0200 through C0400, code refusals as incorrect.
8. Rules for stopping the interview are the same as if for administering the BIMS
verbally.

The following resources may be used, or the facility may develop their own. If the facility
develops their own, they must use the exact language as in these resources.

October 2024

Appendix E-9

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Written Introduction Card – BIMS – Items C0200 – C0400

I would like to ask you some questions, which I will show
you in a moment.
We ask everyone these same questions.
This will help us provide you with better care.

Some of the questions may seem very easy, while others
may be more difficult.
We ask these questions so that we can make sure that our
care will meet your needs.

Written Instruction Cards – Item C0200 – Repetition of
Three Words

I have written 3 words for you to remember.

Please read them.

Then, I will remove the card and ask you
repeat or write down the words as you
remember them.

October 2024

Appendix E-10

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Word Card – Item C0200

SOCK
BLUE

BED

Category Cue Card – Item C0200

SOCK, something to wear

BLUE, a color

BED, a piece of furniture

October 2024

Appendix E-11

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Written Instruction Cards – Item C0300 – Temporal
Orientation
Statement Card – C0300A - Year

Please tell me what
year it is right now.

Question Card – C0300B - Month

What month are we
in right now?
October 2024

Appendix E-12

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Question Card – Item C0300C - Day

What day of the
week is today?

Written Instruction Card – Item C0400 - Recall

Let’s go back to an
earlier question.

What were those three words
that I asked you to repeat?

October 2024

Appendix E-13

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Category Cue Card – Item C0400A - Sock

Something to wear

Category Cue Card – Item C0400B - Blue

A color

October 2024

Appendix E-14

CMS’s RAI Version 3.0 Manual

Appendix E: PHQ and BIMS

Category Cue Card – Item C0400C

A piece of furniture

D
October 2024

Appendix E-15

CMS’s RAI Version 3.0 Manual

Appendix F: MDS Item Matrix

APPENDIX F
MDS ITEM MATRIX

The MDS Item Matrix is located in the “Downloads” section on CMS’s MDS 3.0 RAI Manual Web
page: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html

October 2024

Appendix F-1

CMS’s RAI Version 3.0 Manual

Appendix G: References

APPENDIX G: REFERENCES
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th
ed.). Washington, DC. American Psychiatric Association, 1994.
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.
Bergstrom, N., Smout, R., Horn, S., Spector, W., Hartz, A., and Limcangco, M.R.: Stage 2
pressure ulcer healing in nursing homes. Journal of the American Geriatrics Society 56(7):12521258, 14 May 2008.

Centers for Disease Control and Prevention: 2007 Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in Healthcare Settings. Available from
http://www.cdc.gov/longtermcare/.
Centers for Disease Control and Prevention: The Pink Book: Chapters: Epidemiology and
Prevention of Vaccine Preventable Diseases, 12th ed. Available from
http://www.cdc.gov/vaccines/pubs/pinkbook/index.html

Centers for Disease Control and Prevention: Prevention of pneumococcal disease:
Recommendations of the Advisory Committee on Immunization Practices (ACIP).
Recommended Adult Immunization Schedule – United States. MMWR Recomm. Rep. 57(53);
Q1-Q-4, Jan. 9, 2009.
Centers for Medicare & Medicaid Services: HIPPS Codes. April 2012; available from
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/ProspMedicareFeeSvcPmtGen/HIPPSCodes.html

Centers for Medicare & Medicaid Services: IMPACT Act of 2014 Data Standardization & Cross
Setting Measures. Available from https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACTAct-of-2014-Data-Standardization-and-Cross-Setting-Measures
Centers for Medicare & Medicaid Services: MDS 3.0 Data Submission Specifications. Available
from http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html
Centers for Medicare & Medicaid Services: MDS 3.0 for Nursing Home. Available from
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/NHQIMDS30.html
Centers for Medicare & Medicaid Services: Medicare Benefit Policy Manual (Pub. 100-2).
Available from http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/InternetOnly-Manuals-IOMs-Items/CMS012673.html?DLPage=1&DLSort=0&DLSortDir=ascending

October 2024

Appendix G-1

CMS’s RAI Version 3.0 Manual

Appendix G: References

Centers for Medicare & Medicaid Services: Medicare Claims Processing Manual (Pub. 100-4).
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-ManualsIOMs-Items/CMS018912.html?DLPage=1&DLSort=0&DLSortDir=ascending
Centers for Medicare & Medicaid Services: Medicare General Information, Eligibility, and
Entitlement Manual (Pub. 100-1). Available from http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMsItems/CMS050111.html?DLPage=1&DLSort=0&DLSortDir=ascending
Centers for Medicare & Medicaid Services: Memorandum to State Survey Agency Directors
from CMS Director, Survey and Certification Group: Clarification of Terms Used in the
Definition of Physical Restraints as Applied to the Requirements for Long Term Care Facilities.
Jun. 22, 2007; retrieved Oct. 16, 2009, from https://www.cms.gov/Medicare/ProviderEnrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter07-22.pdf

Centers for Medicare & Medicaid Services: Minimum Data Set (MDS) 3.0 Provider User’s
Guide. Available from https://qtso.cms.gov/reference-and-manuals/mds-30-provider-users-guide
Centers for Medicare & Medicaid Services: Patient Driven Payment Model. Available from
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM

Centers for Medicare & Medicaid Services: State Operations Manual, Appendix PP-Guidance to
Surveyors for Long Term Care Facilities. Section 483.20(b) Utilization Guidelines for
Completion of the RAI. Available from https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
Centers for Medicare & Medicaid Services: Your Discharge Planning Checklist. CMS Product
No. 11376; revised March 2019. Available from https://www.medicare.gov/Pubs/pdf/11376discharge-planning-checklist.pdf

Folstein, M.F., Folstein, S.E., and McHugh, P.R.: "Mini-mental state." A practical method for
grading the cognitive state of patients for the clinician. J. Psychiatr. Res. 12(3):189-198, Nov.
1975.

Healthcentric Advisors: The Holistic Approach to Transformational Change (HATCh™). CMS
NH QIOSC Contract. Providence, RI. 2006. Available from http://healthcentricadvisors.org/wpcontent/uploads/2015/03/INHC_Final-Report_PtI-IV_121505_mam.pdf.
Inouye, S.K., Van Dyck, C.H., Alessi, C.A., et al.: Clarifying confusion: the confusion
assessment method. A new method for detection of delirium. Ann. Intern. Med. 113(12):941948, 1990.
Institute of Medicine: Improving the Quality of Care in Nursing Homes. Washington, DC.
National Academy Press, 1986.
National Institute of Mental Health: Suicide and the Elderly. n.d. Available from
https://www.agingcare.com/Articles/Suicide-and-the-Elderly-125788.htm

October 2024

Appendix G-2

CMS’s RAI Version 3.0 Manual

Appendix G: References

National Institutes of Health: Racial and Ethnic Categories and Definitions for NIH Diversity
Programs and for Other Reporting Purposes. Notice Number: NOT-OD-15-089. Available from
https://grants.nih.gov/grants/guide/notice-files/NOT-OD-15-089.html
National Pressure Injury Advisory Panel: NPIAP Pressure Injury Stages. Retrieved September
29, 2021, from https://npiap.com/page/PressureInjuryStages
Newman, D.K., and Wein, A.J.: Managing and Treating Urinary Incontinence. 2nd ed.
Baltimore, MD. Health Professions Press, 2009.
Office of the National Coordinator for Health Information Technology: What is an electronic
health record (EHR)?. Available from https://www.healthit.gov/faq/what-electronic-healthrecord-ehr

Office of the National Coordinator for Health Information Technology: What is a patient portal?.
Available from https://www.healthit.gov/faq/what-patient-portal
Physicians’ Desk Reference: Physicians’ Desk Reference 2008. Montvale, NJ. Thomson PDR,
2007.
PlainLanguage.gov: Plan Language in Healthcare. Available from
https://www.plainlanguage.gov/resources/content-types/healthcare/

Quality Improvement and Evaluation System (QIES) Technical Support Office: QIES Technical
Support Office Web site. Retrieved April 2, 2019, from https://qtso.cms.gov/
Saliba, D., and Buchanan, J.: Development and Validation of a Revised Nursing Home
Assessment Tool: MDS 3.0 Final Report to CMS. Contract No. 500-00-0027/Task Order #2.
Santa Monica, CA. Rand Corporation, April 2008. Available from
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/downloads/mds30finalreport.pdf.

U.S. Department of Health and Human Services, Health Care Financing Administration:
Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing
Facilities; Final Rule. Fed. Regist. 63(91):26251-26316, May 12, 1998.
U.S. Department of Health and Human Services, Health Care Financing Administration:
Medicare program; Prospective payment system and consolidated billing for skilled nursing
facilities—Update; final rule and notice. Fed. Regist. 64(146):41644-41683, Jul. 30, 1999.

U.S. Department of Health and Human Services, Office of Disease Prevention and Health
Promotion: Healthy People 2020. Available from https://www.healthypeople.gov/2020/default
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

October 2024

Appendix G-3

CMS’s RAI Version 3.0 Manual

Appendix H: MDS 3.0 Forms

APPENDIX H
MDS 3.0 FORMS

The MDS 3.0 Forms are located in the “Downloads” section on CMS’s MDS 3.0 RAI Manual Web
page: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html

October 2024

Appendix H-1

Track Changes
from Title Page v1.18.11
to Title Page v1.19.1
Chapter

Section

Page(s)
in
version
1.19.1

—

Change

Version 1.18.119.1

October 202324

October 202324
For Use Effective October 1, 202324

D
October 2024

Page 1

Track Changes
from TOC v1.18.11
to TOC v1.19.1
Chapter

Section

TOC

—

Page(s)
in
version
1.19.1

Change

Section GG Functional Abilities and Goals .................... GG-1

D
October 2024

Page 1

Track Changes
from Chapter 1 v1.18.11
to Chapter 1 v1.19.1
Chapter

Section

1.2

Page(s)
in
version
1.19.1

1-3

Change

•

Minimum Data Set (MDS). A core set of screening,
clinical, and functional status data elements, including
common definitions and coding categories, which form the
foundation of a comprehensive assessment for all residents
of nursing homes certified to participate in Medicare or
Medicaid. The data elements (also referred to as “items”)
in the MDS standardize communication about resident
problems and conditions within nursing homes, between
nursing homes, and between nursing homes and outside
agencies. The required subsets of data elements for each
MDS assessment and tracking document (e.g.,
Comprehensive, Quarterly, OBRA Discharge, Entry
Tracking, PPS item sets) can be found in Appendix Hon
CMS’s website at
https://www.cms.gov/Medicare/Quality/Nursing-HomeImprovement/Resident-Assessment-Instrument-Manual.

1.7

1-11

Preferences for
Customary Routine and
Activities

Functional Abilities and
Goals

Obtain information regarding the
resident’s preferences for their
daily routine and activities.
Assess the need for assistance
with self-care and mobility
activities, prior function, admission
performance, discharge goals,
discharge performance, functional
limitations in range of motion, and
current and prior device use.
Gather information on the use of
bowel and bladder appliances, the
use of and response to urinary
toileting programs, urinary and
bowel continence, bowel training
programs, and bowel patterns.

October 2024

Bladder and Bowel

Page 1

Track Changes
from Chapter 3 Intro v1.18.11
to Chapter 3 Intro v1.19.1
Chapter

Section

3.2

Page(s)
in
version
1.19.1

Change

3-3

•

As you are completing this test case, read
through the instructions that apply to each
section as you are completing the MDS. Work
through the Manual and item set one section at
a time until you are comfortable coding items.
Make sure you understand this information
before going on to another section.
Review the test case you completed. Would
you still code it the same way? Are you
surprised by any definitions, instructions, or
case examples? For example, do you
understand how to code Functional Abilities
and Goals?
As you review the coding choices in your test
case against the manual, make notations
corresponding to the section(s) of this Manual
where you need further clarification, or where
questions arose. Note sections of the manual
that help to clarify these coding and procedural
questions.

October 2024

Page 1

Track Changes
from Chapter 3 Section B v1.18.11
to Chapter 3 Section B v1.19.1
Chapter

Section

B0100

B1300

Page(s)
in
version
1.19.1

B-1

Change

Code 1, yes: if the record indicates that a physician,

•

nurse practitioner or clinical nurse specialist has
documented a diagnosis of coma or persistent
vegetative state that is applicable during the 7-day
look-back period. Skip to Section GG, Functional
Abilities and Goals.

B-14

B1300. Health Literacy

Complete only if A0310B = 01 or A0310G = 1 and A0310H =
1.

B1300

B-14

Replaced screenshot.
OLD

ra
NEW

ft
October 2024

Page 1

Track Changes
from Chapter 3 Section C v1.18.11
to Chapter 3 Section C v1.19.1
Chapter

Section

C0500

Page(s)
in
version
1.19.1

C-17

Change

Coding Tips
Occasionally, a resident can communicate but chooses
not to participate in the BIMS and therefore does not
attempt any of the items in the section. This would be
considered an incomplete interview; enter 99 for
C0500, BIMS Summary Score, and complete the
Staff Assessment for Mental Status.

•

If all of the BIMS items are coded with a dash, then
C0500, BIMS Summary Score must also be coded
with a dash.

•

ra
October 2024

Page 1

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

—

Page(s)
in
version
1.19.1

GG-1

Change

SECTION GG: FUNCTIONAL ABILITIES
AND GOALS

Intent: This section includes items about functional abilities
and goals. It includes items focused on prior function,
admission and discharge performance, discharge goals,
performance throughout a resident’s stay, mobility device use,
and range of motion. Functional status is assessed based on
the need for assistance when performing self-care and
mobility activities.

October 2024

Page 1

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0130

Page(s)
in
version
1.19.1

GG-11

Change

Replaced screenshot.
OLD

D
NEW

ft
October 2024

Page 2

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0130

Page(s)
in
version
1.19.1

GG-12

Change

Replaced screenshot.
OLD

D
NEW

ft
October 2024

Page 3

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0130

Page(s)
in
version
1.19.1

GG-13

Change

Replaced screenshot.
OLD

D
NEW

ft
October 2024

Page 4

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0130

Page(s)
in
version
1.19.1

GG-16

Change

Coding Instructions
•

GG0170

GG0130

GG-34–
GG-73
GG-34

Page length changed due to revised content.

Discharge Goals: Coding Tips

When coding the resident’s usual performance and
discharge goal(s), use the six-point scale, or use one of the
four “activity was not attempted” codes to specify the
reason why an activity was not attempted.

Discharge goals are coded with each Admission assessment
when A0310B = 01, indicating the start of a PPS stay.
Discharge goals are not required with stand-alone OBRA
assessments.

ra
•

For the SNF Quality Reporting Program (QRP), a
minimum of one self-care or mobility discharge goal
must be coded. However, facilities may choose to
complete more than one self-care or mobility
discharge goal. Code the resident’s discharge goal(s)
using the six-point scale. Identifying multiple goals
helps to ensure that the assessment accurately reflects
resident status and facilitates person-centered
individualized care planning. Use of the “activity was
not attempted” codes (07, 09, 10, and 88) is
permissible to code discharge goal(s). Use of a dash is
permissible for any remaining self-care or mobility
goals that were not coded. Of note, at least one
Discharge Goal must be indicated for either Self-Care
or Mobility. Using the dash in this allowed instance
after the coding of at least one goal does not affect
Annual Payment Update (APU) determination.

October 2024

Page 5

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0130

Page(s)
in
version
1.19.1

GG-34

Change

Licensed, qualified clinicians can establish a resident’s
Discharge Goal(s) at the time of admission based on
the resident’s prior medical condition, admission
assessment self-care and mobility status, discussions
with the resident and family, professional judgment,
practice standards, expected treatments, the resident’s
motivation to improve, anticipated length of stay, and
the resident’s discharge plan. Goals should be
established as part of the resident’s care plan.

•

If the admission performance of an activity was coded
88, Not attempted due to medical condition or safety
concern during the admission assessment, a Discharge
Goal may be entered using the 6-point scale if the
resident is expected to be able to perform the activity
by discharge.

•

GG0130

GG-34

Discharge Goal: Coding Examples
1. Discharge Goal Code Is Higher than 5-Day PPS
Assessment Admission Performance Code
If the qualified clinician determines that the resident is
expected to make gains in function by discharge, the code
reported for Discharge Goal will be higher than the
admission performance code.

ft
October 2024

Page 6

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0130

Page(s)
in
version
1.19.1

GG-34

Change

2. Discharge Goal Code Is the Same as 5-Day PPS
Assessment Admission Performance Code

Oral Hygiene 5-Day PPS Assessment Admission
Performance: In this example, the qualified clinician
anticipates that the resident will have the same level of
function for oral hygiene at admission and discharge.
The resident’s 5-Day PPS admission performance
code is coded and the Discharge Goal is coded at the
same level. Resident E has stated their preference for
participation twice daily in their oral hygiene activity.
Resident E has severe arthritis, Parkinson’s disease,
diabetic neuropathy, and renal failure. These
conditions result in multiple impairments (e.g., limited
endurance, weak grasp, slow movements, and
tremors). The qualified clinician observes Resident E’s
5-Day PPS admission performance and discusses their
usual performance with qualified clinicians,
caregivers, and family to determine the necessary
interventions for skilled therapy (e.g., positioning of
an adaptive toothbrush cuff, verbal cues, lifting, and
supporting Resident E’s limb). The qualified clinician
codes Resident E’s 5-Day PPS assessment admission
performance as 02, Substantial/maximal assistance.
The helper performs more than half the effort when
lifting or holding their limb.

The qualified clinician determines that a medically
complex resident is not expected to progress to a higher
level of functioning during the SNF Medicare Part A stay;
however, the qualified clinician determines that the resident
would be able to maintain their admission functional
performance level. The qualified clinician discusses
functional status goals with the resident and their family
and they agree that maintaining functioning is a reasonable
goal. In this example, the Discharge Goal is coded at the
same level as the resident’s admission performance code.

October 2024

Page 7

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0130

Page(s)
in
version
1.19.1

Change

GG-34

D
3

GG0130

GG-34

Oral Hygiene 5-Day PPS Assessment Discharge
Goal: The qualified clinician anticipates Resident E’s
discharge performance will remain 02,
Substantial/maximal assistance. Due to Resident E’s
progressive and degenerative condition, the qualified
clinician and resident feel that, while Resident E is not
expected to make gains in oral hygiene performance,
maintaining their function at this same level is
desirable and achievable as a Discharge Goal.

3. Discharge Goal Code Is Lower than 5-Day PPS Assessment
Admission Performance Code

The qualified clinician determines that a resident with a
progressive neurologic condition is expected to rapidly
decline and that skilled therapy services may slow the
decline of function. In this scenario, the Discharge Goal
code is lower than the resident’s 5-Day PPS assessment
admission performance code.
Toileting Hygiene: Resident T’s participation in
skilled therapy is expected to slow down the pace of
their anticipated functional deterioration. The
resident’s Discharge Goal code will be lower than the
5-Day PPS Admission Performance code.

ft
October 2024

Page 8

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0130

Page(s)
in
version
1.19.1

Change

GG-34

Toileting Hygiene 5-Day PPS Assessment
Admission Performance: Resident T has a
progressive neurological illness that affects their
strength, coordination, and endurance. Resident T
prefers to use a bedside commode rather than
incontinence undergarments for as long as possible.
The certified nursing assistant currently supports
Resident T while they are standing so that Resident T
can release their hand from the grab bar (next to their
bedside commode) and pull down their underwear
before sitting onto the bedside commode. When
Resident T has finished voiding, they wipe their
perineal area. Resident T then requires the helper to
support their trunk while Resident T pulls up their
underwear. The qualified clinician codes the 5-Day
PPS assessment admission performance as 03,
Partial/moderate assistance. The certified nursing
assistant provides less than half the effort for
Resident T’s toileting hygiene.
Toileting Hygiene Discharge Goal: By discharge, it
is expected that Resident T will need assistance with
toileting hygiene and that the helper will perform more
than half the effort. The qualified clinician codes their
Discharge Goal as 02, Substantial/maximal assistance.

ft
October 2024

Page 9

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1

GG0170

GG-34

Replaced screenshot.
OLD

D
NEW

ft
October 2024

Page 10

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1

GG0170

GG-35

Replaced screenshot.
OLD

D
NEW

ft
October 2024

Page 11

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1

GG0170

GG-36

Replaced screenshot.
OLD

D
NEW

ft
October 2024

Page 12

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1

GG0170

GG-37

Replaced screenshot.
OLD

D
NEW

ft
October 2024

Page 13

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0170

Page(s)
in
version
1.19.1

GG-38

Change

Replaced screenshot.
OLD

D
NEW

ft
October 2024

Page 14

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0170

Page(s)
in
version
1.19.1

GG-39

Change

Replaced screenshot.
OLD

D
NEW

ft
October 2024

Page 15

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0170

Page(s)
in
version
1.19.1

GG-41

Change

Coding Instructions
•

GG0170

GG-58

When coding the resident’s usual performance and the
resident’s discharge goal(s), use the six-point scale, or
one of the four “activity was not attempted” codes (07,
09, 10, and 88), to specify the reason why an activity
was not attempted.

Coding: GG0170I would be coded 09, Not
applicable, not attempted and the resident did not
perform this activity prior to the current illness,
exacerbation, or injury.
Rationale: When assessing a resident for GG0170I,
Walk 10 feet, consider the resident’s status prior to the
current episode of care and current assessment status.
Use code 09, Not applicable, because Resident L did
not walk prior to the current episode of care and did
not walk during the assessment period. Resident L’s
care plan includes fitting and use of bilateral
prostheses and walking as a goal. A discharge goal for
any admission performance item skipped may be
entered if a discharge goal is determined as part of the
resident’s care plan.

2. Walk 10 feet: Resident L had bilateral amputations three
years ago, and prior to the current admission they used a
wheelchair and did not walk. Currently Resident L does
not use prosthetic devices and uses only a wheelchair for
mobility. Resident L’s care plan includes fitting and use of
bilateral lower extremity prostheses.

October 2024

Page 16

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0170

Page(s)
in
version
1.19.1

GG-60

Change

2. Walk 150 feet: Resident R has endurance limitations due
to heart failure and has only walked about 30 feet during
the assessment period. They have not walked 150 feet or
more during the assessment period, including with the
physical therapist who has been working with Resident R.
The therapist speculates that Resident R could walk this
distance in the future with additional assistance.

D
GG0170

GG-61

GG0170

GG-62

•

If, at the time of the assessment, a resident is unable to
complete the activity because of a physician-prescribed
restriction (for instance, of no stair climbing for two
weeks) but could perform this activity prior to the current
illness, exacerbation, or injury, code 88, Not attempted
due to medical condition or safety concern, they may be
able to complete the stair activities safely by some other
means (e.g., stair lift, bumping/scooting on their buttocks).
If so, code based on the type and amount of assistance
required to complete the activity. If, at the time of
assessment, a resident is unable to complete the stair
activities because of a physician prescribed bedrest, code
the stair activity using the appropriate “activity not
attempted” code.

•

While a resident may take a break between ascending or
descending the 4 steps or 12 steps, once they start the
activity, they must be able to ascend (or descend) all the
steps, by any safe means, without taking more than a brief
rest break in order to consider the stair activity completed.

October 2024

Coding: GG0170K would be coded 88, Not
attempted due to medical condition or safety concerns,
and the resident’s ability to walk a shorter distance
would be coded in item GG0170I.
Rationale: The activity was not attempted. The
resident did not complete the activity, and a helper
cannot complete the activity for the resident. A
resident who walks less than 50 feet would be coded in
item GG0170I, Walk 10 feet.

Page 17

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0170

Page(s)
in
version
1.19.1

GG-65

Change

Example for GG0170Q1, Does the resident
use a wheelchair/scooter?
1. Does the resident use a wheelchair/scooter? On
admission, Resident T wheels themself using a manual
wheelchair, but with difficulty due to their severe
osteoarthritis and COPD.
Coding: GG0170Q1 would be coded 1, Yes. The

admission performance codes for wheelchair items
GG0170R and GG0170S are coded; in addition, the
type of wheelchair Resident T uses for GG0170RR1 is
indicated as code 1, Manual. If wheelchair goal(s) are
clinically indicated, then wheelchair goals can be
coded.
Rationale: The resident currently uses a wheelchair.
Coding the resident’s performance and the type of
wheelchair (manual) is indicated. Wheeling goal(s) if
clinically indicated may be coded.

October 2024

Page 18

Track Changes
from Chapter 3 Section GG v1.18.11
to Chapter 3 Section GG v1.19.1
Chapter

Section

GG0170

Page(s)
in
version
1.19.1

GG-74

Change

Discharge Goals: Coding Tips
Discharge goals are coded with each Admission assessment
when A0310B = 01, indicating the start of a PPS stay.
Discharge goals are not required with stand-alone OBRA
assessments.
•

For the SNF QRP, a minimum of one self-care or
mobility goal must be coded. However, facilities may
choose to complete more than one self-care or
mobility discharge goal. Code the resident’s discharge
goal(s) using the six-point scale. Identifying multiple
goals helps to ensure that the assessment accurately
reflects resident status and facilitates person-centered
individualized care planning. Use of “activity not
attempted” codes (07, 09, 10, and 88) is permissible to
code discharge goal(s). The use of a dash is
permissible for any remaining self-care or mobility
goals that were not coded. Using the dash in this
allowed instance after the coding of at least one goal
does not affect APU determination.

•

October 2024

•

Licensed qualified clinicians can establish a resident’s
discharge goal(s) at the time of admission based on the
resident’s prior medical condition, admission
assessment self-care and mobility status, discussions
with the resident and family, professional judgment,
practice standards, expected treatments, resident
motivation to improve, anticipated length of stay, and
the resident’s discharge plan. Goals should be
established as part of the resident’s care plan.
If the performance of an activity was coded 88, Not
attempted due to medical condition or safety concerns,
during the Admission assessment, a discharge goal
may be coded using the six-point scale if the resident
is expected to be able to perform the activity by
discharge.

Page 19

Track Changes
from Chapter 3 Section K v1.18.11
to Chapter 3 Section K v1.19.1
Chapter

Section

K0520

Page(s)
in
version
1.19.1

Change

K-10

DEFINITIONS
PARENTERAL/IV FEEDING
Introduction of a nutritive substance into the
body by means other than the intestinal tract (e.g.,
subcutaneous, intravenous).

FEEDING TUBE
Presence of any type of tube that can deliver food/ nutritional
substances/ fluids/ medications directly into the
gastrointestinal system. Examples include, but are not limited
to, nasogastric tubes, gastrostomy tubes, jejunostomy tubes,
percutaneous endoscopic gastrostomy (PEG) tubes.

K0520

K-12

•

Parenteral/IV feeding—The following fluids may be
included when there is supporting documentation that
reflects the need for additional fluid intake specifically
addressing a nutrition or hydration need. This
supporting documentation should be noted in the
resident’s medical record according to State and
Federal Regulations and/or internal facility policy:
— IV fluids or hyperalimentation, including total
parenteral nutrition (TPN), administered continuously
or intermittently
— IV fluids running at KVO (Keep Vein Open)
— IV fluids contained in IV Piggybacks
— Hypodermoclysis and subcutaneous ports in hydration
therapy
— IV fluids can be coded in K0520A if needed to prevent
dehydration if the additional fluid intake is specifically
needed for nutrition and/or hydration. Prevention of
dehydration should be clinically indicated and
supporting documentation should be provided in the
medical record.

October 2024

Page 1

Track Changes
from Chapter 3 Section N v1.18.11
to Chapter 3 Section N v1.19.1
Chapter

Section

N0415

Page(s)
in
version
1.19.1

N-4

Change

Replaced screenshot.
OLD

D
NEW

N0415

N-8

ra
3

•

N0415K1. Anticonvulsant: Check if an

•

N0415K2. Anticonvulsant: Check if there is an

Do not code flushes to keep an IV access port patent.

anticonvulsant medication was taken by the resident at any
time during the 7-day observation period (or since
admission/entry or reentry if less than 7 days).
indication noted for all anticonvulsant medications taken
by the resident any time during the observation period (or
since admission/entry or reentry if less than 7 days).

N0415

N-9

•

N0415–
N2005

N-8–
N-28

Page length changed due to revised content.

October 2024

Page 1

Track Changes
from Chapter 3 Section O v1.18.11R
to Chapter 3 Section O v1.19.1
Chapter

Section

O0110

O0300

O-9

O-16

Change

•

O0110O1, IV Access

Code IV access, which refers to a catheter inserted into a vein
for a variety of clinical reasons, including long-term
medication administration, large volumes of blood or fluid,
frequent access for blood samples, intravenous fluid
administration, total parenteral nutrition (TPN), or, in some
instances, the measurement of central venous pressure. An
arteriovenous (AV) fistula does not meet the definition of IV
Access for O0110O1.
Replaced screenshot.

Page(s)
in
version
1.19.1

OLD

ra
NEW

O0350

O-19

O0350: Resident’s COVID-19 vaccination
is up to date

ft
October 2024

Page 1

Track Changes
from Chapter 3 Section O v1.18.11R
to Chapter 3 Section O v1.19.1
Chapter

Section

O0350

Page(s)
in
version
1.19.1

O-19

Change

Item Rationale
Health-related Quality of Life
•
•

D
•

The intent of this item is to report if a person is up to
date with their COVID-19 vaccine status.
Age is the strongest risk factor for severe coronavirus
disease 2019 (COVID-19) outcomes. In 2020, persons
aged 65 years or older accounted for 81 percent of
U.S. COVID-19-related deaths.
Severe illness caused by COVID-19 means that the
person with COVID-19 may require hospitalization,
intensive care, or ventilator support for breathing, or
may even die.

ra
October 2024

Page 2

Track Changes
from Chapter 3 Section O v1.18.11R
to Chapter 3 Section O v1.19.1
Chapter

Section

O0350

Page(s)
in
version
1.19.1

Change

Planning for Care

O-19

•
•

•

D
•

A strong infection prevention and control program is
vital to protect both patients and healthcare personnel.
Remaining up to date with all recommended COVID19 vaccine doses is critical to protect both staff and
patients from Severe Acute Respiratory Syndrome
Coronavirus 2 (SARS-CoV-2) infection.
COVID-19 vaccines currently approved or authorized
by the U.S. Food & Drug Administration are effective
in reducing the risk of serious outcomes of COVID19, including severe disease, hospitalization, and
death.
Efforts to increase the number of people in the United
States who are up to date with their COVID-19
vaccines remain an important strategy for preventing
illnesses, hospitalizations, and deaths from COVID19.
A vaccine, like any other medicine, could possibly
cause serious problems, such as severe allergic
reactions. Serious problems from the COVID-19
vaccine are very rare. More information about
potential side effects of the COVID-19 vaccine,
precautions, and contraindications can be found on the
CDC webpage “Interim Clinical Considerations for
Use of COVID-19 Vaccines in the United States” at
https://www.cdc.gov/vaccines/covid-19/clinicalconsiderations/interim-considerationsus.html#contraindications.

•

ft
October 2024

Page 3

Track Changes
from Chapter 3 Section O v1.18.11R
to Chapter 3 Section O v1.19.1
Chapter

Section

O0350

Page(s)
in
version
1.19.1

O-20

Change

Steps for Assessment
•

D
•

O0350

O-20

Vaccination status may be determined based on
information from any available source.
o Review the patient’s medical record or
documentation of COVID-19 vaccination
and/or interview the patient, family or other
caregivers or healthcare providers to determine
whether the patient is up to date with their
COVID-19 vaccine.
If the patient is not up to date, and the facility has the
vaccine available, ask the patient if they would like to
receive the COVID-19 vaccine.

DEFINITION

UP TO DATE for COVID-19 Vaccine
For the definition of “up to date,” providers should refer to the
CDC webpage “Stay Up to Date with COVID-19 Vaccines” at
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-upto-date.html.

O0350

O-20

Coding Instructions
•

•

October 2024

•

Code 0, No, patient is not up to date if the patient does
not meet the CDC’s definition of up to date.
o This includes patients who have not received
one or more recommended COVID-19 vaccine
doses for any reason including medical,
religious, or other qualified exemptions.
o This includes patients for whom vaccination
status cannot be determined.
Code 1, Yes, patient is up to date if the patient meets
the CDC’s definition of up to date.
A dash is a valid response, indicating the item was not
assessed. CMS expects dash use to be a rare
occurrence.

Page 4

Track Changes
from Chapter 3 Section O v1.18.11R
to Chapter 3 Section O v1.19.1
Chapter

Section

O0350

Page(s)
in
version
1.19.1

O-20

Change

Coding Tip
•

O0350–
O0500

O-19–
O-57

Page length changed due to revised content.

Current COVID-19 vaccine recommendations are
available on the Centers for Disease Control and
Prevention’s (CDC’s) webpage “Stay Up to Date with
COVID-19 Vaccines” at
https://www.cdc.gov/coronavirus/2019ncov/vaccines/stay-up-to-date.html.

October 2024

Page 5

Track Changes
from Chapter 4 v1.18.11R
to Chapter 4 v1.19.1
Chapter

Section

4.4

Page(s)
in
version
1.19.1

4-5

Change

Not all triggers identify deficits or problems. Some triggers
indicate areas of resident strengths, and can suggest possible
approaches to improve a resident’s functioning or minimize
decline. For example, Section GG captures the resident’s
goals on admission when they are in an SNF PPS stay,
Section F identifies the resident’s preferences for customary
routine and activities, and Section Q captures information
about the resident’s desire to talk to someone about the
possibility of leaving this facility and returning to live and
receive services in the community. These and other MDS
items can help focus the assessment and care plan on what is
most important to the resident and areas with the greatest
potential for functional improvement.

October 2024

Page 1

Track Changes
from Chapter 5 v1.18.11R
to Chapter 5 v1.19.1
Chapter

Section

5.7

Page(s)
in
version
1.19.1

5-12

Change

The 10/01/2023 Cross-Over Rule
•

When Tthe MDS item sets that are effective October
1, 2023have had significant changes, including the
omission and addition of many items or significant
changes to existing items, clinicians will be required to
collect and code new items, may have different lookback periods, or may need to code the MDS according
to changes in the coding requirements. It is the target
date of the assessment that identifies the required
version of the item set, and, because of the substantial
changes inthat may exist between versions of the item
sets, they are not interchangeable. Therefore,
commonly when there are updates to item sets,
providers may not change target dates on assessments
crossing over October 1, 2023 of specific years.

•

A uniqueWhen item sets are updated, a situation may
exists that will prevent providers from correcting the
target date of any assessment crossing over from
October 1, 2023 of a given year. That is, providers
may not submit a modification to change a target date
on an assessment completed prior to October 1, 2023
of a given year to a target date on or after October 1,
2023 of the same year, nor can they submit a
modification to change a target date on an assessment
completed on or after October 1, 2023 of a given year
to a target date prior to October 1, 2023 of a given
year when the MDS item sets have had substantial
changes.

October 2024

Page 1

Track Changes
from Chapter 5 v1.18.11R
to Chapter 5 v1.19.1
Chapter

Section

5.8

Page(s)
in
version
1.19.1

5-13

Change

5.8 Special Manual Record Correction
Request
A few types of errors in a record in iQIES cannot be corrected
with an automated Modification or Inactivation request. These
errors are:

1. The record is a test record inadvertently submitted as
production.
2. The record has the wrong unit certification or licensure
designation in Item A0410.
3. The record has the wrong state code or facility ID in the
control Items STATE_CD or FAC_ID.
4. The record submitted was not for OBRA or Medicare Part
A purposes.

October 2024

Page 2

Track Changes
from Appendix A v1.18.11
to Appendix A v1.19.1
Chapter

Section

App. A

—

App. A

—

Page(s)
in
version
1.19.1

Change

Indication

The identified, documented
clinical rationale for administering
a medication that is based upon a
physician’s (or prescriber’s)
assessment of a resident’s
condition and therapeutic goals.

A-25

Up to Date
(for COVID19 Vaccine)

For the definition of “up to date,”
providers should refer to the CDC
webpage “Stay Up to Date with
COVID-19 Vaccines” at
https://www.cdc.gov/coronavirus/
2019-ncov/vaccines/stay-up-todate.html.

A-11

October 2024

Page 1

Track Changes
from Appendix C v1.18.11
to Appendix C v1.19.1
Chapter

Section

App. C

—

Page(s)
in
version
1.19.1

C-34

Change



App. C

□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□

Medications
• Antibiotics (N0415F)
• Anticholinergics
• Antihypertensives
• Anticonvulsants (N0415K)
• Antipsychotics (N0415A)
• Cardiac medications
• Cimetidine
• Clonidine
• Chemotherapeutic agents
• Digitalis
• Other
• Glaucoma medications
• Guanethidine
• Immuno-suppressive medications
• Methyldopa
• Opioids (N0415H)
• Nitrates
• Propranolol
• Reserpine
• Steroids
• Stimulants
Dry mouth causing buildup of oral bacteria
• Dehydration (see Dehydration/Fluid
Maintenance CAA)
• Medications
 Antipsychotics (N0415A)
 Antidepressants (N0415C)
 Antianxiety agents (N0415B)
 Sedatives/hypnotics (N0415D)
 Diuretics (N0415G)
 Antihypertensives
 Antiparkinsonian medications
 Opioids (N0415H)
 Anticonvulsants (N0415K)
 Antihistamines
 Decongestants
 Antiemetics
• Antineoplastics

—

C-63



□
□

□

October 2024

Page 1

Track Changes
from Appendix F v1.18.11
to Appendix F v1.19.1
Chapter

Section

App. F

—

Page(s)
in
version
1.19.1

F-1

Change

The MDS Item Matrix is located in the “Downloads” section on
CMS’s MDS 3.0 RAI Manual Web page:
http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.ht
ml

D
October 2024

Page 1

Track Changes
from Appendix H v1.18.11
to Appendix H v1.19.1
Chapter

Section

App. H

—

Page(s)
in
version
1.19.1

Change

H-1

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. (Note: The
RAI mandated by OBRA is exempt from this requirement.)
The valid OMB control number for this information collection
is 0938-1140 (Expires 11/30/2024). The time required to
complete this information collection is estimated to be 51
minutes (for the Nursing Home Prospective Payment System
(NP) item set), including the time to review instructions,
search existing data resources, gather the data needed, and
complete and review the information collection. This estimate
does not include time for training. 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
[email protected].
The MDS 3.0 Forms are located in the “Downloads” section on
CMS’s MDS 3.0 RAI Manual Web page:
http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.ht
ml

October 2024

Page 1

File Type	application/pdf
File Title	Minimum Data Set 3.0 Resident Assessment Instrument User’s Manual v1.19.1
Subject	Minimum Data Set, MDS, MDS 3.0, Resident Assessment Instrument, RAI, User’s Manual, Manual, 1.19.1
Author	Centers for Medicare & Medicaid Services
File Modified	2024-01-24
File Created	2023-12-28