Step-by-Step Coding Guide for Item Set A0410: Unit Certification or Licensure Designation

1. Review of Medical Records

• Objective: Accurately assess and document the unit certification or licensure designation.
• Steps:
  1. Collect Information: Gather comprehensive medical records, including facility certification documents, state licensure information, and resident care unit records.
  2. Identify Documentation of Certification/Licensure: Look for documented instances where the unit’s certification or licensure designation is mentioned, including any relevant official documentation.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Unit Certification or Licensure Designation: Refers to the specific certification or licensure status of the unit where the resident is receiving care. This can include designations such as Medicare, Medicaid, or other state licensure certifications.
• Key Points:
  • Certification: Official recognition by Medicare or Medicaid.
  • Licensure: State-specific licensing that allows the facility to operate and provide care.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the facility’s records the specific certification or licensure designation of the unit.
  2. Verify Documentation: Ensure that the documentation clearly notes the unit’s certification or licensure status, including any relevant official certifications or licenses.
  3. Code Appropriately: Enter the appropriate code for item set A0410 based on the unit’s certification or licensure designation:
     • 1: Unit is Medicare certified.
     • 2: Unit is Medicaid certified.
     • 3: Unit is both Medicare and Medicaid certified.
     • 4: Unit is not certified.

4. Coding Tips

• Accurate Identification: Ensure the certification or licensure status is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the certification or licensure status.
• Clarify with Administrative Staff: If there is any uncertainty, clarify with the administrative staff to ensure accurate coding.

5. Documentation

• Required:
  • Facility Certification Documents: Documents that officially recognize the unit’s certification status by Medicare, Medicaid, or other relevant bodies.
  • State Licensure Information: Records that include state-specific licensing information.
  • Unit Records: Documentation from the specific unit where the resident is receiving care that details the certification or licensure status.
  • Official Certifications/Licenses: Copies of any official certifications or licenses that verify the unit’s status.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the unit’s certification or licensure status through multiple records and official documents.
• Incomplete Documentation: Make sure all relevant facility certification documents, state licensure information, and unit records are included to support the documented status.
• Assumptions: Do not assume the certification or licensure status without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Facility Profile: The Sunrise Nursing Home has a unit that is both Medicare and Medicaid certified.
  • Steps:
    1. Review Records: The administrator reviews the facility’s certification documents and state licensure information, noting that the unit is certified by both Medicare and Medicaid.
    2. Identify Certification: It is confirmed through the documentation that the unit has dual certification.
    3. Document and Code: The administrator documents the certification in the unit’s records and codes A0410 as "3".
  • Outcome: The unit’s certification as both Medicare and Medicaid certified is accurately documented and coded, ensuring compliance and proper care planning.

Please note that the information provided in this guide for MDS 3.0 Item set A0410 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.