CMS-10387 Nursing Home Part A PPS Discharge (NPE) Item Set

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)

MDS 3.0 NPE Item Set v1.19.1

OMB: 0938-1140

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

MINIMUM DATA SET (MDS) - Version 3.0
RESIDENT ASSESSMENT AND CARE SCREENING

Nursing Home Part A PPS Discharge (NPE) Item Set

Section A - Identification Information
A0050. Type of Record

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1.
2.
3.

Enter Code

Add new record → Continue to A0100, Facility Provider Numbers
Modify existing record → Continue to A0100, Facility Provider Numbers
Inactivate existing record → Skip to X0150, Type of Provider

A0100. Facility Provider Numbers

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A. National Provider Identifier (NPI):

B. CMS Certification Number (CCN):
C. State Provider Number:

A0200. Type of Provider
Type of provider
Enter Code
1. Nursing home (SNF/NF)
2. Swing Bed

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A0310. Type of Assessment
Enter Code

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Enter Code

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A. Federal OBRA Reason for Assessment
01. Admission assessment (required by day 14)
02. Quarterly review assessment
03. Annual assessment
04. Significant change in status assessment
05. Significant correction to prior comprehensive assessment
06. Significant correction to prior quarterly assessment
99. None of the above
B. PPS Assessment
PPS Scheduled Assessment for a Medicare Part A Stay
01. 5-day scheduled assessment
PPS Unscheduled Assessment for a Medicare Part A Stay
08. IPA - Interim Payment Assessment
Not PPS Assessment
99. None of the above

Enter Code

Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?
0. No
1. Yes

Enter Code

Entry/discharge reporting
01. Entry tracking record
10. Discharge assessment-return not anticipated
11. Discharge assessment-return anticipated
12. Death in facility tracking record
99. None of the above

A0310 continued on next page

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information
A0310. Type of Assessment - Continued

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Enter Code

G. Type of discharge - Complete only if A0310F = 10 or 11
1. Planned
2. Unplanned
H. Is this a SNF Part A PPS Discharge Assessment?
0. No
1. Yes

A0410. Unit Certification or Licensure Designation
Enter Code

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

1.
2.
3.

A0500. Legal Name of Resident

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A. First name:

B. Middle initial:

C. Last name:

D. Suffix:

A0600. Social Security and Medicare Numbers

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A. Social Security Number:
B. Medicare number:

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

A0800. Gender

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Enter Code

1.
2.

Male
Female

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A0900. Birth Date

Month

Day

Year

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information
A1005. Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
↓

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Check all that apply
A. No, not of Hispanic, Latino/a, or Spanish origin
B. Yes, Mexican, Mexican American, Chicano/a
C. Yes, Puerto Rican
D. Yes, Cuban
E.

Yes, another Hispanic, Latino/a, or Spanish origin

Resident unable to respond

Resident declines to respond

A1010. Race
What is your race?
↓

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Check all that apply
A. White
B. Black or African American
C. American Indian or Alaska Native
D. Asian Indian
E.

Chinese

Filipino

G. Japanese
H. Korean
I.

Vietnamese

Other Asian

K. Native Hawaiian
L.

Guamanian or Chamorro

M. Samoan
N. Other Pacific Islander
X.

Resident unable to respond

Resident declines to respond

None of the above

A1200. Marital Status

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Enter Code

1.
2.
3.
4.
5.

Never married
Married
Widowed
Separated
Divorced

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information
A1250. Transportation (from NACHC©)
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?
↓

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Check all that apply
A. Yes, it has kept me from medical appointments or from getting my medications
B. Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
C. No
X.

Resident unable to respond

Resident declines to respond

© 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.

A1300. Optional Resident Items

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A. Medical record number:
B. Room number:

C. Name by which resident prefers to be addressed:

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

Most Recent Admission/Entry or Reentry into this Facility
A1600. Entry Date

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Month

Day

Year

A1700. Type of Entry

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Enter Code

1.
2.

Admission
Reentry

A1805. Entered From

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Enter Code

01. Home/Community (e.g., private home/apt., board/care, assisted living, group home, transitional living, other
residential care arrangements)
02. Nursing Home (long-term care facility)
03. Skilled Nursing Facility (SNF, swing beds)
04. Short-Term General Hospital (acute hospital, IPPS)
05. Long-Term Care Hospital (LTCH)
06. Inpatient Rehabilitation Facility (IRF, free standing facility or unit)
07. Inpatient Psychiatric Facility (psychiatric hospital or unit)
08. Intermediate Care Facility (ID/DD facility)
09. Hospice (home/non-institutional)
10. Hospice (institutional facility)
11. Critical Access Hospital (CAH)
12. Home under care of organized home health service organization
99. Not listed

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information

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

Month

Day

Year

A2000. Discharge Date
Complete only if A0310F = 10, 11, or 12

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Month

Day

Year

A2121. Provision of Current Reconciled Medication List to Subsequent Provider at Discharge
Complete only if A0310H = 1

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Enter Code

At the time of discharge to another provider, did your facility provide the resident’s current reconciled medication list to the subsequent provider?
0.
1.

No - Current reconciled medication list not provided to the subsequent provider → Skip to A2300, Assessment Reference Date
Yes - Current reconciled medication list provided to the subsequent provider

A2122. Route of Current Reconciled Medication List Transmission to Subsequent Provider
Indicate the route(s) of transmission of the current reconciled medication list to the subsequent provider.
Complete only if A2121 = 1
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Check all that apply
Route of Transmission
A. Electronic Health Record
B. Health Information Exchange
C. Verbal (e.g., in-person, telephone, video conferencing)
D. Paper-based (e.g., fax, copies, printouts)

E. Other methods (e.g., texting, email, CDs)
A2300. Assessment Reference Date

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Observation end date:
Month

Day

Year

A2400. Medicare Stay

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Enter Code

A. Has the resident had a Medicare-covered stay since the most recent entry?
0. No → Skip to B1300, Health Literacy
1. Yes → Continue to A2400B, Start date of most recent Medicare stay

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B. Start date of most recent Medicare stay:
Month

Day

Year

Month

Day

Year

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

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Look back period for all items is 7 days unless another time frame is indicated
Section B - Hearing, Speech, and Vision
B1300. Health Literacy

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Enter Code

How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or
pharmacy?
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
7. Resident declines to respond
8. Resident unable to respond

The Single Item Literacy Screener is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section C - Cognitive Patterns
C0100. Should Brief Interview for Mental Status (C0200-C0500) be Conducted?
Attempt to conduct interview with all residents

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Enter Code

0.
1.

No (resident is rarely/never understood) → Skip to and complete C1310. Signs and Symptoms of Delirium (from CAM©)
Yes → Continue to C0200, Repetition of Three Words

Brief Interview for Mental Status (BIMS)
C0200. Repetition of Three Words
Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
Enter Code
Number of words repeated after first attempt
0. None
1. One
2. Two
3. Three
After the resident’s first attempt, repeat the words using cues (“sock, something to wear; blue, a color; bed, a piece of furniture”). You may repeat
the words up to two more times.
C0300. Temporal Orientation (orientation to year, month, and day)
Ask resident: “Please tell me what year it is right now.”
Enter Code
A. Able to report correct year
0. Missed by > 5 years or no answer
1. Missed by 2-5 years
2. Missed by 1 year
3. Correct

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Ask resident: “What month are we in right now?”
B. Able to report correct month
0. Missed by > 1 month or no answer
1. Missed by 6 days to 1 month
2. Accurate within 5 days
Ask resident: “What day of the week is today?”
Enter Code
C. Able to report correct day of the week
0. Incorrect or no answer
1. Correct
C0400. Recall
Ask resident: “Let’s go back to an earlier question. What were those three words that I asked you to repeat?” If unable to remember a word, give
cue (something to wear; a color; a piece of furniture) for that word.
Enter Code
A. Able to recall “sock”
0. No - could not recall
1. Yes, after cueing (“something to wear”)
2. Yes, no cue required
Enter Code
B. Able to recall “blue”
0. No - could not recall
1. Yes, after cueing (“a color”)
2. Yes, no cue required
Enter Code
C. Able to recall “bed”
0. No - could not recall
1. Yes, after cueing (“a piece of furniture”)
2. Yes, no cue required
Enter Code

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C0500. BIMS Summary Score

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Enter Score

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

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section C - Cognitive Patterns
Delirium
C1310. Signs and Symptoms of Delirium (from CAM©)
A. Acute Onset Mental Status Change

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Enter Code

Is there evidence of an acute change in mental status from the resident’s baseline?
0. No
1. Yes

Coding:
0. Behavior not present
1. Behavior continuously present, does not fluctuate
2. Behavior present, fluctuates (comes and goes, changes in severity)
Enter Codes
in Boxes
↓

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B. Inattention - Did the resident have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of
what was being said?
C. Disorganized Thinking - Was the resident’s thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical
flow of ideas, or unpredictable switching from subject to subject)?
D. Altered Level of Consciousness - Did the resident have altered level of consciousness, as indicated by any of the following criteria?
■
■
■
■

vigilant - startled easily to any sound or touch
lethargic - repeatedly dozed off when being asked questions, but responded to voice or touch
stuporous - very difficult to arouse and keep aroused for the interview
comatose - could not be aroused

Adapted from: Inouye SK, et al. Ann Intern Med. 1990; 113: 941-948. Confusion Assessment Method. Copyright 2003, Hospital Elder Life Program, LLC. Not to be reproduced
without permission.

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

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Enter Code

0.
1.

No (resident is rarely/never understood) → Skip to D0700, Social Isolation
Yes → Continue to D0150, Resident Mood Interview (PHQ-2 to 9©)

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section D - Mood
D0150. Resident Mood Interview (PHQ-2 to 9©)
Say to resident: “Over the last 2 weeks, have you been bothered by any of the following problems?”
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: “About how often have you been bothered by this?”
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
0. No (enter 0 in column 2)
1. Yes (enter 0-3 in column 2)
9. No response (leave column 2 blank)
1.
2.
2. Symptom Frequency
0. Never or 1 day
Symptom
Symptom
1. 2-6 days (several days)
Presence
Frequency
2. 7-11 days (half or more of the days)
↓ Enter Scores in Boxes↓
3. 12-14 days (nearly every day)
A. Little interest or pleasure in doing things
B. Feeling down, depressed, or hopeless

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If both D0150A1 and D0150B1 are coded 9, OR both D0150A2 and D0150B2 are coded 0 or 1, END the PHQ interview; otherwise, continue.
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E.

Poor appetite or overeating

Feeling bad about yourself - or that you are a failure or have let yourself or your
family down

G. Trouble concentrating on things, such as reading the newspaper or watching
television
H. Moving or speaking so slowly that other people could have noticed. Or the
opposite - being so fidgety or restless that you have been moving around a lot
more than usual
I.

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

D0160. Total Severity Score

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Enter Score

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

D0700. Social Isolation
Enter Code

How often do you feel lonely or isolated from those around you?
0. Never
1. Rarely
2. Sometimes
3. Often
4. Always
7. Resident declines to respond
8. Resident unable to respond

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities - Discharge

GG0130. Self-Care (Assessment period is the last 3 days of the Stay)
Complete when A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2.
Code the resident’s usual performance at the end of the stay for each activity using the 6-point scale. If an activity was not attempted at the end
of the stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident’s performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by themself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half
the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the
effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.

If activity was not attempted, code reason:
07. Resident refused
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns
3.

Discharge
Performance
Enter Codes in Boxes
↓

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

Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not
include transferring in/out of tub/shower.

Upper body dressing: The ability to dress and undress above the waist; including fasteners, if applicable.

G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear.
H. Putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility;
including fasteners, if applicable.

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities - Discharge
GG0170. Mobility (Assessment period is the last 3 days of the Stay)
Complete when A0310G is not = 2 and A0310H = 1 and A2400C minus A2400B is greater than 2.
Code the resident’s usual performance at the end of the stay for each activity using the 6-point scale. If an activity was not attempted at the end
of the stay, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident’s performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by themself with no assistance from a helper.
05. Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity.
04. Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident
completes activity. Assistance may be provided throughout the activity or intermittently.
03. Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half
the effort.
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the
effort.
01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is
required for the resident to complete the activity.
If activity was not attempted, code reason:
07. Resident refused
09. Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury.
10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
88. Not attempted due to medical condition or safety concerns
3.

Discharge
Performance

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Enter Codes in Boxes
↓

A. Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back
support.
D. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.
E.

Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).

Toilet transfer: The ability to get on and off a toilet or commode.

G. Car transfer: The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close
door or fasten seat belt.
I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If discharge performance
is coded 07, 09, 10, or 88 → Skip to GG0170M, 1 step (curb)

Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.

K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Discharge
Performance

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Enter Codes in Boxes
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Walking 10 feet on uneven surfaces: The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel.

M. 1 step (curb): The ability to go up and down a curb and/or up and down one step.
If discharge performance is coded 07, 09, 10, or 88 → Skip to GG0170P, Picking up object
N. 4 steps: The ability to go up and down four steps with or without a rail.
If discharge performance is coded 07, 09, 10, or 88 → Skip to GG0170P, Picking up object
O. 12 steps: The ability to go up and down 12 steps with or without a rail.
P.

Picking up object: The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor.

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Q3.

Does the resident use a wheelchair and/or scooter?
0.
1.

No → Skip to J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS),
whichever is more recent
Yes → Continue to GG0170R, Wheel 50 feet with two turns

R. Wheel 50 feet with two turns: Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns.

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RR3. Indicate the type of wheelchair or scooter used.

1.
2.

Manual
Motorized

Wheel 150 feet: Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space.

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SS3. Indicate the type of wheelchair or scooter used.
1.
2.

Manual
Motorized

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section J - Health Conditions
J0200. Should Pain Assessment Interview be Conducted?
Attempt to conduct interview with all residents. If resident is comatose or if A0310G = 2, skip to J1800. Any Falls Since Admission/Entry or Reentry or Prior
Assessment (OBRA or Scheduled PPS). Otherwise, attempt to conduct interview with all residents.

□

Enter Code

0.
1.

No (resident is rarely/never understood) → Skip to J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA
or Scheduled PPS), whichever is more recent
Yes → Continue to J0300, Pain Presence

Pain Assessment Interview
J0300. Pain Presence

□

Enter Code

Ask resident: “Have you had pain or hurting at any time in the last 5 days?”
0.
1.
9.

No → Skip to J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is
more recent
Yes → Continue to J0510. Pain Effect on Sleep
Unable to answer → Skip to J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS),
whichever is more recent

J0510. Pain Effect on Sleep

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Enter Code

Ask resident: “Over the past 5 days, how much of the time has pain made it hard for you to sleep at night?”
1.
2.
3.
4.
8.

Rarely or not at all
Occasionally
Frequently
Almost constantly
Unable to answer

J0520. Pain Interference with Therapy Activities

□

Enter Code

Ask resident: “Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain?”
0.
1.
2.
3.
4.
8.

Does not apply - I have not received rehabilitation therapy in the past 5 days
Rarely or not at all
Occasionally
Frequently
Almost constantly
Unable to answer

J0530. Pain Interference with Day-to-Day Activities

□

Enter Code

Ask resident: “Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions)
because of pain?”
1.
2.
3.
4.
8.

Rarely or not at all
Occasionally
Frequently
Almost constantly
Unable to answer

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

Page 13 of 23

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section J - Health Conditions
J1800. Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS),
whichever is more recent

□

Enter Code

Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more
recent?
0.
1.

No → Skip to K0520, Nutritional Approaches
Yes → Continue to J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS)

J1900. Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever is
more recent
Coding:
0. None
1. One
2. Two or more
Enter Codes in Boxes
↓

□
□
□

A. No injury - no evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury
by the resident; no change in the resident’s behavior is noted after the fall
B. Injury (except major) - skin tears, abrasions, lacerations, superficial bruises, hematomas and sprains; or any fall-related injury that causes
the resident to complain of pain
C. Major injury - bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma

Section K - Swallowing/Nutritional Status
K0520. Nutritional Approaches
Check all of the following nutritional approaches that apply
4. At Discharge
Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C
4.
At
Discharge
Check all that apply
↓
A. Parenteral/IV feeding
B. Feeding tube (e.g., nasogastric or abdominal (PEG))
C. Mechanically altered diet - require change in texture of food or liquids (e.g., pureed
food, thickened liquids)
D. Therapeutic diet (e.g., low salt, diabetic, low cholesterol)
Z.

None of the above

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

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Page 14 of 23

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section M - Skin Conditions

Report based on highest stage of existing ulcers/injuries at their worst;
do not “reverse” stage
M0210. Unhealed Pressure Ulcers/Injuries

□

Enter Code

Does this resident have one or more unhealed pressure ulcers/injuries?

0. No → Skip to N0415, High-Risk Drug Classes: Use and Indication
1. Yes → Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage

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□

Enter Number

B. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present
as an intact or open/ruptured blister

Enter Number

Number of Stage 2 pressure ulcers - If 0 → Skip to M0300C, Stage 3

Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the
time of admission/entry or reentry

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

Enter Number

Number of Stage 3 pressure ulcers - If 0 → Skip to M0300D, Stage 4

Number of these Stage 3 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the
time of admission/entry or reentry

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

Enter Number

Number of Stage 4 pressure ulcers - If 0 → Skip to M0300E, Unstageable - Non-removable dressing/device

Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - enter how many were noted at the
time of admission/entry or reentry

Unstageable - Non-removable dressing/device: Known but not stageable due to non-removable dressing/device

Enter Number

Number of unstageable pressure ulcers/injuries due to non-removable dressing/device - If 0 → Skip to M0300F, Unstageable Slough and/or eschar

Enter Number

Number of these unstageable pressure ulcers/injuries that were present upon admission/entry or reentry - enter how many
were noted at the time of admission/entry or reentry

Enter Number

Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar
1.

Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar - If 0 → Skip to M0300G,
Unstageable - Deep tissue injury

Number of these unstageable pressure ulcers that were present upon admission/entry or reentry - enter how many were noted
at the time of admission/entry or reentry

G. Unstageable - Deep tissue injury:
1.

Number of unstageable pressure injuries presenting as deep tissue injury - If 0 → Skip to N0415, High Risk Drug Classes: Use
and Indication

Number of these unstageable pressure injuries that were present upon admission/entry or reentry - enter how many were noted
at the time of admission/entry or reentry

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

Page 15 of 23

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section N - Medications
N0415. High-Risk Drug Classes: Use and Indication
1.
2.

Is taking
Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry
or reentry if less than 7 days
Indication noted
If Column 1 is checked, check if there is an indication noted for all medications in the drug class
1.
2.
Is taking

Indication noted

↓ Check all that apply↓
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Z.

Antipsychotic
Antianxiety
Antidepressant
Hypnotic
Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin)
Antibiotic
Diuretic
Opioid
Antiplatelet
Hypoglycemic (including insulin)
Anticonvulsants
None of the above

□
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□
□
□
□
□
□
□
□

□
□
□
□
□
□
□
□
□
□
□

N2005. Medication Intervention - Complete only if A0310H = 1
Did the facility contact and complete physician (or physician-designee) prescribed/recommended actions by midnight of the next
Enter Code
calendar day each time potential clinically significant medication issues were identified since the admission?

□

0.
1.
9.

No
Yes
NA - There were no potential clinically significant medication issues identified since admission or resident is not taking any medications

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

Page 16 of 23

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section O - Special Treatments, Procedures, and Programs
O0110. Special Treatments, Procedures, and Programs

Check all of the following treatments, procedures, and programs that were performed
c.

c.
At Discharge

At Discharge
Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C

Check all that apply
↓
Cancer Treatments
A1. Chemotherapy
A2. IV
A3. Oral
A10. Other
B1. Radiation
Respiratory Treatments
C1. Oxygen therapy
C2. Continuous
C3. Intermittent
C4. High-concentration
D1. Suctioning
D2. Scheduled
D3. As needed
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
G1. Non-invasive Mechanical Ventilator
G2. BiPAP
G3. CPAP
Other
H1. IV Medications
H2. Vasoactive medications
H3. Antibiotics
H4. Anticoagulant
H10. Other
I1. Transfusions
O0110 continued on next page

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□

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MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

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Page 17 of 23

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section O - Special Treatments, Procedures, and Programs
O0110. Special Treatments, Procedures, and Programs - Continued
Check all of the following treatments, procedures, and programs that were performed
c.

c.
At Discharge

At Discharge
Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C

J1. Dialysis
J2. Hemodialysis
J3. Peritoneal dialysis
K1. Hospice Care
M1. Isolation or quarantine for active infectious disease
(does not include standard body/fluid precautions)
O1. IV Access
O2. Peripheral
O3. Midline
O4. Central (e.g., PICC, tunneled, port)
None of the Above
Z1. None of the above
O0350. Resident’s COVID-19 vaccination is up to date

□

Enter Code

0.
1.

Check all that apply
↓

□
□
□
□

□
□
□
□
□

No, resident is not up to date
Yes, resident is up to date

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

Page 18 of 23

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section O - Special Treatments, Procedures, and Programs
O0425. Part A Therapies
Complete only if A0310H = 1

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□□□□
□□□□
□□□
□□□□
□□□□
□□□□
Enter Number of Minutes

Enter Number of Minutes

Enter Number of Days

Enter Number of Minutes

□□□□
□□□
□□□□
□□□□
□□□□

A. Speech-Language Pathology and Audiology Services
1.
2.
3.

Individual minutes - record the total number of minutes this therapy was administered to the resident individually since
the start date of the resident’s most recent Medicare Part A stay (A2400B)
Concurrent minutes - record the total number of minutes this therapy was administered to the resident concurrently
with one other resident since the start date of the resident’s most recent Medicare Part A stay (A2400B)
Group minutes - record the total number of minutes this therapy was administered to the resident as part of a group of
residents since the start date of the resident’s most recent Medicare Part A stay (A2400B)

If the sum of individual, concurrent, and group minutes is zero, → skip to O0425B, Occupational Therapy
4.
5.

Co-treatment minutes - record the total number of minutes this therapy was administered to the resident in co-treatment
sessions since the start date of the resident’s most recent Medicare Part A stay (A2400B)
Days - record the number of days this therapy was administered for at least 15 minutes a day since the start date of the
resident’s most recent Medicare Part A stay (A2400B)

B. Occupational Therapy
1.
2.
3.

If the sum of individual, concurrent, and group minutes is zero, → skip to O0425C, Physical Therapy

Enter Number of Minutes

Enter Number of Days

Enter Number of Minutes

□□□□
□□□

4.
5.

C. Physical Therapy
1.
2.
3.

If the sum of individual, concurrent, and group minutes is zero, → skip to O0430, Distinct Calendar Days of Part A Therapy

Enter Number of Minutes

Enter Number of Days

4.
5.

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

Page 19 of 23

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section O - Special Treatments, Procedures, and Programs
O0430. Distinct Calendar Days of Part A Therapy
Complete only if A0310H = 1

□□□

Enter Number of Days

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 since the start date of the resident’s most recent Medicare Part A stay
(A2400B)

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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

□

Enter Code

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

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

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Last name:

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

□

1.
2.

Enter Code

Male
Female

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□□□-□□-□□□□

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

Month

Day

Year

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

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

□□
Enter Code

□

Enter Code

PPS Assessment

Entry/discharge reporting

Is this a SNF Part A PPS Discharge Assessment?

PPS Scheduled Assessment for a Medicare Part A Stay
01. 5-day scheduled assessment
PPS Unscheduled Assessment for a Medicare Part A Stay
08. IPA - Interim Payment Assessment
Not PPS Assessment
99. None of the above

01.
10.
11.
12.
99.
0.
1.

Entry tracking record
Discharge assessment-return not anticipated
Discharge assessment-return anticipated
Death in facility tracking record
None of the above
No
Yes

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

Page 21 of 23

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section X - Correction Request
X0700. Date on existing record to be modified/inactivated - Complete one only

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□□-□□-□□□□

A. Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600F = 99
Month

Day

Year

Month

Day

Year

Month

Day

Year

B. Discharge Date (A2000 on existing record to be modified/inactivated) - Complete only if X0600F = 10, 11, or 12

C. Entry Date (A1600 on existing record to be modified/inactivated) - Complete only if X0600F = 01

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

□□
Enter Number

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

X0900. Reasons for Modification - Complete only if Type of Record is to modify a record in error (A0050 = 2)
↓

□
□
□
□
□

Check all that apply
A. Transcription error
B. Data entry error
C. Software product error
D. Item coding error
Z.

Other error requiring modification
If “Other” checked, please specify:

X1050. Reasons for Inactivation - Complete only if Type of Record is to inactivate a record in error (A0050 = 3)
↓

□
□

Check all that apply
A. Event did not occur
Z.

Other error requiring inactivation
If “Other” checked, please specify:

X1100. RN Assessment Coordinator Attestation of Completion

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A. Attesting individual’s first name:

Attesting individual’s last name:

Attesting individual’s title:

Signature

Attestation date

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Month

Day

Year

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

Page 22 of 23

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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

Title

Sections

Date Section
Completed

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

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Month

Day

Year

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

MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Version 1.19.1 Effective 10/01/2024

Page 23 of 23

File Type	application/pdf
File Title	MDS 3.0 Nursing Home Part A PPS Discharge (NPE) Item Set v1.19.1
Author	Centers for Medicare & Medicaid Services
File Modified	2023-10-12
File Created	2023-09-07