Step-by-Step Coding Guide for Item C0400C: BIMS Resident Interview - Able to Recall "Bed"

1. Review of Medical Records

Objective:

• To gather comprehensive information about the resident’s cognitive status and ability to recall the word "bed" as part of the Brief Interview for Mental Status (BIMS).

Steps:

1. Collect Previous Cognitive Assessments:
   • Review any previous cognitive assessments, including prior BIMS interviews, neuropsychological evaluations, and memory tests.
2. Examine Physician and Specialist Notes:
   • Look at notes from neurologists, primary care physicians, and any specialists involved in the resident’s cognitive care.
3. Review Daily Care Notes:
   • Check for notes from nurses and caregivers about the resident’s daily cognitive function and any memory issues observed.
4. Interdisciplinary Team Discussions:
   • Gather information from interdisciplinary team meetings that discuss the resident’s cognitive status and recall ability.

Example:

• Resident A: Previous BIMS assessment indicates the resident could recall "bed" without cues. Physician notes confirm ongoing mild cognitive impairment.

2. Understanding Definitions

Objective:

• To clearly define terms and components related to the BIMS item C0400C.

Definitions:

• BIMS (Brief Interview for Mental Status): A structured interview designed to assess cognitive function, specifically short-term memory and recall abilities.
• Category Cue: A hint given to help the resident recall a word, such as “a piece of furniture” for the word "bed".

Example:

• Category Cue for "Bed": The interviewer may say "a piece of furniture" if the resident cannot recall the word spontaneously.

3. Coding Instructions

Objective:

• To provide precise steps for coding item C0400C accurately.

Steps:

1. Ask for Recall:
   • Ask the resident to recall the word "bed" without any cues.
2. Allow Time for Response:
   • Give the resident up to 5 seconds to respond.
3. Provide a Category Cue if Needed:
   • If the resident cannot recall "bed" within 5 seconds, provide the category cue “a piece of furniture”.
4. Allow Additional Time After Cueing:
   • Allow up to 5 seconds after providing the cue for the resident to recall the word.
5. Code the Response:
   • Code 0 if the resident could not recall "bed" even after cueing.
   • Code 1 if the resident recalled "bed" after cueing.
   • Code 2 if the resident recalled "bed" without any cues.

Example:

• Resident B: The resident recalls "bed" immediately when asked. Code C0400C as 2.

4. Coding Tips

Objective:

• To offer practical advice to ensure accurate and consistent coding.

Tips:

1. Use Consistent Cues:
   • Use the same category cue (“a piece of furniture”) consistently for all residents.
2. Verify Response:
   • Ensure the resident's response is relevant and specific to the cue given.
3. Consider Multiple Attempts:
   • If the resident names multiple items spontaneously, accept the correct one if it is included.

Example:

• Resident C: If the resident initially says "sofa, chair, bed" without cueing, code as 2 since "bed" was included in the initial response.

5. Documentation

Objective:

• To ensure thorough and accurate documentation supporting the coding of item C0400C.

Steps:

1. Record the Resident’s Response:
   • Document the resident’s exact words and whether a cue was given.
2. Detail the Process:
   • Note the timing and any additional observations during the recall process.
3. Include Staff Observations:
   • Document input from all relevant healthcare providers involved in the assessment.

Example:

• Resident D: Documentation includes the exact time taken for recall, whether a cue was used, and any additional relevant observations from the interviewer.

6. Common Errors to Avoid

Objective:

• To highlight frequent mistakes and provide guidance on how to avoid them.

Errors:

1. Incorrect Coding for No Response:
   • Coding as 1 or 2 when the resident could not recall "bed" even after cueing.
2. Omitting Category Cues:
   • Failing to provide the category cue if the resident does not recall the word spontaneously.
3. Inconsistent Documentation:
   • Not consistently documenting the process and the resident’s response.

Tips to Avoid Errors:

• Double-Check Responses:
  • Verify the resident’s response and ensure it matches the coding criteria.
• Consistent Use of Cues:
  • Always provide the category cue if the resident cannot recall spontaneously.
• Thorough Documentation:
  • Ensure all steps and responses are thoroughly documented.

7. Practical Application

Objective:

• To apply the coding guidelines through practical examples and scenarios.

Scenario 1:

• Resident E: Asked to recall "bed" and responds "bed" immediately.
  • Coding: Enter 2 in C0400C.

Scenario 2:

• Resident F: Asked to recall "bed" and responds after the category cue “a piece of furniture”.
  • Coding: Enter 1 in C0400C.

Scenario 3:

• Resident G: Asked to recall "bed" and does not respond even after the category cue.
  • Coding: Enter 0 in C0400C.

Illustrations:

• Include diagrams or flowcharts illustrating the steps for assessing and coding the resident’s ability to recall "bed".

Please note that the information provided in this guide for MDS 3.0 Item set C0400C 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.