MDS ACCURACY REVIEW TOOL
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1 MDS ACCURACY REVIEW TOOL RESIDENT INFORMATION Name: Medical Record #: Admission Date: MDS Assessment Reference Date: _ Reason for Audit: Complete-all sections Partial-specific section(s) Other: Codes for OBRA required assessments: Admission assessment Quarterly review assessment Annual assessment Significant change in status assessment Significant correction of prior comprehensive assessment Significant correction of prior quarterly assessment None of the above PPS Other Medicare Required Assessment - OMRA: Start of therapy assessment End of therapy assessment Both start and end of therapy assessment Change of therapy assessment REASON FOR ASSESSMENT RECOMMENDATIONS Codes for assessments required for Medicare PPS: Medicare 5-day scheduled assessment Medicare 14-day scheduled assessment Medicare 30-day scheduled assessment Medicare 60-day scheduled assessment Medicare 90-day scheduled assessment Unscheduled assessment used for PPS SNF Part A PPS Discharge assessment Entry/Discharge Reporting: Entry tracking record Discharge assessment return not anticipated Discharge assessment return anticipated Death in facility tracking record MDS coding accurate for completion and transmission to State/CMS. No further review/action needed. Further review and/or actions required prior to completion and transmission to State/CMS: Ensure timely physician skilled certification/recertification present Revise care plan goals/approaches Correct ARD needed Revise physician orders Additional clinical documentation needed in medical record Refile billing claim Modification of accepted record needed to correct error(s) Accepted record needs to be inactivated Review timeliness of ARD, interviews and/or CAA completion needed Other: MDS DATA ELEMENT A0310A-H. Assessment Type A0500A-D. Resident Name A0600A+B. SSN/Medicare A0700. Medicaid A0800. Gender A0900. Birth Date A1000. Race/Ethnicity A1100. Language A1200. Marital Status A1500. PASRR A1510. Level II Conditions A1550. ID/DD Conditions A1600. Entry Date A1800. Entered From A1900. Admission Date A2000. Discharge Date A2100. Discharge Status A2300. Assessment Reference Date A2400. Medicare Stay: B0100. Comatose B0200. Hearing B0300. Hearing Aid B0600. Speech Clarity B0700. Makes Self Understood Form 1160P Rev. 8/18 BRIGGS, Des Moines, IA (800) Unauthorized copying or use violates copyright law. SPECIFY RECOMMENDATION MDS ACCURACY REVIEW TOOL Page 1 of 8
2 B0800. Ability To Understand Others B1000. Vision B1200. Corrective Lenses C0100. Resident BIMS Conducted (C C0400) C0500. BIMS Summary Score C0600. Staff Assessment for Mental Status (C0700-C1000) C1310. CAM :, D D0100. Resident Mood Interview (D0200, D0300, D0350) D0500. Staff Assessment of Resident Mood Interview (PHQ-9-OV) D0600. Total Severity Score D0650. Safety Notification E0100. Psychosis A, B, Z E0200. Behavioral Symptoms: E0300. Overall Presence of Behavioral Symptoms E0500. Impact on Resident: E0600. Impact on Others: E0800. Rejection of Care Presence & Frequency E0900. Wandering Presence & Frequency E1000. Wandering Impact: A, B E1100. Change in Behavior or Other Symptoms F0300. Interview Daily and Activity Preferences F0400. Interview for Daily Preferences: A-H F0500. Interview for Activity Preferences: A-H F0600. Daily and Activity Preferences Primary Respondent F0700. Staff Assessment of Daily and Activity Preferences F0800. Staff Assessment of Preferences: A-T, Z G0110A. ADL - Bed Mobility: G0110B. ADL - Transfer: G0110C: ADL - Walk in Room: G0110D: ADL - Walk in Corridor: G0110E: ADL - Locomotion on unit: G0110F: ADL - Locomotion off unit: G0110G: ADL - Dressing: G0110H: ADL - Eating:, SPECIFY RECOMMENDATION MDS ACCURACY REVIEW TOOL Page 2 of 8
3 , SPECIFY RECOMMENDATION G0110I: ADL - Toilet Use: G0110J: ADL - Personal Hygiene: G0120: Bathing, A, B G0300: Balance During Transitions and Walking: A-E G0400. Functional Limitation in Range of Motion: A, B G0600. Mobility Devices:, D, Z G0900. Functional Rehabilitation Potential: A, B GG0100. Prior Functioning GG0110. Prior Device Use GG0130A. Eating GG0130B. Oral Hygiene GG0130C. Toilet Hygiene GG0130E. Shower/Bathe GG0130F. Upper Body Dress GG0130G. Lower Body Dress GG0130H. Footwear (Admit): GG0170A. Roll GG0170B. Sit to Lying (Admit): GG0170C. Lying to Sit (Admit): GG0170D. Sit to Stand GG0170E. Chair/Bed-to-Chair Transfer GG0170F. Toilet Transfer GG0170G. Car Transfer GG0170I. Walk 10 Feet GG0170J. Walk 50 Feet GG0170K. Walk 150 Feet GG0170L. Walk-Uneven Surfaces GG0170M. 1 Step/Curb GG0170N. 4 Steps (Admit): GG0170O. 12 Steps (Admit): GG0170P. Picking Up Object GG0170Q1. Wheelchair/ Scooter GG0170R+RR1. Wheel 50 Feet GG0170S+SS1. Wheel 150 MDS ACCURACY REVIEW TOOL Page 3 of 8
4 GG0 130A. Eating GG0130B. Oral Hygiene GG0130C. Toileting Hygiene GG0130E. Shower/Bathe GG0130F. Upper Body Dress GG0130G. Lower Body Dress GG0130H. Footwear GG0170A. Roll GG0170B. Sit to Lying GG0170C. Lying to Sit GG0170D. Sit to Stand GG0170E. Chair/Bed-to-Chair Transfer GG0170F. Toilet Transfer GG0170G. Car Transfer GG0170I. Walk 10 Feet GG0170J. Walk 50 Feet GG0170K. Walk 150 Feet GG0170L. Walk-Uneven Surfaces GG0170M. 1 Step/Curb GG0170N. 4 Steps GG0170O. 12 Steps GG0170P. Picking Up Object GG0170Q1. Wheelchair/ Scooter GG0170R+RR1. Wheel 50 Feet GG0170S+SS1. Wheel 150 Feet H0100. Appliances:, D, Z H0200. Urinary Toileting Program: H0300. Urinary Continence H0400: Bowel Continence H0500. Bowel Toileting Program H0600. Bowel Patterns I0020/I0020A. Primary Reason for Admit I0100. Cancer I0200. Anemia I0300. Atrial Fibrillation or Other Dysrhythmias I0400. Coronary Artery Disease (CAD) I0500. Deep Venous Thrombosis (DVT), Pulmonary Embolus (PE), or Pulmonary Thrombo-Embolism (PTE) I0600. Heart Failure I0700. Hypertension I0800. Orthostatic Hypotension I0900. Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD) I1100. Cirrhosis, SPECIFY RECOMMENDATION MDS ACCURACY REVIEW TOOL Page 4 of 8
5 , SPECIFY RECOMMENDATION I1200. Gastroesophageal Reflux Disease (GERD) or Ulcer I1300. Ulcerative Colitis, Crohn s Disease, or Inflammatory Bowel Disease I1400. Benign Prostatic Hyperplasia (BPH) I1500. Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD) I1550. Neurogenic Bladder I1650. Obstructive Uropathy I1700. Multidrug-Resistant Organism (MDRO) I2000. Pneumonia I2100. Septicemia I2200. Tuberculosis I2300. Urinary Tract Infection (UTI) (last 30 days) I2400. Viral Hepatitis I2500. Wound Infection I2900. Diabetes Mellitus (DM) I3100. Hyponatremia I3200. Hyperkalemia I3300. Hyperlipidemia I3400. Thyroid Disorder I3700. Arthritis I3800. Osteoporosis I3900. Hip Fracture I4000. Other Fracture I4200. Alzheimer s Disease I4300. Aphasia I4400. Cerebral Palsy I4500. Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke I4800. Non-Alzheimer s Dementia I4900. Hemiplegia or Hemiparesis I5000. Paraplegia I5100. Quadriplegia I5200. Multiple Sclerosis (MS) I5250. Huntington s Disease I5300. Parkinson s Disease I5350. Tourette s Syndrome I5400. Seizure Disorder or Epilepsy I5500. Traumatic Brain Injury (TBI) I5600. Malnutrition I5700. Anxiety Disorder I5800. Depression I5900. Manic Depression I5950. Psychotic Disorder I6000. Schizophrenia I6100. Post Traumatic Stress Disorder (PTSD) MDS ACCURACY REVIEW TOOL Page 5 of 8
6 , SPECIFY RECOMMENDATION I6200. Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease I6300. Respiratory Failure I6500. Cataracts, Glaucoma, or Macular Degeneration I7900. None of the Above Active Diagnoses Within the Last 7 Days I8000. Additional Active Diagnosis: A-J J0100. Pain Management: J0200. Resident Pain Assessment Interview J0300. Pain Presence J0400. Pain Frequency J0500. Pain Effect on Function: A, B J0600. Pain Intensity: A or B J0700. Staff Assessment for Pain J0800. Indicators of Pain or Possible Pain:, D, Z J0850. Frequency of Indicator of Pain or Possible Pain J1100. Shortness of Breath (dyspnea):, Z J1300: Current Tobacco Use J1400. Prognosis of 6 Months or Less to Live J1550. Problem Conditions:, D, Z J1700. Fall History on Admission: J1800. Any Falls Since Admit or Prior Assessment J1900. Number of Falls: K0100. Swallowing Disorder: A, B, C, D, Z K0200. Height and Weight: A, B K0300. Weight Loss K0310. Weight Gain K0510. Nutritional Approaches:, D, Z K0710. Percent Intake by Artificial Route:, 3, and A, B L0200. Dental:, D, E, F, G, Z M0100. Determination of Pressure Ulcer/Injury Risk:, Z M0150. Risk of Pressure Ulcers/Injuries M0210. Unhealed Pressure Ulcers/Injuries M0300A. Current Number of Stage 1 Pressure Ulcers/ Injuries M0300B. Current Number of Stage 2 Pressure Ulcers/ Injuries : MDS ACCURACY REVIEW TOOL Page 6 of 8
7 , SPECIFY RECOMMENDATION M0300C. Current Number of Stage 3 Pressure Ulcers/ Injuries: M0300D. Current Number of Stage 4 Pressure Ulcers/ Injuries: M0300E. Unstageable - Non-removable Dressing/ Device: M0300F. Unstageable - Slough and/or Eschar: M0300G. Unstageable - Deep Tissue: M1030. Number of Venous and Arterial Ulcers M1040. Other Ulcers, Wounds and Skin Problems:, D, E, F, G, H, Z M1200. Skin and Ulcer/Injury Treatments:, D, E, F, G, H, I, Z N0300. Injections N0350. Insulin: A, B N0410. Medications Received:, D, E, F, G, H N0450. Antipsychotic Medication Review: A-E N2001. Drug Regimen Review N2003. Medication Follow-Up N2005. Medication Intervention O0100A: Chemotherapy: O0100B: Radiation: O0100C: Oxygen Therapy: O0100D: Suctioning: O0100E. Tracheostomy Care: O0100F. Invasive Mechanical Ventilator (Ventilator or Respirator): O0100G: Non-Invasive Mechanical Ventilator (BiPAP, CPAP): O0100H: IV Medications: O0100I: Transfusions: O0100J: Dialysis: O0100K: Hospice Care: O0100L: Respite Care: 2 O0100M: Isolation or Quarantine for Active Infectious Disease: O0250. Influenza Vaccine: O0300. Pneumococcal Vaccine: A, B O0400A. Speech-Language Pathology and Audiology Services: 1-6 O0400B. Occupational Therapy: 1-6 O0400C. Physical Therapy: 1-6 O0400D. Respiratory Therapy: O0400E. Psychological Therapy: O0400F. Recreational Therapy: MDS ACCURACY REVIEW TOOL Page 7 of 8
8 O0420. Distinct Calendar Days of Therapy O0450. Resumption of Therapy: A, B O0500. Restorative Nursing Programs Technique: O0500. Restorative Nursing Programs Training and Skills: D, E, F, G, H, I, J O0600. Physician Examinations O0700. Physician Orders P0100. Physical Restraints:, D, E, F, G, H P0200. Alarms:, D, E, F Q0100. Participation in Assessment: Q0300. Resident s Overall Expectation: A, B Q0400. Discharge Plan Q0490. Resident s Preference to Avoid Being Asked Question Q0500B Q0500. Return to Community Q0550. Resident s Preferences to Avoid Being Asked Question Q0500B Again: A, B Q0600. Referral V0200: CAAs and Care Planning: A, (I-20), B, C X0150. Type of Provider X0200. Resident Name: A, C X0300. Gender X0400. Birth Date X0500. Social Security Number X0600. Assessment Type: A, B, C, D, F, H X0700. Modification/ Inactivation-Date: X0800. Correction Number X0900. Reasons for Modification X1050. Reasons for Inactivation X1100. RN Coordinator Attestation Z0400. Signature of Persons Completing the Assessment: A-L Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion: A, B IF IF, SPECIFY RECOMMENDATION Additional Notes: Reviewer(s): (Name and Title) (Name and Title) Date: Date: MDS ACCURACY REVIEW TOOL Page 8 of 8
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