Step-by-Step Coding Guide for MDS 3.0 Item A0050: Type of Record

Step 1: Determine the Record Type

• Code 1 - Add New Record: Select this option if you are creating a record for an assessment or tracking form that has not been previously submitted and accepted in iQIES.

Step 2: Identifying Duplicate Records

• Before proceeding with coding the record as new, verify that there isn't an existing record for the same resident, in the same facility, for the same assessment or tracking reason, and with the same date (Assessment Reference Date (ARD), entry date, or discharge date). If such a record exists, it's considered a duplicate.

Step 3: Action for New Records

• If the record is new (coded as 1 in A0050), you must continue to section A0100, Facility Provider Numbers, to enter relevant facility identification information.

Step 4: Managing Duplicate Records

• If your review identifies the record as a duplicate, refrain from coding it as new. This record will be rejected by iQIES, and a “fatal” error will be reported to your facility in the Final Validation Report.

Step 5: Modify an Existing Record

• Code 2 - Modify Existing Record: Choose this code if you need to make changes to an MDS item in a record that has already been submitted and accepted in iQIES. Continue to A0100, Facility Provider Numbers, and ensure you follow the instructions for modification requests as outlined by iQIES.

Step 6: Inactivating a Record

• Code 3 - Inactivate Existing Record: Use this code to request the inactivation of a record that has previously been accepted in iQIES. Skip to X0150, Type of Provider, and adhere to the inactivation request procedures specified by iQIES.

Step 7: Identification for Modification/Inactivation

• When modifying or inactivating a record, you must accurately reproduce the information from Section X items (X0200 through X0700) as it appeared on the original record, even if incorrect. This step is critical for iQIES to locate the existing record for modification or inactivation.

Example Scenario for Modification:

• If a record for "Joan L. Smith" was accepted but contained a typographical error in the resident's first name (entered as "John" instead of "Joan"), use the name "John" in X0200A (Resident First Name) for iQIES to locate the record. Correct the name to "Joan" in A0500A (Resident First Name) in the modification record. Submit this record to apply the correction in iQIES.

By following these detailed steps, you can accurately code and manage MDS 3.0 records in accordance with iQIES requirements, ensuring that your submissions are accurate and compliant with regulatory standards

Avoiding these common mistakes is crucial for ensuring the integrity of the resident's record and the facility's standing in the Internet Quality Improvement and Evaluation System (iQIES). Here are some common errors to avoid:

1. Incorrectly Identifying the Type of Record

• Ensure you accurately determine whether the record is a new record, a modification of an existing record, or a request to inactivate a record. Misclassification can lead to processing errors and rejection of the record.

2. Failure to Check for Duplicate Records

• Before coding a record as new, thoroughly check for any existing records for the same resident, in the same facility, with the same reasons for assessment/tracking, and the same date. Submitting a duplicate can result in a "fatal" error and rejection of the record.

3. Incorrectly Proceeding to Subsequent Sections

• Pay attention to the instructions regarding which section to proceed to next, based on the type of record you're coding. For example, after coding a new record or modifying an existing record, you should continue to A0100. If inactivating a record, skip to X0150.

4. Misidentifying Records for Modification or Inactivation

• When modifying or inactivating a record, it's essential to accurately reproduce the information from the erroneous record, even if it contains mistakes. Failing to do so may prevent the system from locating the original record, leading to rejection of your request.

5. Overlooking the Requirement for Complete Information in Modifications

• When modifying a record, ensure that all sections appropriate for that assessment are included, not just the items being corrected. Incomplete modifications may result in rejection.

6. Entering Incorrect Information in Section X for Modifications/Inactivations

• In the Section X items, reproduce the information exactly as it appeared on the existing erroneous record. Incorrectly entering corrected information here can prevent the identification and correct modification or inactivation of the record.

7. Not Utilizing the Final Validation Report

• The Final Validation Report is crucial for identifying and correcting any errors in submitted records. Ignoring or misinterpreting the errors reported in this document can lead to unresolved issues and potential compliance problems.

8. Lack of Familiarity with iQIES Requirements and Processes

• Staying updated on the latest iQIES requirements and processes is vital. Lack of familiarity can lead to errors in record submission and management.

Avoiding these errors requires thorough training, attention to detail, and regular review of the latest guidelines and best practices for MDS 3.0 completion and submission. Ensuring accuracy and compliance in the Type of Record section is a critical step in the broader process of resident assessment and care planning.

Please note that the information provided in this guide for MDS 3.0 Item A0050: Type of Record was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0.

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding.

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.