Step-by-Step Coding Guide for Item Set C0400B: BIMS Resident Interview: Able to Recall "Blue"

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s cognitive abilities and previous BIMS assessments.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including previous BIMS assessments, nursing notes, and cognitive evaluations.
  2. Identify Cognitive Baseline: Look for documented instances of the resident’s cognitive abilities, focusing on short-term memory and recall.
  3. Confirm Details: Verify the consistency of the resident’s ability to recall information through various sources within the medical records.

2. Understanding Definitions

• BIMS (Brief Interview for Mental Status): A structured interview used to assess cognitive function, specifically memory and orientation.
• Recall "Blue": During the BIMS interview, the resident is asked to recall the word "blue" as part of a short-term memory test.

3. Coding Instructions

• Steps:
  1. Conduct the Interview: Administer the BIMS interview, ensuring the resident is attentive and understands the instructions.
  2. Ask for Recall: After a brief interval, ask the resident to recall the word "blue" that was mentioned earlier.
  3. Code Appropriately: Code C0400B based on the resident’s response:
     • 0: No, could not recall
     • 1: Yes, able to recall

4. Coding Tips

• Accurate Assessment: Ensure the environment is conducive to a focused interview, free from distractions.
• Clarify Instructions: Make sure the resident clearly understands the task and the word to be recalled.
• Consistent Terminology: Use consistent terminology and phrasing when conducting the interview and documenting the response.

5. Documentation

• Required:
  • Interview Notes: Record the exact question asked and the resident’s verbatim response.
  • Assessment Records: Completed BIMS assessments that include the resident’s responses.
  • Progress Notes: Document any relevant observations about the resident’s behavior or condition during the interview.

6. Common Errors to Avoid

• Leading Questions: Avoid leading the resident to a particular response. Ensure the resident provides their own assessment.
• Inconsistent Timing: Conduct the interview at a consistent time to avoid confusion and ensure the resident is oriented.
• Inadequate Documentation: Ensure all aspects of the interview and the resident’s responses are thoroughly documented.

7. Practical Application

• Example:
  • Resident Profile: Alice, an 80-year-old resident, is being assessed for cognitive function using the BIMS interview.
  • Steps:
    1. Conduct Interview: The nurse asks Alice, “Please remember the word ‘blue’. I will ask you to recall it in a few minutes.”
    2. Ask for Recall: After a brief interval, the nurse asks, “Can you tell me the word I asked you to remember?”
    3. Record Response: Alice successfully recalls the word “blue.”
    4. Document and Code: The nurse documents Alice’s response and codes C0400B as "1".
  • Outcome: Alice’s ability to recall the word “blue” is 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 C0400B 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.