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MDS 3.0 and the RAI Process

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 Injury
    The 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 v1.0
    This 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 v2.9
    This 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 Checklist
    Respiratory 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 GG
    AAPACN’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 v1.20.1
    On 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 Coding
    The 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 V2.4000
    This 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 Changes
    AAPACN 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 Files
    NOTABLE 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 Crosswalks
    The 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 …
  • MDS Item J2100 Feeds Into PDPM: Learn What’s at Stake and How to Boost Accuracy
    MDS 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 …
  • FY 2028 (CY 2026 Data) SNF QRP Reporting Requirements and Data Submission Deadlines
    SNF 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 2026 ICD-10 PDPM Mappings File
    This 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
  • Crack the Code: Staff Assessment for Mental Status Items
    The 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 Disease
    The 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 …
  • Patient Health Questionnaire Completion Determination
    Effective 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-Glance
    The 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 …
  • MDS Data Specifications V3.10.2 (FINAL) for Oct. 1, 2025
    The 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 Knowledge
    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 a …
  • Back to PDPM Basics – Part 2: The SLP Component
    Since 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 …
  • SNF QRP and SNF VBP Validation Program FAQs Updated
    Overview 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 Manual
    This 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
  • iQIES User Roles Matrix Job Aid
    This 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/CDC
    CDC 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 …
  • MDS Nutrition Is Not Limited to Section K
    Written 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 Tool
    AAPACN 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 Posted
    On 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 Components
    In 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 …
  • Crack the Code: A0310E
    When 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 Links
    Myers 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 …
  • MDS Changes Oct. 2025 – What We Know Right Now
    In 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 Accuracy
    N0415 (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 Discharges
    In 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 Updated
    Provider 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 N
    MDS 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 …
  • Resident Interview Toolkit
    The 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 Tracker
    The 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. …
  • SNF QRP Quick Reference Guide
    An 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 Sequencing
    In 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 …
  • Deep Dive into ICD-10-CM: Diagnosis Sequencing Guidelines
    The 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 …
  • GG Trivia Game
    AAPACN’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 Meeting
    A 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 …
  • Breathe Easy: Code Respiratory Therapy Accurately
    In 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 Measures
    In 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 …
  • 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 …
  • Uncomplicating Drug Classifications
    Medications are an essential part of the care and interventions provided to residents in a skilled nursing facility. These medications may be used to manage chronic conditions, slow disease progress, ease symptoms, or even prevent …
  • October 2025 MDS Draft Item Sets: The SDOH Should Drive the NAC’s Planning
    On Oct. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) released the draft MDS version 1.20.1 item sets and item matrix for implementation on Oct. 1, 2025. The change history included with the …
  • MDS 3.0 QM User’s Manual V17.0 and Risk Adjustment Appendix
    The Minimum Data Set (MDS) 3.0 Quality Measures (QM) User’s Manual Version (V)17.0 is now available. The MDS 3.0 QM User’s Manual V17.0 contains detailed specifications for the MDS 3.0 QMs and includes a Notable …
  • ICD-10-CM: Navigating the Term “With,” Combination Codes, and Complications of Care
    Accurate diagnosis coding is critical in nursing facilities (NFs) for care planning, reimbursement, and quality measurement. NF coders must understand ICD-10-CM conventions, general coding guidelines, and chapter-specific coding guidelines that affect how diagnoses are assigned. …
  • Q&A: When a resident received IV fluids (K0520A) for hydration, but did not have any calories from the fluids, do we code K0710A (Proportion of total calories the resident received through parenteral or tube feeding) as 1. 25% or less?
    Question: When a resident received IV fluids (K0520A) for hydration, but did not have any calories from the fluids, do we code K0710A (Proportion of total calories the resident received through parenteral or tube feeding) …
  • Q&A: A resident was admitted to our facility on Medicare Part A and passed in facility after only a couple of hours. I had scheduled a 5-Day/Admission for the 7th day before she passed. How do I set up MDS assessments?
    Question: A resident was admitted to our facility on Medicare Part A and passed in facility after only a couple of hours. I had scheduled a 5-Day/Admission for the 7th day before she passed. How …
  • Demystifying the Discharge Function Score for Post-Acute Care
    By Greg Seiple Navigating the complexities of healthcare, especially in post-acute care, can often feel daunting. For professionals involved in skilled nursing facilities, understanding the metrics that influence patient care is crucial. One of these …
  • Why Getting MDS Right Is Non-Negotiable: The Importance of MDS Accuracy
    Written by Kristine Martinez BSN, RN, RAC-CTA, QCP Completing a Minimum Data Set (MDS) correctly is no small task. With approximately 510 answers or choices on a comprehensive MDS (not including CAA investigation), and approximately530 answers …
  • Mastering the Discharge Function Score for Skilled Nursing Facilities
    By Greg Seiple Discharge planning is an essential component of patient care in skilled nursing facilities. But how do healthcare professionals determine when a resident is ready to leave and manage daily activities independently? Enter …
  • GG0130 and GG0170: Using Clinical Judgment to Establish Usual Performance
    The ability to exercise clinical judgment to define usual performance in MDS items GG0130 (Self-Care) and GG0170 (Mobility) offers nursing homes unprecedented opportunity to impact quality measures (QMs), says Rosanna Benbow, RN, CCM, ICC, IP, …
  • OIG: Nursing Facility Industry Segment-Specific Compliance Program Guidance
    From https://oig.hhs.gov/compliance/nursing-facility-icpg/ The Nursing Facility ICPG—together with OIG’s General Compliance Program Guidance (GCPG) that applies to all individuals and entities involved in the health care industry—serves as OIG’s updated and centralized source of voluntary compliance program guidance for …
  • SNF ABN Update: What Changed and How to Keep the Process Running Smoothly
    Effective Oct. 31, 2024, skilled nursing facilities (SNFs) now are required to use an updated Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage (SNF ABN), also known as form CMS-10055, and the corresponding revised instructions …
  • Ethics and Ramifications of Backdating the MDS
    Backdating, or placing an earlier date than the actual date on a document, is only permissible in limited Minimum Data Set (MDS) scenarios. Has anyone asked the nurse assessment coordinator (NAC) to change the assessment …
  • Break the Bad Data Cycle: Keys to Boosting Accuracy in GG0130 and GG0170
    MDS items GG0130 (Self-Care) and GG0170 (Mobility) are a common source of headaches for both the nurse assessment coordinator (NAC) and the interdisciplinary team (IDT). While there is no one-size-fits-all approach for obtaining accurate documentation …
  • Follow-Up Answers to Q&A from ICD-10 Updates Sept. 12, 2024, AAPACN Webinar
    In this podcast, AAPACN Curriculum Development Specialists, Jessie McGill, RN, BSN, RAC-MT, RAC-MTA and Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC, discuss a few of the questions asked during the recent AAPACN webinar, “How to …
  • Moving Forward Coalition Guide to Addressing Resident Goals, Preferences, and Priorities
    The Moving Forward Coalition, in partnership with A.G. Rhodes, Kansas State University (KSU), Dash Media, and The John A. Hartford Foundation, presents “The Foundation of Our Work: What Matters Most to Residents”! Why do we …
  • Section GG Strategies: Documentation and Collaboration
    Section GG has greatly evolved since 2016. It was first introduced as just a few functional items completed only for Medicare Part A residents, but now it requires 26 functional tasks for all long-term care …
  • Improving Resident Care Through Effective Communication: The MDS 3.0 Scripted Interview
    Effective communication with residents in skilled nursing facilities (SNFs) is essential to understand their needs and preferences. In accordance with Appendix D of the Long-Term Care Facility Resident Assessment 3.0 User’s Manual (RAI User’s Manual) …
  • PPS Discharge Assessment: 10 Steps to a More Complete, Accurate MDS
    The Medicare Part A PPS Discharge assessment (i.e., the NPE item set) is now a crucial assessment with far-reaching impacts for skilled nursing facilities (SNFs) in the Skilled Nursing Facility Quality Reporting Program (SNF QRP), …
  • Sepsis: Nurse Documentation Training Aid
    Starting Oct. 1, 2024, additional supporting documentation is required to capture a diagnosis of sepsis at I2100, Septicemia on the MDS. Nurse assessment coordinators can use the AAPACN Sepsis: Nurse Documentation Training Aid to provide …
  • GG Goals: Not Really Gone
    Effective Oct. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) removed column 2, discharge goals, from items GG0130 and GG0170 on the Minimum Data Set (MDS). Many nurse assessment coordinators will welcome the …
  • I0020B: Avoid Common Sources of Confusion When Coding This MDS Item
    The ICD-10-CM code captured in MDS item I0020B (ICD-10 Code/Primary Medical Condition Category) is the foundation of case-mix classification for the Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) payment components in the …
  • Section GG Web-based Training Series From CMS
    The Centers for Medicare & Medicaid Services (CMS) is offering an updated series of web-based training courses that provide an overview of the assessment and guidance to promote accurate coding of the post-acute care (PAC) …
  • Preferences and Routines: Use Section F to Collaborate on the Care Plan
    The Resident Assessment Instrument (RAI) process begins with the Minimum Data Set (MDS) assessment and ends with the resident-centered comprehensive care plan. In the MDS, section F focuses on the resident’s preferences for customary routines …
  • Template for Care Area Assessment Summary Note
    AAPACN’s Template for Care Area Assessment (CAA) Summary Note can help guide the interdisciplinary team members through how to determine and document rationale for the care plan determination by summarizing the underlying causes, contributing factors, …
  • CMS Patient Mood Interview (Patient Health Questionnaire PHQ-2 to 9) Video Tutorial
    The Centers for Medicare & Medicaid Services (CMS) is offering a video tutorial for completing D0150, Patient Mood Interview (PHQ-2 to 9) and D0160, Total Severity Score. This video depicts two scenarios that demonstrate the coding …
  • Individualized Care Plan: Made to Order
    Think about individualization like the almost endless variations of coffee drinks available these days. With an extra pump of this or a drizzle of that, we enjoy endless ways to individualize our order. Beyond coffee, …
  • PPS Discharge Assessment: Why Is It More Important Than Ever?
    Nurse assessment coordinators (NACs) will soon begin preparing the interdisciplinary team for the finalized MDS 3.0 version 1.19.1 item set changes, as well as the revised coding instructions in the yet-to-be-finalized Long-Term Care Facility Resident …
  • FY 2025 Final MDS 3.0 Item Sets version 1.19.1 Effective Oct. 1, 2024
    The final Minimum Data Set (MDS) 3.0 Item Sets version (v)1.19.1 are now available. The MDS Item Sets v1.19.1 will be effective beginning October 01, 2024. Items in sections A, B, D, GG, I, J, …
  • Social Determinants of Health (SDOH) MDS Coding Explainer Video
    The Centers for Medicare & Medicaid Services is offering a 4-minute, animated explainer video, Social Determinants of Health (SDOH) Items: Using Sources Other Than the Resident to Code for SNF providers. This video is intended to assist providers …
  • MDS Tools to Make the NAC’s Job Easier
    In this podcast, 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, and Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, curriculum development specialists for …
  • MDS Coding Criteria for Restorative Nursing Programs
    Restorative nursing programs must meet specific criteria to code on the MDS. Failure to meet these criteria will result in inability to capture restorative nursing on the MDS. Nurse assessment coordinators can use the MDS …
  • Navigating B0700 and MDS Interviews
    It’s the “Which came first, the chicken or the egg?” question of the Minimum Data Set (MDS) world: Which do you assess first, B0700 or the MDS scripted interviews? It’s easy to get lost in …
  • Isolation Coding on the MDS: MAC Target Drives Home Documentation Needs
    Almost all nursing homes are currently staffing-challenged, and that has a direct impact on the quality of the documentation available to support MDS coding, points out Brenda Sowash, RN, RAC-CT, director of clinical assessments, standards, …
  • Medication Indication of Use: The Big Why
    Nurses use a common problem-solving technique in root-cause analysis called the “Five Whys.” This method asks “why?” as many times as needed to determine the root cause of the problem. Sometimes this process requires more …
  • Section GG: Key Insights into Determining Usual Performance
    In this podcast, 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, curriculum development specialist for AAPACN, discuss key insights to determine section GG …
  • 4 Key Purposes of the Care Area Assessment Process
    The care area assessments (CAAs) are a vital part of the Resident Assessment Instrument (RAI) process to develop a plan for individualized resident care. Taking shortcuts with the CAA process can result in generic care …
  • Interrupted Stays: Five Takeaways To Remember
    The interrupted-stay policy in the Patient-Driven Payment Model (PDPM) of the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS) governs when multiple SNF stays are combined into a single interrupted stay (i.e., …
  • iQIES Essentials for the Nurse Assessment Coordinator
    In the ever-evolving realm of healthcare data management, the transition of the Minimum Data Set (MDS) submission process to the Internet Quality Improvement and Evaluation System (iQIES) in April 2023 marked a significant milestone for …
  • MDS 3.0 Final Validation Reports Quick Facts and Resources
    Nurse assessment coordinators (NACs) are responsible for the coordination and completion of the MDS assessments; however, to ensure these assessments are accepted without error into the National Submissions Database, the Final Validation Report must also …
  • Deep Tissue Injury: Section M Assessment and Coding Tips
    Pressure-related deep tissue injury (DTI) coded in M0300G (Unstageable Pressure Injuries Related to Deep Tissue Injury) does not play a role in Medicare payment under the Patient-Driven Payment Model (PDPM). While DTI is an unstageable …
  • iQIES Resources Site Updated
    iQIES is the Internet Quality Improvement and Evaluation System, which is the system that the MDS submissions system is being transferred to. The QIES Technical Support Office maintains a website with iQIES reference materials, including …
  • Getting Care Area Assessments Back on Track
    In this podcast, 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, curriculum development specialist for AAPACN, discuss the common challenges nurse assessment coordinators …
  • Respiratory Outbreak! How to Protect the MDS and Capture Key Assessment Data
    With the influenza season in full swing plus the ongoing peaks and valleys of COVID-19 and respiratory syncytial virus (RSV) outbreaks across the United States, nurse assessment coordinators (NACs) should take steps both to protect …
  • Anticonvulsants on the MDS: What to Expect in October 2024
    The Centers for Medicare & Medicaid Services (CMS) announced on the Dec. 7 Skilling Nursing Facilities/Long-Term Care Open Door Forum that the drug classification of anticonvulsants will be added to the Minimum Data Set (MDS) …
  • Speak Up! Improve Communication to Bolster the MDS Process
    Effective communication is the glue holding the MDS process together, says Stacy Grondel, BSN, RN, RAC-MT, CMAC, QCP. director of reimbursement operations at QRM in Addison, TX. “The nurse assessment coordinator (NAC) who is a …
  • MDS Daily Startup for the NAC Backup Tool
    When the nurse assessment coordinator (NAC) goes on vacation, there’s a lot to keep track of while they are out of office. The MDS Daily Startup for the NAC Backup tool is intended to help …
  • Keep Significant Corrections Simple: Tips for NACs
    The nurse assessment coordinator (NAC) role is a complex one that requires managing numerous deadlines, compliance regulations, and the involvement of the interdisciplinary team (IDT) in the Minimum Data Set (MDS) assessment. The job can …
  • Coding Hallucinations and Delusions on the MDS: Keys to Accuracy and Better Care Plans
    MDS items E0100A (Hallucinations) and E0100B (Delusions) are qualifiers for the Behavioral Symptoms and Cognitive Performance category in the nursing component of the Patient-Driven Payment Model (PDPM). Even more importantly, these conditions that form the …