MDS 3.0 and the RAI Process
The MDS 3.0 and the RAI (Resident Assessment Instrument) is a comprehensive nurse assessment and care planning process used by the long-term and post-acute care field as a requirement for reimbursement under Medicare and Medicaid. AAPACN nurse experts help you stay up to date on changes to the MDS with breaking news, articles, and practical tools.
- TIP: Updated MDS 3.0 RAI User’s Manual Changes – New Definitions for Fall, Injury, and Major InjuryThe Centers for Medicare & Medicaid Services (CMS) released the final version of the RAI User’s Manual, version 1.20.1, which went into effect Oct. 1, 2025. CMS made several changes, including a new definition for …
- iQIES MDS Error Message Reference Guide and Message List v1.0This user guide addresses Minimum Data Set (MDS) error messages and troubleshooting. iQIES MDS Error Message Reference Guide v1.0 (posted 10/01/2025) iQIES MDS Error Messages v1.0 (posted 10/01/2025) From https://qtso.cms.gov/providers/nursing-home-mdsswing-bed-providers/reference-manuals
- CMS iQIES Reports User Manual v2.9This user manual provides information for CMS, Providers, Vendors, Accrediting Organizations, Contractors, and State Agencies to effectively perform Reports functions and the processes necessary to request, view, download, and save reports in iQIES. From https://qtso.cms.gov/software/iqies/reference-manuals
- Respiratory Therapy MDS Coding ChecklistRespiratory therapy, coded at O0390D and O0400D, must meet definitions and complex instructions per the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual). AAPACN’s Respiratory Therapy MDS Coding Checklist tool delineates the requirements …
- Question: How do you code walking if the resident only walks with therapy staff?Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, and Jessie McGill, RN, BSN, RAC-MTA, RAC-CTA: If the resident only walked with therapy, then the assessment for usual performance is based on the resident’s usual …
- Question: With the new definition of fall with major injury, would a bump on the head or a laceration be a head injury? With the new definition of fall with major injury, would a bump on the head or a laceration be a head injury?Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, and Jessie McGill, RN, BSN, RAC-MTA, RAC-CTA: Your team will need to assess each individual injury from a fall, using clinical standards of practice and clinical …
- Question: I am confused by the new section GG guidance for when the activity “is being/will be” routinely performed. What does “will” mean?Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, and Jessie McGill, RN, BSN, RAC-MTA, RAC-CTA: The term “will” in this coding tip is likely referring to the resident’s goals or preferences. The example in …
- QAPI Focus: Section GGAAPACN’s QAPI Focus: Section GG tool can be used at quality assurance and performance improvement (QAPI) meetings to focus specifically on concerns regarding section GG documentation and coding accuracy. This tool identifies specific section GG …
- TIP: CMS Released Additional Updates to RAI User’s Manual v1.20.1On Sept. 24, 2025, the Centers for Medicare & Medicaid Services (CMS) released an updated RAI User’s Manual version 1.20.1 and updated MDS item sets v1.20.1v4. The last-minute updates aligned the MDS item sets with …
- Should SNFs Collect Removed Section R MDS Data—and Why Do HRSN Even Matter?MDS section R (Health-Related Social Needs) did not go into effect on Oct. 1, 2025. The Centers for Medicare & Medicaid Services (CMS) followed through on its proposal and eliminated—prior to implementation—items R0310 (Living Situation), …
- Section O Overhaul: Changes to Therapy CodingThe Long-Term Care Resident Assessment Instrument (RAI) 3.0 User’s Manual (RAI User’s Manual) version 1.20.1, effective Oct. 1, 2025, will bring major changes to section O of the MDS 3.0. The most significant update introduces …
- PDPM Grouper JAR Package V2.4000This release was updated to support FY2026 ICD-10 codes which are used with MDS assessments with a target date on or after October 1, 2025. As part of this release, 487 clinical category mappings were added, …
- AAPACN Resources to Help Prepare for Oct. 1, 2025, MDS ChangesAAPACN Resources to Help Prepare for Oct. 1, 2025, MDS Changes The Long Term-Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual version 1.20.1 from the Centers for Medicare & Medicaid Services (CMS) goes into …
- Oct. 2025 RAI User’s Manual – Unexpected Updates In this LTC NAC Chat podcast episode, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, senior curriculum development specialist for AAPACN, discuss some …
- MDS 3.0 Quality Measures (QM) User’s Manual v17.0 Effective Jan. 1, 2025 and Associated User Manual FilesNOTABLE CHANGES TO THE MDS QM USER’S MANUAL V17 Guidance on Selecting MDS Section GG Item Columns for Measure Calculation An updated .zip file for the Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s …
- SNF QRP Measure Calculations and Reporting User’s Manual V7.0, Change Table, Risk Adjustment and Imputation Appendix Files, and HCC ICD-10 CrosswalksThe Skilled Nursing Facility Quality Reporting Program (SNF QRP) Measure Calculations and Reporting User’s Manual v7.0 and accompanying files are now available. These materials serve as an update to the specifications used to calculate quality measures that …
- OIG: Nursing Homes Failed To Report 43 Percent of Falls With Major Injury and Hospitalization Among Their Medicare-Enrolled ResidentsIssued on 09/15/2025 | Posted on 09/18/2025 | Report number: OEI-05-24-00180 Report Materials Why OIG Did This Review What OIG Found Nursing homes failed to report 43 percent of falls with major injury and hospitalization among Medicare-enrolled residents, as required, in …
- Q&A: We had a resident on a Medicare Part A stay admit and discharge back to the hospital that same evening after a few hours. We could not assess much information during that brief amount of time. What are all the required MDS assessments that need to be completed on this resident? I know an entry tracker and an OBRA discharge, but do we need to also complete a 5-Day PPS?Question: We had a resident on a Medicare Part A stay admit and discharge back to the hospital that same evening after a few hours. We could not assess much information during that brief amount …
- Q&A: The new definition of a fall includes an overwhelming external force, but the definition of fracture related to a fall states, “Do not include fractures caused by trauma related to car crashes or pedestrian versus car accidents or impact of another person or object against the resident.” Does this instruction contradict the new definition of a fall?Question: The new definition of a fall includes an overwhelming external force, but the definition of fracture related to a fall states, “Do not include fractures caused by trauma related to car crashes or pedestrian versus …
- MDS Item J2100 Feeds Into PDPM: Learn What’s at Stake and How to Boost AccuracyMDS item J2100 (Did the Resident Have a Major Surgical Procedure During the Prior Inpatient Hospital Stay That Requires Active Care During the SNF Stay?) is the gateway question for receiving enhanced reimbursement in the …
- Q&A: Can Isolation be coded for methicillin-resistant staphylococcus aureus (MRSA) on a wound?Question: Can Isolation be coded for methicillin-resistant staphylococcus aureus (MRSA) on a wound? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: No, the RAI User’s Manual specifically states that isolation cannot be coded for …
- FY 2028 (CY 2026 Data) SNF QRP Reporting Requirements and Data Submission DeadlinesSNF QRP Data Collection and Final Submission Deadlines The SNF QRP Data Collection and Final Submission Deadlines have been updated to provide the data collection time frames and final submission deadlines for the FY 2028 …
- FY 2027 (CY 2025 Data) Revised SNF QRP MDS Reporting Requirements and Data Submission DeadlinesSNF QRP Data Elements Used for Reporting Assessment-Based QMs and Standardized Patient Assessment Data Elements Affecting FY 2027 APU Determination and Data Collection and Final Submission Deadlines for FY 2027 posted The Skilled Nursing Facility …
- FY 2026 ICD-10 PDPM Mappings FileThis file can be used by NACs to determine how ICD-10-CM codes entered on the MDS “map” to PDPM payment components. https://www.cms.gov/medicare/payment/prospective-payment-systems/skilled-nursing-facility-snf/patient-driven-model
- Q&A: If an open area is found on day four after admission, is that still present on admission (7-day look-back period)? The definition of “present on admission” is “as close to admission as possible.”Question: If an open area is found on day four after admission, is that still present on admission (7-day look-back period)? The definition of “present on admission” is “as close to admission as possible.” Answer from …
- Q&A: A long-term resident went out to the hospital and returned on a skilled stay using his Managed Care plan. He has both a 5-Day and Annual scheduled for the same day, but at separate times. Do both of these get coded as “the first assessment” in A0310E?Question: A long-term resident went out to the hospital and returned on a skilled stay using his Managed Care plan. He has both a 5-Day and Annual scheduled for the same day, but at separate …
- Q&A: For section GG, the nurse aides use a mechanical lift transfer with two-person assist for transfers four times, but physical therapy transfers with one person and maximal assist once. Part of the dependent definition is “helper does all the effort” – but this was not true for all transfers—would this be dependent or maximal assistance?Question: For section GG, the nurse aides use a mechanical lift transfer with two-person assist for transfers four times, but physical therapy transfers with one person and maximal assist once. Part of the dependent definition …
- Crack the Code: Staff Assessment for Mental Status ItemsThe nurse assessment coordinator (NAC) plays an essential role in capturing a resident’s cognitive status by coordinating and coding the Staff Assessment for Mental Status in the Minimum Data Set (MDS). The Brief Interview for …
- Documentation Template: Isolation for Active Infectious DiseaseThe strict coding criteria for O0110M1, Isolation or quarantine for active infectious disease, requires precise documentation to support the MDS. AAPACN’s new Documentation Template: Isolation for Active Infectious Disease tool can help nurse assessment coordinators …
- TIP: CMS Released Final RAI User’s Manual for Oct. 1, 2025The Centers for Medicare & Medicaid Services (CMS) recently released the final version of the RAI User’s Manual, version 1.20.1, which goes into effect Oct. 1, 2025. While the draft version has been available for …
- Patient Health Questionnaire Completion DeterminationEffective Oct. 1, 2023, the full Patient Health Questionnaire (PHQ)-9 will only be completed if the resident responds to the gateway PHQ-2 questions in a certain way. The Patient Health Questionnaire Completion Determination chart clarifies …
- Oct. 1, 2025: MDS Changes At-a-GlanceThe Centers for Medicare & Medicaid Services (CMS) released unexpected changes in the final RAI User’s Manual, version 1.20.1, which goes into effect Oct. 1, 2025. The AAPACN MDS Changes At-a-Glance tool provides a high-level …
- Top Four GG Strategies: Preparing for the October UpdatesThe importance of accurate coding of section GG, Functional Abilities, continues to grow as this data is used in care planning, Quality Measures, reimbursement, and regulatory compliance. The Centers for Medicare & Medicaid Services (CMS) …
- MDS Data Specifications V3.10.2 (FINAL) for Oct. 1, 2025The MDS Data Specifications V3.10.2 (FINAL) are now available for download. This version reflects changes finalized in the FY 2026 SNF PPS final rule (90 FR 37310). Note that there are some minor changes since DRAFT 3 …
- A New Way to Validate Your NAC KnowledgeIn this LTC NAC Chat podcast episode, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, senior curriculum development specialist for AAPACN, discuss a …
- Back to PDPM Basics – Part 2: The SLP ComponentSince the implementation of the Patient-Driven Payment Model (PDPM), nursing facilities have had to take a more nuanced approach to how a resident’s needs are assessed and documented. As discussed in part 1 of this …
- Q&A: Can I count IV fluids and IV antibiotics that were administered in the hospital before admission and within the 7-day look-back period?Question: Can I count IV fluids and IV antibiotics that were administered in the hospital before admission and within the 7-day look-back period? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: IV fluid provided …
- Q&A: I miscalculated the ARD window for a 5-Day and scheduled the 5-Day/PPS Discharge on day 9 of the Medicare stay. What do I need to do?Question: I miscalculated the ARD window for a 5-Day and scheduled the 5-Day/PPS Discharge on day 9 of the Medicare stay. What do I need to do? Answer from Jeff Taylor:Leave everything as it is …
- Q&A: Does the 14-day look-back period for section O include days prior to entry into the facility?Question: Please clarify if section O “while a resident.” Per the RAI User’s Manual, “Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within …
- SNF QRP and SNF VBP Validation Program FAQs UpdatedOverview What is the SNF Validation Program? The SNF Validation Program is an audit-driven initiative aimed at evaluating the accuracy of quality measure data elements derived from the Minimum Data Set (MDS), which are used …
- iQIES Assessment Management: Assessment Submitter ManualThis document shows how to upload assessments, create and manage assessments, complete change requests, and review Final Validation Reports (FVR) in iQIES. CMS iQIES Assessment Management for Assessment Submitter v2.0 From https://qtso.cms.gov/software/iqies/reference-manuals
- May 2025 Falls With Major Injury Technical Expert Panel (TEP) Summary ReportThe Centers for Medicare & Medicaid Services (CMS) convened a Technical Expert Panel (TEP) on May 12 and 14, 2025, to obtain input on potential cross-setting updates to the Falls with Major Injury (FMI) measure. …
- iQIES User Roles Matrix Job AidThis job aid outlines the user roles and privileges in iQIES. All users must have a role in iQIES. iQIES User Roles Matrix Job Aid v4.5 – 07/29/2025 (PDF 2.56 MB)
- FY 2026 ICD-10-CM Code Updates and Coding Guidelines for Oct. 1, 2025 From CMS/CDCCDC announces new ICD-10-CM codes effective October 1, 2025. The October 1, 2025 diagnosis code update files are now available. Use these files for discharges occurring from October 1, 2025 – September 30, 2026, and for …
- Q&A: When should I set an assessment reference date (ARD) for a Significant Change in Status Assessment (SCSA) after a resident elected hospice?Question: When should I set an assessment reference date (ARD) for a Significant Change in Status Assessment (SCSA) after a resident elected hospice? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: The …
- Q&A: I know that McGeer criteria must be met when coding a UTI that develops in-house during the SNF stay, but what is required when a resident is transferred to the hospital and returns to the SNF with a documented UTI diagnosis (e.g., listed on the discharge summary and on antibiotics)?Question: I know that McGeer criteria must be met when coding a UTI that develops in-house during the SNF stay, but what is required when a resident is transferred to the hospital and returns to …
- TIP: CMS Finalizes Removal of Section RThe Centers for Medicare & Medicaid Services (CMS) noted in the FY 2026 SNF PPS Final Rule, “After consideration of the public comments, we are finalizing our proposal to remove four standardized patient assessment data …
- MDS Nutrition Is Not Limited to Section KWritten by Kristine Martinez, BSN, RN, RAC-CT, RAC-CTA, QCP, DNS-CT, MDS Consultants Often, section K on the minimum data set (MDS), along with the associated care area assessments (CAAs) and care planning are delegated to …
- Nurse Assessment Coordinator FTE Calculator ToolAAPACN has re-released the Nurse Assessment Coordinator (NAC) FTE Calculator for SNF leaders to estimate the time needed to complete assessments as well as project how many hours the NAC needs for meetings and other …
- FY 2026 SNF PPS Final Rule PostedOn July 31, 2025, the Centers for Medicare & Medicaid Services (CMS) issued a final rule for updates to Medicare payment policies and rates for skilled nursing facilities under the Skilled Nursing Facility Prospective Payment …
- Back to PDPM Basics – Part 1: The PT and OT ComponentsIn skilled nursing facilities (SNFs), staff members often find the Patient-Driven Payment Model (PDPM) process complex and unfamiliar, especially when determining how Medicare (and, in many states, Medicaid) payment is calculated. PDPM is based on …
- Q&A: A resident elected hospice on July 9, 2025. What is the required completion date for the Significant Change in Status Assessment (SCSA), and what steps should be taken if the resident passes away before the assessment is completed?Question: A resident elected hospice on July 9, 2025. What is the required completion date for the Significant Change in Status Assessment (SCSA), and what steps should be taken if the resident passes away before …
- Q&A: Is aspirin coded as an antiplatelet in N0415I?Question: Is aspirin coded as an antiplatelet in N0415I? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: The RAI User’s Manual includes aspirin as an antiplatelet medication on page N-9: “N0415I1. Antiplatelet: Check if …
- Q&A: How do we code interviews that were not complete when a Medicare resident has an unplanned discharge to the hospital?Question: How do we code interviews that were not complete when a Medicare resident has an unplanned discharge to the hospital? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: If the interviews were not …
- Crack the Code: A0310EWhen completing any Minimum Data Set (MDS) assessment, accurate coding of A0310E is critical. This item is completed on OBRA (Omnibus Budget Reconciliation Act), scheduled PPS (Prospective Payment System), and OBRA discharge assessments. It asks, …
- Myers and Stauffer Medicaid LinksMyers and Stauffer provides documentation resources and training opportunities for several state Medicaid programs. Learn more below. State Clients Alabama Iowa North Carolina Arkansas Kentucky Ohio California Louisiana Oregon Colorado Maryland Tennessee Connecticut Minnesota Texas …
- Q&A: If a resident initiates his/her discharge for the following day and the facility was able to organize home care, equipment, etc., is this considered a planned or unplanned discharge?Question: If a resident initiates his/her discharge for the following day and the facility was able to organize home care, equipment, etc., is this considered a planned or unplanned discharge? Answer from Jessie McGill RN, …
- Q&A: The RAI User’s Manual guidance for mechanically altered diet mentions “soft solids.” Would that include solids that are naturally soft or solids that we would “soften”?Question: The RAI User’s Manual guidance for mechanically altered diet mentions “soft solids.” Would that include solids that are naturally soft or solids that we would “soften”? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, …
- MDS Changes Oct. 2025 – What We Know Right NowIn this LTC NAC Chat podcast episode, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, Jessie McGill, RN, BSN, RAC-MT, RAC-MTA, senior curriculum development specialist with AAPACN, discuss the MDS …
- Coding High-Risk Drug Classes: How to Improve N0415 AccuracyN0415 (High-Risk Drug Classes: Use and Indication) is much more than just paperwork. This MDS item impacts resident care through the care area triggers (CATs) and the care area assessments (CAAs), as well as facility …
- Out the Door, On a Leave, or Gone for Good? Uncomplicating DischargesIn the fast-paced position of a nurse assessment coordinator (NAC), keeping track of all the residents’ whereabouts can be challenging. The NAC must know who is coming into the facility and if this resident is …
- CMS Nursing Home Data Sets UpdatedProvider Information General information on currently active nursing homes, including number of certified beds, quality measure scores, staffing and other information used in the Five-Star Rating System. Data are presented as one row per nursing …
- From the CATs to the QMs: Key Impacts of MDS Section NMDS section N (Medications)—in particular item N0415 (High-Risk Drug Classes: Use and Indication)— plays a key role in a nursing home’s ability to provide comprehensive, resident-centered care via the care area triggers (CATs) and the …
- Q&A: If the resident was in the emergency department (ED) and then admitted to the hospital before readmitting to the nursing home, can I capture IV fluids at the ED visit? Question: If the resident was in the emergency department (ED) and then admitted to the hospital before readmitting to the nursing home, can I capture IV fluids at the ED visit? Answer from Jessie …
- Q&A: A long-term care resident has a Quarterly assessment due on 6/19 and an Annual assessment due on 6/27. Can I do the Annual assessment early, before the Quarterly deadline?Question: A long-term care resident has a Quarterly assessment due on 6/19 and an Annual assessment due on 6/27. Can I do the Annual assessment early, before the Quarterly deadline? Answer from Carol Maher, RN, …
- Resident Interview ToolkitThe AAPACN Resident Interview Toolkit helps nursing home staff conduct effective resident interviews as part of the MDS 3.0 assessment process. It provides clear guidance and resources for the entire interdisciplinary team—nurses, dietary managers, social …
- COVID-19 Vaccine “Up to Date” Guidance TrackerThe Centers for Disease Control and Prevention (CDC) has updated the “Staying Up to Date with COVID-19 Vaccines” guidance several times since requiring COVID-19 vaccinations to be coded on the MDS as of October 2024. …
- Q&A: When a resident returns from an interrupted stay, is an IPA required or any kind of readmission assessment if no change?Question: When a resident returns from an interrupted stay, is an IPA required or any kind of readmission assessment if no change? Answer from Jeff Taylor: IPAs are always optional. In an interrupted stay, no …
- Q&A: A resident on a Medicare Part A stay discharged return not anticipated. His last covered day of Medicare was the day before. Can I combine the Part A PPS Discharge with the OBRA discharged return not anticipated?Question: A resident on a Medicare Part A stay discharged return not anticipated. His last covered day of Medicare was the day before. Can I combine the Part A PPS Discharge with the OBRA discharged …
- Q&A: For section GG documentation, the direct care staff was given the wrong dates. It was supposed to be the ARD and the two days before, but they did the first 3 days of the look-back period. Am I able to use any of the GG documentation they completed?Question: For section GG documentation, the direct care staff was given the wrong dates. It was supposed to be the ARD and the two days before, but they did the first 3 days of the …
- TIP: CMS Released Updated Draft MDS Item Sets for Oct. 2025The Centers for Medicare & Medicaid Services (CMS) recently released the updated draft Minimum Data Set (MDS) 3.0 Item Sets version (v)1.20.1v3-Section and updated Matrix. The newly added section R has been removed with this …
- SNF QRP Quick Reference GuideAn updated Quick Reference Guide is now available. The Quick Reference Guide provides high-level information on the SNF Quality Reporting Program, including frequently asked questions and helpful links. PAC-SNF-QuickReferenceGuide-20250508 (PDF) From https://www.cms.gov/medicare/quality/snf-quality-reporting-program/submission-deadlines
- ICD-10-CM Diagnosis SequencingIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, chief nursing officer for AAPACN, and Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, curriculum development specialist with AAPACN, discuss the sequencing of ICD-10-CM diagnosis coding. Additional …
- Q&A: Do I code J1400, Prognosis, as yes when a resident is under palliative care and not hospice? There is no physician documentation certifying or stating the physician’s belief that the resident’s terminal illness is that their life expectancy is six months or less. Question: Do I code J1400, Prognosis, as yes when a resident is under palliative care and not hospice? There is no physician documentation certifying or stating the physician’s belief that the resident’s terminal illness is that their …
- Q&A: What is considered as the most updated COVID-19 vaccine to code on the MDS?Question: What is considered as the most updated COVID-19 vaccine to code on the MDS? Answer from Jessie McGill RN, BSN, RAC-MTA, RAC-CTA: To determine up to date, we must reference the Staying Up to …
- Q&A: For the PHQ-2 to 9 interview, if the resident is at least sometimes understood and the interview is attempted, but the resident did not respond to the first two questions, how is this coded and can we proceed to the Staff Interview of Mood?Question: For the PHQ-2 to 9 interview, if the resident is at least sometimes understood and the interview is attempted, but the resident did not respond to the first two questions, how is this coded …
- Deep Dive into ICD-10-CM: Diagnosis Sequencing GuidelinesThe International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code assignment continues to be a bit of an enigma in the long-term care setting. Members regularly ask questions about ICD-10-CM coding in AAPACN’s online …
- Q&A: A resident discharged to the hospital with an unstageable pressure ulcer due to eschar (occurred in house). The wound was debrided in the hospital and then the resident returned with it being a Stage 3 pressure ulcer. Would this be presented upon reentry since it’s now a Stage 3?Question: A resident discharged to the hospital with an unstageable pressure ulcer due to eschar (occurred in house). The wound was debrided in the hospital and then the resident returned with it being a Stage …
- Q&A: A resident had a chest tube placed in the hospital and removed prior to re-admission. In the 5-Day look-back period, we have orders for an ointment and dressing to the area daily until resolved. Would I capture this under surgical wound and surgical wound care?Question: A resident had a chest tube placed in the hospital and removed prior to re-admission. In the 5-Day look-back period, we have orders for an ointment and dressing to the area daily until resolved. …
- Q&A: Is an OBRA Discharge assessment required when a non-skilled resident has an unplanned transfer to the hospital, was not admitted, but was there for 30 hours?Question: Is an OBRA Discharge assessment required when a non-skilled resident has an unplanned transfer to the hospital, was not admitted, but was there for 30 hours? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, …
- GG Trivia GameAAPACN’s GG Trivia Game is a fun education tool to help nurse aides and other direct care staff understand the performance levels and functional tasks for section GG. The nurse assessment coordinator or delegate hosts …
- Care Conference 101: Keys to a Meaningful MeetingA well-run care conference or care plan meeting can help the interdisciplinary team (IDT) improve the resident’s quality of care and quality of life by establishing a more resident-centered, individualized, culturally competent, and trauma-informed care …
- Q&A: On admission, our infection control nurse asks about the COVID-19 vaccine and documents the resident’s vaccine status and acceptance or refusal of the vaccine. Since we are no longer providing the vaccine in the facility, should I be dashing this item? Question: On admission, our infection control nurse asks about the COVID-19 vaccine and documents the resident’s vaccine status and acceptance or refusal of the vaccine. Since we are no longer providing the vaccine in the …
- Q&A: Do the medications gabapentin/Neurontin get coded in section J, Scheduled pain medication regimen, if the doctor noted they are for pain management, and are they also coded as anticonvulsants in section N?Question: Do the medications gabapentin/Neurontin get coded in section J, Scheduled pain medication regimen, if the doctor noted they are for pain management, and are they also coded as anticonvulsants in section N? Answer from …
- TIP: CMS Released Draft RAI User’s Manual for Oct. 2025The Centers for Medicare & Medicaid Services (CMS) released a draft of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (RAI User’s Manual) v1.20.1, which is planned to become effective Oct. 1, 2025. This …
- October 2025: Draft MDS Item Sets and RAI User’s ManualThe Centers for Medicare & Medicaid Services (CMS) recently released a second version of the draft item set files for Oct. 1, 2025, updates, version 1.20.1v2, and the draft Long-Term Care Facility Resident Assessment Instrument …
- Q&A: When coding urinary tract infection (UTI) at I2300, if the diagnosis of UTI was made prior to resident admission, is it optional to use evidence-based criteria (e.g., NHSN), which would exclude the UTI prior to admission? Question: When coding urinary tract infection (UTI) at I2300, the RAI User’s Manual states that if diagnosis of UTI was made prior to resident admission it is not necessary to evaluate for evidence-based criteria and …
- Q&A: We recently had a state case-mix audit, and I had to correct an error that resulted in a new Care Area Assessment (CAA) triggering. My software gave me a warning that a significant correction was indicated. How do I know if a significant correction is needed and how do I schedule this?Question: We recently had a state case-mix audit, and I had to correct an error that resulted in a new Care Area Assessment (CAA) triggering. My software gave me a warning that a significant correction …
- Q&A: Should MDS Item I0020B always be the diagnosis from the qualifying hospital stay? How do I code this for a resident who has been in long-term care for many years and has no recent hospital stays?Question: Should MDS Item I0020B always be the diagnosis from the qualifying hospital stay? How do I code this for a resident who has been in long-term care for many years and has no recent …
- Breathe Easy: Code Respiratory Therapy AccuratelyIn long-term care (LTC) facilities, many residents need care for chronic and acute respiratory problems, such as chronic obstructive pulmonary disease (COPD), pneumonia, tracheostomy, and post-COVID complications. LTC nurses need to know how to manage …
- Ethics in MDS Coding: Reimbursement and Quality MeasuresIn long-term care, the Minimum Data Set (MDS) ensures appropriate care planning, accurate reimbursement, and quality measurement while maintaining compliance with federal and state regulations. However, MDS coding may pose some ethical challenges. Completing the …
- Q&A: When coding K0100, Swallowing Disorders, can we capture signs and symptoms if they were identified when the resident was working with speech-language pathology (SLP) and on a trial diet?Question: When coding K0100, Swallowing Disorders, can we capture signs and symptoms if they were identified when the resident was working with speech-language pathology (SLP) and on a trial diet? Answer from Jennifer LaBay RN, …
- Q&A: A resident enrolled in hospice services and expired the next day. Do I still need to complete a Significant Change in Status Assessment (SCSA)?Question: A resident enrolled in hospice services and expired the next day. Do I still need to complete a Significant Change in Status Assessment (SCSA)? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC The …
- Section GG Accuracy: Helping Nursing Homes Get Fair Payment and ReferralsThe ongoing staffing shortage amid growing economic turbulence and payment pressures means that every nursing home in the country is currently struggling with reimbursement, says Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC, director …
- Q&A: We have a Medicare Part A resident who was only skilled by nursing at the end of the stay. How do we code GG items that only therapy perform, such as car transfers and stairs, if the resident was no longer receiving therapy services during the 3-day look-back window at the time of discharge? Question: We have a Medicare Part A resident who was only skilled by nursing at the end of the stay. How do we code GG items that only therapy perform, such as car transfers and …
- Q&A: A Medicare Part A resident passed away in the emergency department. I know a Death in Facility record needs to be completed, but do I also need to complete a Medicare Part A PPS discharge assessment?Question: A Medicare Part A resident passed away in the emergency department. I know a Death in Facility record needs to be completed, but do I also need to complete a Medicare Part A PPS …
- Q&A: To code K0300A for a physician-ordered weight loss, does the physician need to write a progress note that weight loss is intended or will an order for a diuretic automatically make the weight loss planned?Question: To code K0300A for a physician-ordered weight loss, does the physician need to write a progress note that weight loss is intended or will an order for a diuretic automatically make the weight loss …
- Care Conference: How Do Resident Rights Connect to Care Planning?Some nurse assessment coordinators (NACs) may believe that having a care conference (aka care plan meeting) with the resident and/or their responsible party or family member is a regulatory requirement. “However, no regulations actually use …
- Q&A: Our facility had an influenza-A outbreak with testing from lab. Can we write an ICD-10 code for this for all impacted residents?Question: Our facility had an influenza-A outbreak with testing from lab. Can we write an ICD-10 code for this for all impacted residents? Answer from Jeff Taylor: You need a provider (physician or physician extender) …
- Q&A: For GG0130A, Eating, the RAI User’s Manual states this is the ability to bring food/liquids to the mouth once the meal is placed in front of the resident. How do you code if the resident only needs help opening cartons? Question: For GG0130A, Eating, the RAI User’s Manual states this is the ability to bring food/liquids to the mouth once the meal is placed in front of the resident. How do you code if the …