Step-by-Step Coding Guide for Item Set A1510C: Level II PASRR Conditions - Other Related Conditions

1. Review of Medical Records

• Objective: Accurately determine and document the presence of other related conditions under the Level II PASRR (Preadmission Screening and Resident Review) criteria.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including psychiatric evaluations, PASRR Level II assessments, physician notes, and previous assessments.
  2. Identify Documentation of Other Related Conditions: Look for documented instances where the resident’s other related conditions are noted.
  3. Confirm Details: Verify the consistency and accuracy of the documentation across various sources within the medical records.

2. Understanding Definitions

• Level II PASRR: This assessment is required for individuals with serious mental illness, intellectual disability, or other related conditions to determine the need for specialized services.
• Other Related Conditions: These include developmental disabilities or conditions similar to intellectual disabilities but do not fit the strict criteria for intellectual disability.
• Key Points:
  • Conditions Covered: Conditions such as cerebral palsy, epilepsy, autism, and other similar developmental disabilities.
  • Criteria: These conditions must meet the functional and adaptive behavior limitations criteria as defined by PASRR regulations.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records the presence of other related conditions as specified in the Level II PASRR assessment.
  2. Verify Documentation: Ensure that these conditions are clearly noted and consistent across all records.
  3. Code Appropriately: Enter the appropriate code for item set A1510C:
     • 0: No, the resident does not have other related conditions.
     • 1: Yes, the resident has other related conditions.

4. Coding Tips

• Accurate Identification: Ensure the conditions are correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the conditions.
• Verification: Double-check the records for accuracy to prevent any discrepancies.

5. Documentation

• Required:
  • Psychiatric Evaluations: Detailed evaluations from psychiatrists or mental health professionals.
  • PASRR Level II Assessments: Comprehensive assessments that include the diagnosis and recommendations for other related conditions.
  • Physician Notes: Notes from physicians detailing any diagnosed related conditions.
  • Previous Assessments: Any previous assessments that have documented these related conditions.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the presence of related conditions through multiple records and notes.
• Incomplete Documentation: Make sure all relevant psychiatric evaluations, PASRR Level II assessments, and physician notes are included to support the documented conditions.
• Assumptions: Do not assume the presence of conditions without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: Sarah, a 65-year-old resident, has a diagnosis of cerebral palsy and epilepsy noted in her medical records.
  • Steps:
    1. Review Records: The nurse reviews Sarah’s medical records, including her PASRR Level II assessment and psychiatric evaluations.
    2. Identify Conditions: It is confirmed through the documentation that Sarah has cerebral palsy and epilepsy, which qualify as other related conditions under PASRR criteria.
    3. Document and Code: The nurse documents these conditions in Sarah’s records and codes A1510C as "1".
  • Outcome: Sarah’s related conditions are 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 A1510C 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.