Step-by-Step Coding Guide for Item Set A1010Y: Resident Declines to Respond

1. Review of Medical Records

• Objective: Verify that the resident has declined to respond to the specific question.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including previous assessments, interview notes, and nursing records.
  2. Identify Documentation of Decline: Look for documented instances where the resident declined to respond to questions during assessments or interviews.
  3. Confirm Details: Verify that the documentation is consistent and accurately reflects the resident's decision not to respond.

2. Understanding Definitions

• Resident Declines to Respond: This indicates that the resident chooses not to answer a specific question during the assessment or interview.
• Key Points:
  • It is important to distinguish between a resident being unable to respond and a resident choosing not to respond.
  • Documentation should clearly state that the resident declined to answer, not that they were unable to.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records and interview notes that the resident explicitly declined to respond.
  2. Verify Documentation: Ensure that the resident’s decision to decline responding is clearly noted in the records.
  3. Code Appropriately: Enter the code for resident declines to respond in item set A1010Y:
     • 1: Yes, the resident declined to respond.
     • 0: No, the resident did not decline to respond.

4. Coding Tips

• Accurate Identification: Ensure that the decision of the resident to decline responding is correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the resident’s choice to decline responding.
• Clarify with the Resident: If possible, clarify with the resident if they are declining to respond or if there is another reason they are not answering.

5. Documentation

• Required:
  • Interview Notes: Document the resident’s response during the assessment or interview, noting specifically that they declined to respond.
  • Nursing Notes: Include any observations or notes from nursing staff regarding the resident’s decision to decline responding.
  • Assessment Records: Ensure that the refusal to respond is clearly indicated in the resident’s assessment records.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying that the resident’s decision to decline responding is clearly documented and not mistaken for an inability to respond.
• Incomplete Documentation: Make sure all relevant notes and records are included to support the resident’s decision to decline responding.
• Assumptions: Do not assume the resident declined to respond without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: James, a 70-year-old resident, was asked about his preferences for recreational activities during an assessment but chose not to respond.
  • Steps:
    1. Review Records: The nurse reviews James’s medical records and interview notes, noting that James explicitly declined to respond to the question.
    2. Identify Decline: It is confirmed through the notes that James declined to answer the question regarding recreational activities.
    3. Document and Code: The nurse documents James’s decision in the records and codes A1010Y as "1".
  • Outcome: James’s decision to decline responding is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set A1010Y 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.