MDS 3.0 RAI Manual - Free Online Resource - brought to you by AOD Software: the First Certified EHR in Long Term Care

Centers for Medicare & Medicaid Services’
Long-Term Care Facility
Resident Assessment Instrument (RAI)
User’s Manual
April 2012
For Use Effective April 1, 2012

Quick Access Drop-Down:

Other Quick Resources:

List of all RAI MDS Coordinators by State

Recap of all April 2012 Change Tables (Updates to the RAI Manual)
Recap of all October 2011 Change Tables (Updates to the RAI Manual)
Recap of all May 2011 Change Tables (Updates to the RAI Manual)
Errata Document of v1.08

www.cms.gov/SNFPPS/03_RUGIVEdu12.asp#TopOfPage

The Long-Term Care Facility Resident Assessment Instrument User’s Manual for Version 3.0 is published by the Centers for Medicare & Medicaid Services (CMS) and is a public document. It may be copied freely, as our goal is to disseminate information broadly to facilitate accurate and effective resident assessment practices in long-term care facilities.

If you have comments concerning the accuracy of the time estimates(s) or suggestions for improving these forms, please write to: CMS, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland 21244-1850.

Table of Contents (please click on the links to access the pages indicated)

Chapter 1: Resident Assessment Instrument (RAI) (V1.08)

1.1 Overview .................................................................. 1-4

1.2 Content of the RAI for Nursing Homes ............................ 1-4

1.3 Completion of the RAI ................................................. 1-5

1.4 Problem Identification Using the RAI ............................... 1-7

1.5 MDS 3.0 .................................................................. 1-10

1.6 Components of the MDS ............................................. 1-11

1.7 Layout of the RAI Manual ........................................... 1-11

1.8 Protecting the Privacy of the MDS Data ......................... 1-13

Chapter 2: Assessments for the Resident Assessment Instrument (RAI) (V1.08)

2.1 Introduction to the Requirements for the RAI .................. 2-1

2.2 State Designation of the RAI for Nursing Homes .............. 2-1

2.3 Responsibilities of Nursing Homes for Completing Assessments .... 2-2

2.4 Responsibilities of Nursing Homes for Reproducing and Maintaining Assessments ......... 2-5

2.5 Assessment Types and Definitions ................................. 2-7

2.6 Required OBRA Assessments for the MDS .................... 2-14

2.7 The Care Area Assessment (CAA) Process and Care Plan Completion ......... 2-38

2.8 The Skilled Nursing Facility Medicare Prospective Payment System Assessment Schedule ................... 2-39

2.9 MDS Medicare Assessments for SNFs .............................. 2-44

2.10 Combining Medicare Scheduled and Unscheduled Assessments ............. 2-51

2.11 Combining Medicare Assessments and OBRA Assessments ............ 2-55

2.12 Medicare and OBRA Assessment Combinations ................ 2-58

2.13 Factors Impacting the SNF Medicare Assessment Schedule ....... 2-69

2.14 Expected Order of MDS Records ................................ 2-72

2.15 Determining the Item Set for an MDS Record .................... 2-74

Chapter 3: Overview to the Item-by-Item Guide to the MDS 3.0

Chapter 3 Introduction

Section A Identification Information (V1.08) ......................... A-1

CMS' YouTube Training Video on Section A

Section B Hearing, Speech, and Vision (V1.05) ...................... B-1

CMS' YouTube Training Video on Section B

Section C Cognitive Patterns (V1.08) ................................. C-1

CMS' YouTube Training Video on Section C

Section D Mood (V1.05) .................................................. D-1

CMS' YouTube Training Video on Section D

Section E Behavior (V1.08) .............................................. E-1

CMS' YouTube Training Video on Section E

Section F Preferences for Customary Routine and Activities (V1.05) ....... F-1

CMS' YouTube Training Video on Section F

Section G Functional Status (V1.08) .................................... G-1

CMS' YouTube Training Video on Section G

Section H Bladder and Bowel (V1.08) .................................. H-1

Section I Active Diagnoses (V1.08) ..................................... I-1

CMS' YouTube Training Video on Sections I, N and L

Section J Health Conditions (V1.08) ..................................... J-1

CMS' YouTube Training Video on Section J

Section K Swallowing/Nutritional Status (V1.08) ..................... K-1

CMS' YouTube Training Video on Section K

Section L Oral/Dental Status (V1.04) ................................... L-1

CMS' YouTube Training Video on Section L

Section M Skin Conditions (V1.08) ...................................... M-1

CMS' YouTube Training Video on Section M

Section N Medications (V1.08) ........................................... N-1

CMS' YouTube Training Video on Sections I, N and L

Section O Special Treatments, Procedures, and Programs (V1.08) ....... O-1

CMS' YouTube Training Video on Section O

Section P Restraints (V1.04) ........................................... P-1

CMS' YouTube Training Video on Section P

Section Q Participation in Assessment and Goal Setting (V1.08) ....... Q-1

CMS' YouTube Training Video on Section Q Training - Other Section Q related discussion videos are also hyperlinked below.

Developing an implementation strategy for your State
Creating Successful Outcomes
Section Q Pilot Test Discussion
Recurring Themes and Next Steps
Case Study of Gladys & Linda (Residents) Returning to Community

Section S (Reserved) .................................................... S-1

Section V Care Area Assessment (CAA) Summary (V1.08) .......... V-1

Section X Correction Request (V1.08) ............................... X-1

CMS' YouTube Training Video on Sections X & Z

Section Z Assessment Administration (V1.08) ........................ Z-1

CMS' YouTube Training Video on Sections X & Z

Chapter 4: Care Area Assessment (CAA) Process and Care Planning (V1.08)

4.1 Background and Rationale ......................................... 4-1

4.2 Overview of the Resident Assessment Instrument (RAI) and Care Area Assessments (CAAs) .......................... 4-1

4.3 What Are the Care Area Assessments (CAAs)? ............................................................. 4-2

4.4 What Does the CAA Process Involve? .............................4-3

4.5 Other Considerations Regarding Use of the CAAs ............... 4-6

4.6 When Is the RAI Not Enough? ....................................... 4-7

4.7 The RAI and Care Planning ........................................... 4-8

4.8 CAA Tips and Clarifications .......................................... 4-11

4.9 Using the Care Area Assessment (CAA) Resources ............. 4-12

4.10 The Twenty Care Areas ............................................. 4-16

4.11 (Reserved) .............................................................. 4-40

Chapter 5: Submission and Correction of the MDS Assessments (V1.08)

5.1 Transmitting MDS Data .............................................. 5-1

5.2 Timeliness Criteria .................................................... 5-2

5.3 Validation Edits ....................................................... 5-4

5.4 Additional Medicare Submission Requirements that Impact Billing Under the SNF PPS ........................ 5-5

5.5 Correcting the MDS .............................................. 5-7

5.6 Correcting Errors in MDS Records That Have Not Yet Been Accepted Into the QIES ASAP System ........................................ 5-8

5.7 Correcting Errors in MDS Records That Have Been Accepted Into the QIES ASAP System .............................................. 5-10

5.8 Special Manual Record Correction Request .............................. 5-12

Chapter 6: Medicare Skilled Nursing Facility Prospective Payment System (SNF PPS) (V1.08)

6.1 Background ......................................................... 6-1

6.2 Using the MDS in the Medicare Prospective Payment System ....... 6-1

6.3 Resource Utilization Groups Version IV (RUG-IV) .................... 6-2

6.4 Relationship between the Assessment and the Claim ................ 6-5

6.5 SNF PPS Eligibility Criteria ................................................. 6-21

6.6 RUG-IV 66-Group Model Calculation Worksheet for SNFs ............. 6-22

6.7 SNF PPS Policies ........................................................... 6-51

6.8 Non-compliance with the SNF PPS Assessment Schedule ............. 6-52

Appendices

Appendix A: Glossary and Common Acronyms (V1.08) ............... A-1

Appendix B: State Agency and CMS Regional Office RAI/MDS Contacts (V1.07) ...... B-1

Appendix C: Care Area Assessment (CAA) Resources (V1.08) ............. C-1

Appendix D: Interviewing to Increase Resident Voice in MDS Assessments (V1.08) .. D-1

Appendix E: PHQ-9 Scoring Rules and Instruction for BIMS (When Administered In Writing) (V1.08) .................. E-1

Appendix F: Item Matrix (V1.08) ............................. F-1

Appendix G: References (V1.08) ....................................... G-1

Appendix H: MDS 3.0 Forms ............................................ H-1

Item Changes

Nursing Home Comprehensive Item Set

Nursing Home Discharge Item Set 

Nursing Home and Swing Bed OMRA (NO/SO) Item Set

Nursing Home OMRA-Discharge (NOD) Item Set

Nursing Home PPS (NP) Item Set

Nursing Home Quarterly (NQ) Item Set

Nursing Home and Swing Bed OMRA-Start of Therapy (NS/SS) Item Set

Nursing Home OMRA-Start of Therapy and Discharge (NSD) Item Set

Nursing Home and Swing Bed Tracking (NT/ST) Item Set

Swing Bed Discharge (SD) Item Set

Swing Bed OMRA-Discharge (SOD) Item Set

Swing Bed PPS (SP) Item Set

Swing Bed OMRA-Start of Therapy and Discharge (SSD) Item Set