CMS-10387 Interim Payment Assessment (IPA) Item Set

Resident_____________________________________________________________ Identifier_________________________________ Date________________________

MINIMUM DATA SET (MDS) - Version 3.0
RESIDENT ASSESSMENT AND CARE SCREENING
Interim Payment Assessment (IPA) Item Set

Section A - Identification Information
A0050. Type of Record

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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

E.

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

F.

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

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

A0410. Unit Certification or Licensure Designation
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.

Enter Code

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

A0900. Birth Date

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Month

Day

Year

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

X.

Resident unable to respond

Y.

Resident declines to respond

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section A - Identification Information
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

F.

Filipino

G. Japanese
H. Korean
I.

Vietnamese

J.

Other Asian

K. Native Hawaiian
L.

Guamanian or Chamorro

M. Samoan
N. Other Pacific Islander
X.

Resident unable to respond

Y.

Resident declines to respond

Z.

None of the above

A1110. Language

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A. What is your preferred language?

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Enter Code

B. Do you need or want an interpreter to communicate with a doctor or health care staff?
0. No
1. Yes
9. Unable to determine

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
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:

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 B0100, Comatose
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:

Look back period for all items is 7 days unless another time frame is indicated
Section B - Hearing, Speech, and Vision
B0100. Comatose

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Enter Code

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

B0700. Makes Self Understood
Enter Code

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

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Resident_____________________________________________________________ Identifier_________________________________ 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 C0700-C1000, Staff Assessment for Mental Status
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

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

0.
1.

No (resident was able to complete Brief Interview for Mental Status) → Skip to D0100, Should Resident Mood Interview be
Conducted?
Yes (resident was unable to complete Brief Interview for Mental Status) → Continue to C0700, Short-term Memory OK

Staff Assessment for Mental Status
Do not conduct if Brief Interview for Mental Status (C0200-C0500) was completed
C0700. Short-term Memory OK
Seems or appears to recall after 5 minutes
Enter Code
0. Memory OK
1. Memory problem

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C1000. Cognitive Skills for Daily Decision Making
Enter Code

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

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section D - Mood
D0100. Should Resident Mood Interview be Conducted?

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Enter Code

0.
1.

No (resident is rarely/never understood) → Skip to and complete D0500-D0600, Staff Assessment of Resident Mood (PHQ-9-OV)
Yes → Continue to D0150, Resident Mood Interview (PHQ-2 to 9©)

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

F.

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

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

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

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).

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

MDS 3.0 Interim Payment Assessment (IPA) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section D - Mood
D0500. Staff Assessment of Resident Mood (PHQ-9-OV*)
Do not conduct if Resident Mood Interview (D0150-D0160) was completed
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
Then move to column 2, Symptom Frequency, and indicate symptom frequency.
1. Symptom Presence
0. No (enter 0 in column 2)
1. Yes (enter 0-3 in column 2)
2. Symptom Frequency
1.
2.
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)
3. 12-14 days (nearly every day)
↓ Enter Scores in Boxes↓
A. Little interest or pleasure in doing things
B. Feeling or appearing down, depressed, or hopeless
C. Trouble falling or staying asleep, or sleeping too much
D. Feeling tired or having little energy
E.

Poor appetite or overeating

F.

Indicating that they feel bad about self, are a failure, or have let self or family down

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

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

J.

Being short-tempered, easily annoyed

D0600. Total Severity Score

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Enter Score

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

*Copyright © Pfizer Inc. All rights reserved.

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section E - Behavior
E0100. Potential Indicators of Psychosis
↓ Check all that apply

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A. Hallucinations (perceptual experiences in the absence of real external sensory stimuli)
B. Delusions (misconceptions or beliefs that are firmly held, contrary to reality)

Z. None of the above
Behavioral Symptoms
E0200. Behavioral Symptom - Presence & Frequency
Note presence of symptoms and their frequency
Coding:
0. Behavior not exhibited
1. Behavior of this type occurred 1 to 3 days
2. Behavior of this type occurred 4 to 6 days, but less than daily
3. Behavior of this type occurred daily

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Enter Code

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

Enter Code

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

Enter Code

C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing,
rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming,
disruptive sounds)
E0800. Rejection of Care - Presence & Frequency
Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident’s
goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care planning with the
resident or family), and determined to be consistent with resident values, preferences, or goals.
Enter Code
0. Behavior not exhibited
1. Behavior of this type occurred 1 to 3 days
2. Behavior of this type occurred 4 to 6 days, but less than daily
3. Behavior of this type occurred daily
E0900. Wandering - Presence & Frequency

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Enter Code

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

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities - OBRA/Interim
GG0130. Self-Care (Assessment period is the ARD plus 2 previous calendar days)
Complete column 5 when A0310A = 02 - 06 and A0310B = 99 or when A0310B = 08.
Code the resident’s usual performance for each activity using the 6-point scale. If an activity was not attempted, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident’s performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by 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
5.
OBRA/Interim
Performance

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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.

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section GG - Functional Abilities - OBRA/Interim
GG0170. Mobility (Assessment period is the ARD plus 2 previous calendar days)
Complete column 5 when A0310A = 02 - 06 and A0310B = 99 or when A0310B = 08.
Code the resident’s usual performance for each activity using the 6-point scale. If an activity was not attempted, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident’s performance is unsafe or of poor quality, score according to
amount of assistance provided.
Activities may be completed with or without assistive devices.
06. Independent - Resident completes the activity by 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
5.
OBRA/Interim
Performance

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Enter Codes in Boxes
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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).

F.

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

I.

Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If interim performance is coded 07, 09,
10, or 88 → Skip to H0100, Appliances

J.

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

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

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section H - Bladder and Bowel
H0100. Appliances
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Check all that apply
C. Ostomy (including urostomy, ileostomy, and colostomy)
D. Intermittent catheterization
Z.

None of the above

H0200. Urinary Toileting Program

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Enter Code

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

H0500. Bowel Toileting Program
Enter Code
Is a toileting program currently being used to manage the resident’s bowel continence?
0. No
1. Yes

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Section I - Active Diagnoses
I0020.

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Enter Code

Indicate the resident’s primary medical condition category
Indicate the resident’s primary medical condition category that best describes the primary reason for
admission
01. Stroke
02. Non-Traumatic Brain Dysfunction
03. Traumatic Brain Dysfunction
04. Non-Traumatic Spinal Cord Dysfunction
05. Traumatic Spinal Cord Dysfunction
06. Progressive Neurological Conditions
07. Other Neurological Conditions
08. Amputation
09. Hip and Knee Replacement
10. Fractures and Other Multiple Trauma
11. Other Orthopedic Conditions
12. Debility, Cardiorespiratory Conditions
13. Medically Complex Conditions

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I0020B. ICD Code

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section I - Active Diagnoses
Active Diagnoses in the last 7 days - Check all that apply
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists
Gastrointestinal
I1300. Ulcerative Colitis, Crohn’s Disease, or Inflammatory Bowel Disease
Infections
Infections

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I1700. Multidrug-Resistant Organism (MDRO)
I2000. Pneumonia
I2100. Septicemia
I2500. Wound Infection (other than foot)

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I4300. Aphasia
I4400. Cerebral Palsy
I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke
I4900. Hemiplegia or Hemiparesis
I5100. Quadriplegia
I5200. Multiple Sclerosis (MS)
I5300. Parkinson’s Disease
I5500. Traumatic Brain Injury (TBI)

Metabolic
Metabolic

I2900. Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)
Neurological
Neurological

Nutritional
Nutritional

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I5600. Malnutrition (protein or calorie) or at risk for malnutrition
Pulmonary
Pulmonary

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I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and restrictive lung
diseases such as asbestosis)
I6300. Respiratory Failure
None
Above
None of
of Above

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Other
Other

I7900. None of the above active diagnoses within the last 7 days
I8000. Additional active diagnoses
Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box.

A.

________________________________________________________________________________

B.

________________________________________________________________________________

C.

________________________________________________________________________________

D.

________________________________________________________________________________

E.

________________________________________________________________________________

F.

________________________________________________________________________________

G. ________________________________________________________________________________
H.

________________________________________________________________________________

I.

________________________________________________________________________________

J.

________________________________________________________________________________

MDS 3.0 Interim Payment Assessment (IPA) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section J - Health Conditions
Other Health Conditions
J1100. Shortness of Breath (dyspnea)
↓

□
□

Check all that apply
C. Shortness of breath or trouble breathing when lying flat
Z.

None of the above

J1550. Problem Conditions
↓

□
□
□

Check all that apply
A. Fever
B. Vomiting
Z.

None of the above

J2100. Recent Surgery Requiring Active SNF Care

□

Enter Code

Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay?
0.
1.
8.

No
Yes
Unknown

Surgical Procedures - Complete only if J2100 = 1
↓

Check all that apply

Major Joint Replacement

□
□
□
□

J2300. Knee Replacement - partial or total
J2310. Hip Replacement - partial or total
J2320. Ankle Replacement - partial or total
J2330. Shoulder Replacement - partial or total
Spinal Surgery

□
□
□
□

J2400. Involving the spinal cord or major spinal nerves
J2410. Involving fusion of spinal bones
J2420. Involving Iamina, discs, or facets
J2499. Other major spinal surgery
Other Orthopedic Surgery

□
□
□
□
□

J2500. Repair fractures of the shoulder (including clavicle and scapula) or arm (but not hand)
J2510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot)
J2520. Repair but not replace joints
J2530. Repair other bones (such as hand, foot, jaw)
J2599. Other major orthopedic surgery
Neurological Surgery

□
□
□
□

J2600. Involving the brain, surrounding tissue or blood vessels (excludes skull and skin but includes cranial nerves)
J2610. Involving the peripheral or autonomic nervous system - open or percutaneous
J2620. Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices
J2699. Other major neurological surgery

MDS 3.0 Interim Payment Assessment (IPA) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section J - Health Conditions
Surgical Procedures - Continued
↓

Check all that apply

Cardiopulmonary Surgery

□
□
□

J2700. Involving the heart or major blood vessels - open or percutaneous procedures
J2710. Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords - open or endoscopic
J2799. Other major cardiopulmonary surgery

□
□
□

J2800. Involving genital systems (such as prostate, testes, ovaries, uterus, vagina, external genitalia)
J2810. Involving the kidneys, ureters, adrenal glands, or bladder - open or laparoscopic (includes creation or removal of
nephrostomies or urostomies)
J2899. Other major genitourinary surgery

□
□
□
□
□
□

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

Genitourinary Surgery

Other Major Surgery

Section K - Swallowing/Nutritional Status
K0100. Swallowing Disorder
Signs and symptoms of possible swallowing disorder
↓

□
□
□
□
□

Check all that apply
A. Loss of liquids/solids from mouth when eating or drinking
B. Holding food in mouth/cheeks or residual food in mouth after meals
C. Coughing or choking during meals or when swallowing medications
D. Complaints of difficulty or pain with swallowing
Z.

None of the above

K0300. Weight Loss

□

Enter Code

Loss of 5% or more in the last month or loss of 10% or more in last 6 months
0.
1.
2.

No or unknown
Yes, on physician-prescribed weight-loss regimen
Yes, not on physician-prescribed weight-loss regimen

MDS 3.0 Interim Payment Assessment (IPA) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section K - Swallowing/Nutritional Status
K0520. Nutritional Approaches
Check all of the following nutritional approaches that apply
2. While Not a Resident
Performed while NOT a resident of this facility and within the last 7 days.
Only check column 2 if resident entered (admission or reentry) IN THE LAST 7 DAYS. If resident last entered 7 or more days ago, leave column 2 blank.
3. While a Resident
Performed while a resident of this facility and within the last 7 days
2.

3.

While Not a
Resident

While a
Resident

↓ 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)
Z. None of the above

□

K0710. Percent Intake by Artificial Route - Complete K0710 only if Column 2 and/or Column 3 are checked for K0520A and/or K0520B
2. While a Resident
3.

Performed while a resident of this facility and within the last 7 days

During Entire 7 Days

Performed during the entire last 7 days

2.

3.

While a

During Entire

Resident

7 Days

↓

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

MDS 3.0 Interim Payment Assessment (IPA) Version 1.19.1 Effective 10/01/2024

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□
□
□

Enter Codes

□
□

↓

□
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Page 16 of 24

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.
1.

No → Skip to M1030, Number of Venous and Arterial Ulcers
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

□
□

Enter Number

Enter Number

□
□
□

Enter Number

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
1.

Number of Stage 2 pressure ulcers

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

Number of Stage 3 pressure ulcers

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

Number of Stage 4 pressure ulcers

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

M1030. Number of Venous and Arterial Ulcers
Enter Number

Enter the total number of venous and arterial ulcers present

M1040. Other Ulcers, Wounds and Skin Problems
↓

□
□
□
□
□
□
□

Check all that apply
Foot Problems
A. Infection of the foot (e.g., cellulitis, purulent drainage)
B. Diabetic foot ulcer(s)
C. Other open lesion(s) on the foot
Other Problems
D. Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion)
E.

Surgical wound(s)

F.

Burn(s) (second or third degree)

None of the Above
Z.

None of the above were present

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

Section M - Skin Conditions
M1200. Skin and Ulcer/Injury Treatments
↓

□
□
□
□
□
□
□
□
□
□

Check all that apply
A. Pressure reducing device for chair
B. Pressure reducing device for bed
C. Turning/repositioning program
D. Nutrition or hydration intervention to manage skin problems
E.

Pressure ulcer/injury care

F.

Surgical wound care

G. Application of nonsurgical dressings (with or without topical medications) other than to feet
H. Applications of ointments/medications other than to feet
I.

Application of dressings to feet (with or without topical medications)

Z.

None of the above were provided

Section N - Medications
N0350. Insulin

□
□

Enter Days

Enter Days

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

MDS 3.0 Interim Payment Assessment (IPA) Version 1.19.1 Effective 10/01/2024

Page 18 of 24

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
b.

b.
While a Resident

While a Resident
Performed while a resident of this facility and within the last 14 days

Check all that apply
↓
Cancer Treatments
A1. Chemotherapy
B1. Radiation
Respiratory Treatments

C1. Oxygen therapy
D1. Suctioning
E1. Tracheostomy care
F1. Invasive Mechanical Ventilator (ventilator or respirator)
Other
H1. IV Medications
I1. Transfusions
J1. Dialysis

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□
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□

□
□
□
□

□

M1. Isolation or quarantine for active infectious disease
(does not include standard body/fluid precautions)
None of the Above
Z1. None of the above
O0400. Therapies

□

Enter Number of Days

D. Respiratory Therapy
2.

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

MDS 3.0 Interim Payment Assessment (IPA) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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

□
□
□

Number
of Days

□
□
□
□
□
□
□

A. Range of motion (passive)
B. Range of motion (active)
C. Splint or brace assistance
Training and Skill Practice In:
D. Bed mobility
E.

Transfer

F.

Walking

G. Dressing and/or grooming
H. Eating and/or swallowing
I.

Amputation/prostheses care

J.

Communication

MDS 3.0 Interim Payment Assessment (IPA) 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

□□
Enter Code

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

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

MDS 3.0 Interim Payment Assessment (IPA) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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

□□-□□-□□□□

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

Day

Year

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

□□
Enter Number

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

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

□
□
□
□
□

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

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

MDS 3.0 Interim Payment Assessment (IPA) Version 1.19.1 Effective 10/01/2024

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Resident_____________________________________________________________ Identifier_________________________________ Date________________________

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

□
□

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

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

X1100. RN Assessment Coordinator Attestation of Completion

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□□□□□□□□□□□□□□□□□□

A. Attesting individual’s first name:

B.

Attesting individual’s last name:

C.

Attesting individual’s title:

D.

Signature

E.

Attestation date

□□-□□-□□□□
Month

Day

Year

Section Z - Assessment Administration
Z0100. Medicare Part A Billing

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□□□□□□□□□□

A. Medicare Part A HIPPS code:
B. Version code:

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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:

□□-□□-□□□□
Month

Day

Year

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

MDS 3.0 Interim Payment Assessment (IPA) Version 1.19.1 Effective 10/01/2024

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