Step-by-Step Coding Guide for Item Set C0300B: BIMS Res Interview: Able to Report Correct Month

1. Review of Medical Records

• Objective: Gather accurate information on the resident’s cognitive status.
• Steps:
  1. Review medical records, previous assessments, and cognitive evaluations.
  2. Note any medications affecting cognitive function.

2. Understanding Definitions

• BIMS: Brief Interview for Mental Status to assess cognitive function.
• Correct Month: Ability to correctly identify the current month during the interview.

3. Coding Instructions

• Steps:
  1. Interview: Ask, "What is the current month?"
  2. Record Response: Document the resident’s exact response.
  3. Evaluate: Code "1" if correct, "0" if incorrect.

4. Coding Tips

• Clarify Without Leading: Ensure the resident understands the question without giving away the answer.
• Consistency: Perform the interview in a comfortable, distraction-free setting.

5. Documentation

• Required:
  • Verbatim response.
  • Date and time of the interview.
  • Observations during the interview.
  • Outcome of the coding.

6. Common Errors to Avoid

• Leading Questions: Ensure the resident identifies the month independently.
• Inconsistent Timing: Conduct the interview at a consistent time.

7. Practical Application

• Example:
  • Resident Profile: Mary, 82, with mild cognitive impairment.
  • Interview: Ask, “Mary, can you tell me what month it is?”
  • Response: Mary answers correctly, code "1".
  • Outcome: Accurate documentation of Mary's cognitive status.

Please note that the information provided in this guide for MDS 3.0 Item set C0300B 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.