Step-by-Step Coding Guide for Item C0100: Should Brief Interview for Mental Status (C0200-C0500) be Conducted?

1. Definition of Terms

• C0100: This item determines if the Brief Interview for Mental Status (BIMS), comprising items C0200 to C0500, should be conducted based on the resident's ability to communicate.
• Brief Interview for Mental Status (BIMS): A structured interview designed to assess cognitive function and mental status, focusing on memory, orientation, and recall abilities.
• Communication Barrier: Any condition or situation that significantly impairs the resident's ability to participate in a verbal or written interview.

2. Common Errors to Avoid

• Overlooking Non-Verbal Cues: Assuming a resident cannot participate in the BIMS without considering non-verbal communication abilities.
• Ignoring Temporary Barriers: Failing to reassess the resident's ability to participate in the BIMS if the initial inability was due to a temporary condition (e.g., acute illness, emotional distress).
• Inadequate Effort to Facilitate Communication: Not utilizing available resources such as communication boards, interpreters, or alternative communication methods for residents with hearing, speech, or language difficulties.

3. Coding Tips

• Evaluate Communication Ability: Carefully assess the resident's ability to understand and respond to verbal or written questions. This includes observing the resident's usual communication methods and any temporary factors affecting their ability to participate.
• Use Supportive Communication Tools: Employ aids like hearing devices, glasses, or translation services if they can facilitate the resident's participation in the interview.
• Consider Reassessment: If the resident is unable to complete the BIMS due to a temporary condition, plan for reassessment once the condition improves.
• Documentation: Clearly document the reasoning for determining whether the BIMS should or should not be conducted, including any attempts made to facilitate the interview and the nature of communication barriers encountered.

Example

A resident with a recent stroke has aphasia, significantly impairing their ability to verbally communicate. The MDS coordinator reviews the resident's current communication status and consults with the speech therapist to evaluate if alternative communication methods could enable participation in the BIMS. The speech therapist suggests using a communication board and confirms the resident's ability to understand simple questions and indicate yes/no answers. Based on this assessment, the coordinator decides to attempt the BIMS with the support of the speech therapist to facilitate communication.

The Step-by-Step Coding Guide for item C0100 in MDS 3.0 Section C 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.