Step-By-Step Coding Guide for B1000: Vision

1. Review of Medical Record

• Objective: To gather information about the resident's vision capabilities.
• Key Steps:
  • Review the resident’s medical records for any documented vision assessments.
  • Look for notes indicating the use of corrective lenses, vision aids, or any recent changes in vision.

2. Understanding the Definition

• Definition: B1000 assesses the resident's ability to see objects nearby, including reading regular print.
• Key Components:
  • Understanding of adequate lighting.
  • Identification of the need for corrective lenses.

3. Coding Instructions

• Objective: Accurately code the resident’s vision ability.
• Coding Options:
  • 0 (Adequate): Sees fine detail, regular print.
  • 1 (Impaired): Sees large print, not regular print.
  • 2 (Moderately Impaired): Limited vision, identifies objects but not newspaper headlines.
  • 3 (Highly Impaired): Limited ability, but eye movements follow objects.
  • 4 (Severely Impaired): No vision or sees only light, colors, or shapes.

4. Coding Tips

• Consider if the resident uses corrective lenses during the assessment.
• Observe the resident's interaction with their environment and reading materials.

5. Documentation

• Document observations and resident statements regarding their vision capabilities.
• Include information about the use of any visual aids.

6. Common Errors to Avoid

• Not considering the resident's use of corrective lenses during assessment.
• Misinterpreting the resident’s inability to read due to other factors like illiteracy as a vision problem.

7. Practical Application

• Scenario: A resident reports they can read newspapers with glasses. Without glasses, they struggle with small print.
  • Coding: Code 0 (Adequate), as the resident can see fine detail with corrective lenses.

The Step-by-Step Coding Guide for item B0100 in MDS 3.0 Section B is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.