Minimum Data Set Training

The MDS is a powerful tool for implementing standardized assessment and for facilitating care management in nursing homes (NHs) and non-critical access hospital swing beds (SBs). Its content has implications for residents, families, providers, researchers, and policymakers.

Information for All Sections

RAI Manual is CMSs official guide to MDS 3.0 - This manual contains six chapters plus appendices. Chapter 3 includes step-by-step instructions for completing each section of the MDS 3.0.

MDS 3.0 Technical Information Visit this page and scroll down to the download section. Sometimes you may find two releases of the Item Subsets in the download section; you will need to pay attention to the dates to get the right one to meet your needs. Select the MDS 3.0 Item Subsets to download the files. MDS 3.0 Forms (Resident Assessment & Care Screening All Item Listing)

Link to Case Mix Manuals

Training Videos

List of MDS 3.0 videos on YouTube - Please note that several of the videos have been uploaded by CMSHHSGOV. While there are many videos on this YouTube channel, the videos posted by CMS would be most recommended by the State of Maine as this is the primary source of guidance on the MDS 3.0 from CMS.

Some things, such as interview techniques have not changed since the implementation of MDS 3.0 in 2010, other sections may not have current information.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Certain responses to questions in the MDS 3.0 will point to conditions, symptoms and other areas of concern that need further assessment in order to help the facility develop a comprehensive individualized care plan. These responses will trigger (Care Area Trigger, CAT) the need to complete a Care Area Assessment (CAA). Chapter 4 of the RAI Manual covers the Care Area Assessment (CAA) Process and Care Planning.

Directions: Open the MDS 3.0 RAI Manual page located on the U.S. Department of Health and Human Service, Centers for Medicare and Medicaid Services (CMS) site. Once you are on this page, scroll down to the download section. Select MDS 3.0 RAI Manual. See Chapter 4 in the MDS 3.0 RAI Manual.

Case Mix

Long Term Care facilities receive reimbursement through two government programs: Medicare and MaineCare. Both programs reimburse Long Term Care facilities based on measures of the intensity of care and services required for each resident. Case Mix refers to the aggregate level of services and care needed by all the residents of a Long-Term Care facility.

Medicare reimbursement is based on a category-based classification system called Resource Utilization Group IV (RUG-IV). Certain responses on the MDS 3.0 determine assignment of a resident to a RUG-IV group. Medicare reimbursement guidelines are the same all across the country.

Medicaid reimbursement rules and guidelines differ from state to state. Currently Maine's Medicaid program (called MaineCare) uses a Case Mix system that differs from the Medicare system.

CMS does not require the completion of C0600 and C0700. However, the State of Maine does require these items to be completed in order to calculate Case Mix payment.

Section A: Identification Information

Updated 2019

The intent of this section is to obtain key information to uniquely identify each resident, the home in which he or she resides, and the reasons for assessment. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section A. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Supplemental Training Handouts - Section A Training Aids (PDF) (refer to Chapter 2, RAI Manual, table for OBRA, Section A. Pages 15-16)

Training Videos - 34-minute video of the actual CMS Training of Trainers session on Section A presented by Dave Malitz, PhD (August 2010) and 29-minute video of ICD-10 Coding Basics (January 2014).

Section A, I, J, and O Updates

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following items in Section A: Identification Information may trigger the facility to conduct a Care Area Assessment.

• C1310C (CAA1 Delirium) [Effective on or after 10/01/2016]
• C1310D (CAA1 Delirium) [Effective on or after 10/01/2016]
• D0300 (CAA 8 Mood State)
• D0600 (CAA 8 Mood State)
• J1700A (CAA 11 Falls)
• J1700B (CAA 11 Falls)
• K0310 (CAA 12 Nutritional Status) [Effective on or after 04/01/2012]
• K0500A (CAA 12 Nutritional Status & CAA 14 Dehydration/Fluid Maintenance) [Effective prior to 04/01/2012]
• K0500B (CAA 13 Feeding Tubes & CAA 14 Dehydration/Fluid Maintenance) [Effective prior to 4/1/12]
• K0500C (CAA 12 Nutritional Status) [Effective prior to 04/01/2012]
• K0500D (CAA 12 Nutritional Status) [Effective prior to 04/01/2012]
• K0510A1 (CAA 12 Nutritional Status & CAA 14 Dehydration/Fluid Maintenance) [Effective on or after 04/01/2012]
• K0510A2 (CAA 12 Nutritional Status & CAA 14 Dehydration/Fluid Maintenance) [Effective on or after 04/01/2012]
• K0510B1 (CAA 13 Feeding Tubes & CAA 14 Dehydration/Fluid Maintenance) [Effective on or after 04/01/2012]
• K0510B2 (CAA 13 Feeding Tubes & CAA 14 Dehydration/Fluid Maintenance) [Effective on or after 04/01/2012]
• K0510C1 (CAA 12 Nutritional Status) [Effective on or after 04/01/2012]
• K0510C2 (CAA 12 Nutritional Status) [Effective on or after 04/01/2012]
• K0510D1 (CAA 12 Nutritional Status) [Effective on or after 04/01/2012]
• K0510D2 (CAA 12 Nutritional Status) [Effective on or after 04/01/2012]
• M1040H (CAA 6 Urinary Incontinence & Indwelling Catheter) [Effective prior to 04/01/2012]
• N0400A (CAA 17 Psychotropic Medication Use) [Effective prior to 04/01/2012]
• N0400B (CAA 11 Falls & CAA 17 Psychotropic Medication Use) [Effective prior to 04/01/2012]
• N0400C (CAA 11 Falls & CAA 17 Psychotropic Medication Use) [Effective prior to 04/01/2012]
• N0400D (CAA 17 Psychotropic Medication Use) [Effective prior to 04/01/2012]
• N0410A (CAA 17 Psychotropic Medication Use) [Effective on or after 04/01/2012]
• N0410B (CAA 11 Falls & CAA 17 Psychotropic Medication Use) [Effective on or after 04/01/2012]
• N0410C (CAA11 Falls & CAA 17 Psychotropic Medication Use) [Effective on or after 04/01/2012]
• N0410D (CAA 17 Psychotropic Medication Use) [Effective on or after 04/01/2012]
• V0100D (CAA 1 Delirium) [Effective prior to 10/1/2015]
• V0100E (CAA 8 Mood State)
• V0100F (CAA 8 Mood State)

Additional, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Section A: Identification Information

• C0500 (CAA1 Delirium) [Effective prior to 10/01/2016]
• C1310A (CAA1 Delirium) [Effective on or after 10/01/2016]
• C1310B (CAA1 Delirium) [Effective on or after 10/01/2016]

Case Mix

Some questions in Section A, Identification Information affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section B: Hearing, Speech, and Vision

The intent of items in this section is to document the residents ability to hear (with assistive hearing devices, if they are used), understand, and communicate with others and whether the resident experiences visual limitations or difficulties related to diseases common in aged persons. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section B. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section B: Hearing, Speech, and Vision may trigger the facility to conduct a Care Area Assessment.

• B0200 (CAA 4 Communication)
• B0700 (CAA 4 Communication)
• B0800 (CAA 4 Communication) 
• B1000 (CAA 3 Visual Function)

Case Mix

Some questions in Section B: Hearing, Speech, and Vision affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section C: Cognitive Patterns

The items in this section are intended to determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in many care-planning decisions. (CMS's Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes. Section C Brief Interview for Mental Status (BIMS) and Section C (Staff)

Presentation Slides - This PowerPoint includes only the slides; it does not include trainer notes or audio of the training. Section C Brief Interview for Mental Status (BIMS) and Section C (Staff)

Training Videos -  August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Special Note: If the resident was unable to complete the BIMS, a staff assessment for Mental Status needs to be conducted. Do NOT conduct a staff assessment if the BIMS was completed.

Responses to the following Items in Section C may trigger the facility to conduct a Care Area Assessment.

• C0500 (CAA 2 Cognitive Loss/Dementia & CAA 5 ADL Functional/Rehabilitation Potential)
• C0700 (CAA 2 Cognitive Loss/Dementia)
• C0800 (CAA 2 Cognitive Loss/Dementia)
• C1000 (CAA 2 Cognitive Loss/Dementia & CAA 5 ADL Functional/Rehabilitations Potential)
• C1300A (CAA 2 Cognitive Loss/Dementia) [Effective prior to 10/1/2016]
• C1300B (CAA 2 Cognitive Loss/Dementia) [Effective prior to 10/1/2016]
• C1300C (CAA 2 Cognitive Loss/Dementia) [Effective prior to 10/1/2016]
• C1300D (CAA 2 Cognitive Loss/Dementia) [Effective prior to 10/1/2016]
• C1310A (CAA 1 Delirium) [Effective on or after 10/1/2016]
• C1310B (CAA 1 Delirium & CAA 2 - Cognitive Loss/Dementia) [Effective on or after 10/1/2016]
• C1310C (CAA 1 Delirium & CAA 2 - Cognitive Loss/Dementia) [Effective on or after 10/1/2016]
• C1310D (CAA 1 Delirium & CAA 2 - Cognitive Loss/Dementia) [Effective on or after 10/1/2016]
• C1600 (CAA 1 Delirium) [Effective prior to 10/1/2016]

Additionally, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Cognitive Patterns:

• A0310A (CAA 1 Delirium)
• G0110A1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110B1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110C1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110D1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110E1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110F1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110G1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110H1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110I1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110J1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0120A (CAA 5 ADL Functional/Rehabilitation Potential)
• G0300A (CAA 5 ADL Functional/Rehabilitation Potential)
• G0300B (CAA 5 ADL Functional/Rehabilitation Potential)
• G0300C (CAA 5 ADL Functional/Rehabilitation Potential)
• G0300D (CAA 5 ADL Functional/Rehabilitation Potential)
• G0300E (CAA 5 ADL Functional/Rehabilitation Potential)
• G0900A (CAA 5 ADL Functional/Rehabilitation Potential)
• G0900B (CAA 5 ADL Functional/Rehabilitation Potential)

Case Mix

Some questions in Section C: Cognitive Patterns affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

 

Section D: Mood

The items in this section address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable.

It is important to note that coding the presence of indicators in Section D does not automatically mean that the resident has a diagnosis of depression or other mood disorder. Assessors do not make or assign a diagnosis in Section D, they simply record the presence or absence of specific clinical mood indicators. Facility staff should recognize these indicators and consider them when developing the residents individualized care plan. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3).

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section D. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section D: Mood may trigger the facility to conduct a Care Area Assessment.

• D0200A1 (CAA 7 Psychosocial Well-Being & CAA 10 - Activities)
• D0200I1 (CAA 8 Mood State)
• D0300 (CAA 8 Mood State)
• D0500A1 (CAA 7 Psychosocial Well-Being & CAA 10 - Activities)
• D0500I1 (CAA 8 Mood State)
• D0600 (CAA 8 Mood State)

Additional, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Section D: Mood.

• A0310A (CAA 8 Mood State)
• V0100E (CAA 8 Mood State)
• V0100F (CAA8 Mood State)

Case Mix

Some questions in Section D: Mood effect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section E: Behavior

The items in this section identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Behaviors include those that are potentially harmful to the resident himself or herself. The emphasis is identifying behaviors, which does not necessarily imply a medical diagnosis. Identification of the frequency and the impact of behavioral symptoms on the resident and on others is critical to distinguish behaviors that constitute problems from those that are not problematic. Once the frequency and impact of behavioral symptoms are accurately determined, follow-up evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact.

This section focuses on the resident's actions, not the intent of his or her behavior. Because of their interactions with residents, staff may have become used to the behavior and may underreport or minimize the residents behavior by presuming intent (e.g., Mr. A. doesnt really mean to hurt anyone. Hes just frightened.). Resident intent should not be taken into account when coding for items in this section. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter.

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section E. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section E: Behavior may trigger the facility to conduct a Care Area Assessment.

• E0200A (CAA2 Cognitive Loss/Dementia, & CAA7 Psychosocial Well-Being)
• E0200B (CAA2 Cognitive Loss/Dementia, & CAA7 Psychosocial Well-Being)
• E0200C (CAA2 Cognitive Loss/Dementia) E0300 (CAA 9 Behavioral Symptoms)
• E0800 (CAA2 Cognitive Loss/Dementia, & CAA9 Behavioral Symptoms)
• E0900 (CAA2 Cognitive Loss/Dementia, & CAA9 Behavioral Symptoms & CAA11 Falls)
• E1100 (CAA9 Behavioral Symptoms)

Additional, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Section E: Behavior.

• I4800 (CAA7 Psychosocial Well-Being)
• I4200 (CAA7 Psychosocial Well-Being)

Case Mix

Some questions in Section E: Behavior effect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section F: Preferences for Customary Routine and Activities

The intent of items in this section is to obtain information regarding the residents preferences for his or her daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. The information obtained during this interview is just a portion of the assessment. Nursing homes should use this as a guide to create an individualized plan based on the residents preferences and is not meant to be all-inclusive. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3).

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section F. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section F: Preferences for Customary Routine and Activities may trigger the facility to conduct a Care Area Assessment.

• F0500A (CAA 7 Psychosocial Well-Being & CAA 10 Activities)
• F0500B (CAA 7 Psychosocial Well-Being & CAA 10 Activities)
• F0500C (CAA 7 Psychosocial Well-Being & CAA 10 Activities)
• F0500D (CAA 7 Psychosocial Well-Being & CAA 10 Activities)
• F0500E (CAA 7 Psychosocial Well-Being & CAA 10 Activities)
• F0500F (CAA 7 Psychosocial Well-Being & CAA 10 Activities)
• F0500G (CAA 7 Psychosocial Well-Being & CAA 10 Activities)
• F0500H (CAA 7 Psychosocial Well-Being & CAA 10 Activities)
• F0600 (CAA 7 Psychosocial Well-Being)
• F0800L (CAA 10 Activities)
• F0800M (CAA 10 Activities)
• F0800N (CAA 10 Activities)
• F0800O (CAA 10 Activities)
• F0800P (CAA 10 Activities)
• F0800Q (CAA 7 Psychosocial Well-Being & CAA 10 Activities)
• F0800R (CAA 10 Activities)
• F0800S (CAA 10 Activities)
• F0800T (CAA 10 Activities)

Case Mix

Some questions in Section F: Preferences for Customary Routine and Activities effect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section G: Functional Status

Items in this section assess the need for assistance with activities of daily living (ADLs), altered gait and balance, and decreased range of motion. In addition, on admission, resident and staff opinions regarding functional rehabilitation potential are noted. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3).

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section G. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Supplemental Training Handouts - Balance During Transitions and Walking Algorithm (PDF) and Activities of Daily Living (ADL) Self-Performance Algorithm (PDF)

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section G: Functional Status may trigger the facility to conduct a Care Area Assessment.

• G0110A1 (CAA 5 ADL Functional/Rehabilitation Potential & CAA 16 Pressure Ulcer)
• G0110B1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110C1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110D1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110E1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110F1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110G1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110H1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0110I1 (CAA 5 ADL Functional/Rehabilitation Potential & CAA 6 Urinary Incontinence and Indwelling Catheter)
• G0110J1 (CAA 5 ADL Functional/Rehabilitation Potential)
• G0120A (CAA 5 ADL Functional/Rehabilitation Potential)
• G0300A (CAA 5 ADL Functional/Rehabilitation Potential & CAA 11 Falls)
• G0300B (CAA 5 ADL Functional/Rehabilitation Potential & CAA 11 Falls)
• G0300C (CAA 5 ADL Functional/Rehabilitation Potential & CAA 11 Falls)
• G0300D (CAA 5 ADL Functional/Rehabilitation Potential & CAA 11 Falls)
• G0300E (CAA 5 ADL Functional/Rehabilitation Potential & CAA 11 Falls)
• G0900A (CAA 5 ADL Functional/Rehabilitation Potential)
• G0900B (CAA 5 ADL Functional/Rehabilitation Potential)

Additional, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Section G: Functional Status

• C0500 (CAA 5 - ADL Functional/Rehabilitation Potential)
• C1000 (CAA 5 - ADL Functional/Rehabilitation Potential)

Case Mix

Some questions in Section G: Functional Status affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section GG: Functional Abilities and Goals

Updated 2019

Items in this section assess the need for assistance with activities of daily living (ADLs), altered gait and balance, and decreased range of motion. In addition, on admission, resident and staff opinions regarding functional rehabilitation potential are noted. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3).

Coding Training

Instructor Guides - CMS website for Skilled Nursing Facility Quality Reporting Program Measures and Technical Information. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Training Videos

• August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training
• Decision Tree for Coding GG0130, Self-Care and GG0170, Mobility
• Coding GG0130A, Eating
• Coding GG0170C, Lying to sitting side of bed
• Coding GG110 Prior Device Use with Information from Multiple Sources
• Coding GG0130B, Oral Hygiene

Care Area Triggers (CAT) and Care Area Assessments (CAA)

There are no CAAs and CATs for Section GG.

Case Mix

Some questions in Section GG: Functional Abilities and Goals affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section H: Bladder and Bowel

The intent of the items in this section is to gather information on the use of bowel and bladder appliances, the use of and response to urinary toileting programs, urinary and bowel continence, bowel training programs, and bowel patterns. Each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible. (CMS's Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers in the summer of 2010. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section H. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section H: Bladder and Bowel may trigger the facility to conduct a Care Area Assessment.

• H0100A (CAA 6 Urinary Incontinence and Indwelling Catheter)
• H0100B (CAA 6 Urinary Incontinence and Indwelling Catheter)
• H0100D (CAA 6 Urinary Incontinence and Indwelling Catheter)
• H0300 (CAA 6 Urinary Incontinence and Indwelling Catheter & CAA 16 Pressure Ulcer)
• H0400 (CAA 16 Pressure Ulcer)
• H0600 (CAA 14 Dehydration/Fluid Maintenance)

Additional, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Section H: Bladder and Bowel.

There are no compound responses for Section H: Bladder and Bowel.

Case Mix

Some questions in Section H: Bladder and Bowel affect Case Mix for RUG-IV (Medicare) and RUG-IV (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section I: Active Diagnoses

Updated 2019

The items in this section are intended to code diseases that have a direct relationship to the residents current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the residents current health status. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides (PDF) with Instructor Notes MDS used in CMS Training of Trainers (2010). You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the MDS Manual and MDS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section I. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos

• August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training
• Section A, I, J, and O Updates

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section I: Active Diagnoses may trigger the facility to conduct a Care Area Assessment

• I1700 (CAA 14 Dehydration/Fluid Maintenance)
• I2000 (CAA 14 Dehydration/Fluid Maintenance)
• I2100 (CAA 14 Dehydration/Fluid Maintenance)
• I2200 (CAA 14 Dehydration/Fluid Maintenance)
• I2300 (CAA 14 Dehydration/Fluid Maintenance)
• I2400 (CAA 14 Dehydration/Fluid Maintenance)
• I2500 (CAA 14 Dehydration/Fluid Maintenance)
• I4200 (CAA 7 Psychosocial Well-Being)
• I4800 (CAA 7 Psychosocial Well-Being)
• I6500 (CAA 3 Visual Function)

Additional, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Section I: Active Diagnoses Status

• E0200A (CAA 7 Psychological Well-Being)
• E0200B (CAA 7 Psychological Well-Being)
• M1040A (CAA 14 Dehydration/Fluid Maintenance)

Case Mix

Some questions in Section I: Active Diagnoses affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section J: Health Conditions

Updated 2019

The intent of the items in this section is to document a number of health conditions that impact the residents functional status and quality of life. The items include an assessment of pain which uses an interview with the resident or staff if the resident is unable to participate. The pain items assess the presence of pain, pain frequency, effect on function, intensity, management and control. Other items in the section assess dyspnea, tobacco use, prognosis, problem conditions, and falls. (CMS's Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section J. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Supplemental Training Handout - MDS 3.0 Training Aids for Section J: Health Conditions (PDF).

Training Videos

• August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training
• Section A, I, J, and O Updates

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section J: Health Conditions may trigger the facility to conduct a Care Area Assessment.

• J0400 (CAA 19 Pain)
• J0500A (CAA 19 Pain)
• J0500B (CAA 19 Pain)
• J0600A (CAA 19 Pain)
• J0600B (CAA 19 Pain)
• J0800A (CAA 19 Pain)
• J0800B (CAA 19 Pain)
• J0800C (CAA 19 Pain)
• J0800D (CAA 19 Pain)
• J1550A (CAA 14 Dehydration/Fluid Maintenance)
• J1550B (CAA 14 Dehydration/Fluid Maintenance)
• J1500C (CAA 12 Nutritional Status & CAA 14 Dehydration/Fluid Maintenance)
• J1550D (CAA 14 Dehydration/Fluid Maintenance)
• J1700A (CAA 11 Falls)
• J1700B (CAA 11 Falls)
• J1800 (CAA 11 Falls)

Additional, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Section J: Health Conditions

• A0310A (CAA 11 Falls)

Case Mix

Some questions in Section J: Health Conditions affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section K: Swallowing/Nutritional Status

The items in this section are intended to assess the many conditions that could affect the residents ability to maintain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss, and nutritional approaches. The assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have been assessed and calculated accurately. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for K. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section K: Swallowing/Nutritional Status may trigger the facility to conduct a Care Area Assessment.

• K0200A (CAA 12 Nutritional Status)
• K0200B (CAA 12 Nutritional Status)
• K0300 (CAA 12 Nutritional Status & CAA 16 Pressure Ulcer)
• K0310 (CAA 12 Nutritional Status) [Effective on or after 04/01/2012]
• K0500A (CAA 12 Nutritional Status & CAA 14 Dehydration/Fluid Maintenance) [Effective prior to 04/01/2012]
• K0500B (CAA 13 Feeding Tubes & CAA 14 Dehydration/Fluid Maintenance) [Effective prior to 04/01/2012]
• K0500C (CAA 12 Nutritional Status) [Effective prior to 04/01/2012]
• K0500D (CAA 12 Nutritional Status) [Effective prior to 04/01/2012]
• K0510A1 (CAA 12 Nutritional Status & CAA 14 Dehydration/Fluid Maintenance) [Effective on or after 04/01/2012]
• K0510A2 (CAA 12 Nutritional Status & CAA 14 Dehydration/Fluid Maintenance) [Effective on or after 04/01/2012]
• K0510B1 (CAA 13 Feeding Tubes & CAA 14 Dehydration/Fluid Maintenance) [Effective on or after 04/01/2012]
• K0510B2 (CAA 13 Feeding Tubes & CAA 14 Dehydration/Fluid Maintenance) [Effective on or after 04/01/2012]
• K0510C1 (CAA 12 Nutritional Status) [Effective on or after 04/01/2012]
• K0510C2 (CAA 12 Nutritional Status) [Effective on or after 04/01/2012]
• K0510D1 (CAA 12 Nutritional Status) [Effective on or after 04/01/2012]
• K0510D2 (CAA 12 Nutritional Status) [Effective on or after 04/01/2012]

Case Mix

Some questions in Section K: Swallowing/Nutritional Status affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section L: Oral/Dental Status

This item is intended to record any dental problems present in the 7-day look-back period. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers in the summer of 2010. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section L. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Video - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section L: Oral/Dental Status may trigger the facility to conduct a Care Area Assessment.

• L0200A (CAA 15 Dental Care)
• L0200B (CAA 15 Dental Care)
• L0200C (CAA 15 Dental Care)
• L0200D (CAA 15 Dental Care)
• L0200E (CAA 15 Dental Care)
• L0200F (CAA 15 Dental Care)

Additional, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Section L: Oral/Dental Status

There are no compound responses for Section L: Oral/Dental Status.

Case Mix

Some questions in Section L: Oral/Dental Status affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section M: Skin

The items in this section document the risk, presence, appearance, and change of pressure ulcers. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. It is important to recognize and evaluate each residents risk factors and to identify and evaluate all areas at risk of constant pressure. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Be certain to include in the assessment process, a holistic approach. It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound.

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section M. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Supplemental Training Handouts and Interview Aids Section M Activity Sheet Scenario 1 Activity 1 (PDF) and Section M Activity Sheet Scenario 2 Activity 2 (PDF). You will need these to complete the activities that are embedded in the CMS training on Section M.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section M: Skin may trigger the facility to conduct a Care Area Assessment.

• M0150 (CAA 16 – Pressure Ulcer/Injury)
• M0300A (CAA 16 – Pressure Ulcer/Injury)
• M0300B1 (CAA 12 – Nutritional Status & CAA 16 – Pressure Ulcer/Injury)
• M0300C1 (CAA 12 – Nutritional Status & CAA 16 – Pressure Ulcer/Injury)
• M0300D1 (CAA 12 – Nutritional Status & CAA 16 – Pressure Ulcer/Injury)
• M0300E1 (CAA 12 – Nutritional Status & CAA 16 – Pressure Ulcer/Injury)
• M0300F1 (CAA 12 – Nutritional Status & CAA 16 – Pressure Ulcer/Injury)
• M0300G1 (CAA 12 – Nutritional Status & CAA 16 – Pressure Ulcer/Injury)
• M0800A (CAA 16 – Pressure Ulcer/Injury) [Effective prior to 10/1/2018]
• M0800B (CAA 16 – Pressure Ulcer/Injury) [Effective prior to 10/1/2018]
• M0800C (CAA 16 – Pressure Ulcer/Injury) [Effective prior to 10/1/2018]
• M1040A (CAA 14 – Dehydration/Fluid Maintenance)
• M1040H (CAA 6 – Urinary Incontinence) [Effective on or after 04/01/2012]

Additionally, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Skin.

• I1700 (CAA 14 - Dehydration/Fluid Maintenance)
• I2000 (CAA 14 - Dehydration/Fluid Maintenance)
• I2100 (CAA 14 - Dehydration/Fluid Maintenance)
• I2200 (CAA 14 - Dehydration/Fluid Maintenance)
• I2300 (CAA 14 - Dehydration/Fluid Maintenance)
• I2400 (CAA 14 - Dehydration/Fluid Maintenance)
• I2500 (CAA 14 - Dehydration/Fluid Maintenance)

Case Mix

Some questions in Section M: Skin Conditions affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section N: Medications

The intent of the items in this section is to record the number of days, during the last 7 days (or since admission/reentry is less than 7 days) that any type of injection (subcutaneous, intramuscular or intradermal), insulin, and/or select medications were received by the resident. (CMS's) Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section N. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section N: Medications may trigger the facility to conduct a Care Area Assessment.

• N0400A (CAA 17 – Psychotropic Medication Use) [Effective prior to 04/01/2012]
• N0400B (CAA 11 – Falls & CAA 17 – Psychotropic Medication Use) [Effective prior to 04/01/2012]
• N0400C (CAA 11 – Falls & CAA 17 – Psychotropic Medication Use) [Effective prior to 04/01/2012]
• N0400D (CAA 17 – Psychotropic Medication Use) [Effective prior to 04/01/2012]
• N0410A (CAA 17 – Psychotropic Medication Use) [Effective on or after 04/01/2012]
• N0410B (CAA 11 – Falls & CAA 17 – Psychotropic Medication Use) [Effective on or after 04/01/2012]
• N0410C (CAA 11 – Falls & CAA 17 – Psychotropic Medication Use) [Effective on or after 04/01/2012]
• N0410D (CAA 17 – Psychotropic Medication Use) [Effective on or after 04/01/2012]

Case Mix

Some questions in Section N: Medications affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

 

Section O: Special Treatments, Procedures, and Programs

Updated 2019

The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods. (CMS's) Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section O. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Supplemental Training Handouts and Interview Aids Section O Activity 1 (PDF) and Section O Interview Aid (PDF). You will need these to complete the activities that are embedded in the CMSs training on Section O.

Training Videos

• August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training
• Section A, I, J, and O Updates

Care Area Triggers (CAT) and Care Area Assessments (CAA)

There are no responses in Section O that will trigger the facility to conduct a Care Area Assessment.

Case Mix

Some questions in Section O: Special Treatments, Procedures, and Programs affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section P: Restraints

The intent of this section is to record the frequency over the 7-day look-back period that the resident was restrained by any of the listed devices at any time during the day or night. Assessors will evaluate whether or not a device meets the definition of a physical restraint and code only the devices that meet the definition in the appropriate categories of Item P0100. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers in the summer of 2010. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - PowerPoint Slides (PDF) developed for Training of Trainers for Section P. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section P: Restraints may trigger the facility to conduct a Care Area Assessment.

• P0100A (CAA 18 – Physical Restraints)
• P0100B (CAA 11 – Falls, CAA 16 – Pressure Ulcer/Injury & CAA 18 - Physical Restraints)
• P0100C (CAA 18 – Physical Restraints) P0100D (CAA 18 – Physical Restraints)
• P0100D (CAA 18 – Physical Restraints)
• P0100E (CAA 11 – Falls, CAA 16 – Pressure Ulcer/Injury, & CAA 18 – Physical Restraints)
• P0100F (CAA 18 – Physical Restraints) P0100G (CAA 18 – Physical Restraints)
• P0100H (CAA 18 – Physical Restraints)

Additional, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Section P: Restraints.

There are no compound responses related to Section P: Restraints.

Case Mix

Some questions in Section P: Restraints affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section Q: Participation in Assessment and Goal Setting

The items in this section are intended to record the participation and expectations of the resident, family members, or significant other(s) in the assessment, and to understand the residents overall goals. Discharge planning follow-up is already a regulatory requirement (CFR 483.20(i)(3)). Section Q of the MDS uses a person-centered approach to ensure that all individuals have the opportunity to learn about home and community-based services and have an opportunity to receive long term care in the least restrictive setting possible. Interviewing the resident or designated individuals places the resident or their family at the center of decision-making. (CMS s Resident Assessment Instrument (RAI) Manual, Chapter 3)

Nursing Facility MDS 3.0 Section Q Referral Form (PDF)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section Q. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Supplemental Training Handouts - Section Q Supplemental Training Handout; Changes to Section Q as of April 1, 2012; Homeward Bound: Money Follows the Person; The Role of the Local Contact Agency in MDS Section Q

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following items in Section Q: Participation in Assessment and Goal Setting may trigger the facility to conduct a Care Area Assessment.

Q0600 (CAA 20 Return to Community Referral)

Case Mix

Some questions in Section Q: Participation in Assessment and Goal Setting affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). The MDS 3.0 Item Subset identifies relevant questions.

Section S: State of Maine Specific Items / Special Projects

Maine uses Section S to document location of the residents last community address. Maine's Section S Manual (PDF).

Access the Maine MDS Submission Management Systems (SMS) for validation reports.

Section V: Care Area Assessment (CAA) Summary

The MDS does not constitute a comprehensive assessment. Rather, it is a preliminary assessment to identify potential resident problems, strengths, and preferences. Care Areas are triggered by MDS item responses that indicate the need for additional assessment based on problem identification, known as triggered care areas, which form a critical link between the MDS and decisions about care planning.

There are 20 CAAs in Version 3.0 of the RAI, which includes the addition of Pain and Return to the Community Referral. These CAAs cover the majority of care areas known to be problematic for nursing home residents. The Care Area Assessment (CAA) process provides guidance on how to focus on key issues identified during a comprehensive MDS assessment and directs facility staff and health professionals to evaluate triggered care areas. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers in the summer of 2010. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS Power Point Slides (PDF) developed for Training of Trainers for Section V. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

Responses to the following Items in Section V: Care Area Assessment (CAA) Summary may trigger the facility to conduct a Care Area Assessment.

• V0100D (CAA 1 Delirium) [Effective prior to 10/1/2015]
• V0100E (CAA 8 Mood State)
• V0100F (CAA 8 Mood State)

Additional, compound responses to the following sections of the MDS 3.0 can trigger a Care Area Assessment directly related to Section V: Care Area Assessment Summary

• A0310A (CAA 1 Delirium) [Effective prior to 10/1/2015]
• A0310A (CAA 8 Mood State) [Effective prior to 10/1/2015]
• C0500 (CAA 1 Delirium) [Effective prior to 10/1/2015]
• D0300 (CAA 8 Mood State)
• D0600 (CAA 8 Mood State)

Section X: Correction Request

Updated 2019

The purpose of Section X is to identify an MDS record to be modified or inactivated. The following items identify the existing assessment record that is in error. Section X is only completed if Item A0050, Type of Record, is coded a 2 (Modify existing record) or a 3 (Inactivate existing record). In Section X, the facility must reproduce the information EXACTLY as it appeared on the existing erroneous record, even if the information is incorrect. This information is necessary to locate the existing record in the National MDS Database. (CMS's Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers in the summer of 2010. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section X. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training

Care Area Triggers (CAT) and Care Area Assessments (CAA)

There are no items in Section X: Correction Request that trigger a facility to conduct a Care Area Assessment.

There are no compound responses to Section X: Correction Request.

Section Z: Assessment Administration

Updated 2019

The intent of the items in this section is to provide billing information and signatures of persons completing the assessment. (CMSs Resident Assessment Instrument (RAI) Manual, Chapter 3)

Coding Training

Instructor Guides - PowerPoint Slides with Instructor Notes (PDF) used in CMS Training of Trainers in the summer of 2010. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.

Presentation Slides - CMS PowerPoint Slides (PDF) developed for Training of Trainers for Section Z. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.

Training Videos - August 2019 Skilled Nursing Facility Quality Reporting Program Provider Training.

Care Area Triggers (CAT) and Care Area Assessments (CAA)

There are no Items in Section Z: Assessment Administration that trigger a facility to conduct a Care Area Assessment.

There are no compound responses to Section Z: Assessment Administration