Step-by-Step Coding Guide for Item Set A1510B: Level II PASRR Conditions: Intellectual Disability

1. Review of Medical Records

• Start by thoroughly reviewing the resident's medical records to find any documentation related to the Pre-Admission Screening and Resident Review (PASRR) which assesses for intellectual disabilities and other conditions.
• Check for PASRR evaluations, psychological assessments, or other diagnostic tests that confirm or deny the presence of intellectual disability.

2. Understanding Definitions

• Intellectual Disability: A condition characterized by significant limitations both in intellectual functioning (reasoning, learning, problem-solving) and in adaptive behavior, which covers a range of everyday social and practical skills. This diagnosis is typically made through standardized tests and clinical assessment.
• Level II PASRR: A detailed evaluation to determine the specific needs of individuals diagnosed with mental illness, intellectual disability, or related conditions and to ascertain the appropriate level of care.

3. Coding Instructions

• Code "1" if a Level II PASRR evaluation confirms the resident has an intellectual disability.
• Code "0" if the Level II PASRR evaluation does not confirm intellectual disability, or if no Level II PASRR evaluation has been conducted for intellectual disability.

4. Coding Tips

• Verify that any assessments specifically mention a Level II PASRR evaluation as it pertains to intellectual disability.
• Ensure that any documentation regarding intellectual disability is current and relevant to the resident's current condition.

5. Documentation

• Clearly document the source, date, and results of the Level II PASRR evaluation in the resident's medical record.
• Include notes on any additional assessments or relevant medical history that support the PASRR findings.

6. Common Errors to Avoid

• Coding a resident as having an intellectual disability without a formal Level II PASRR evaluation confirming the condition.
• Confusing a diagnosis of dementia or other cognitive impairments with intellectual disability.

7. Practical Application

• Example: During the admission process, a new resident, Mr. John Doe, has been identified as potentially having intellectual disability based on previous medical history. A Level II PASRR evaluation is conducted, which confirms the diagnosis through comprehensive psychological testing and interviews. In the MDS item A1510B, you would code "1" to indicate that a Level II PASRR evaluation has confirmed intellectual disability.

Please note that the information provided in this guide for MDS 3.0 Item set A1510B 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.