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 a fall, injury (except major), and major injury, which are as follows: This AAPACN resource is …

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

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 to validate that all required aspects have been met before coding the Minimum Data Set …

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 performance with therapy. The only coding tip that restricts using the walking performance during therapy …

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 judgement. Your team’s assessment of the injury, its effect on the resident (e.g., neuro checks, …

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 this instruction states “walking might be assessed for a resident who did/does/will use a wheelchair …

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 key performance indicators (KPIs) that can be used to demonstrate progress toward a data-driven proactive …

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 the revisions to item J1900, which changed the definitions of injury (except major) and major …

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), R03020A (Within the Past 12 Months, You Worried That Your Food Would Run Out Before …