Step-by-Step Coding Guide for C0500. BIMS Summary Score

1. Review of Medical Records

Before coding C0500, the BIMS Summary Score, review the resident's medical records to gather relevant information on their cognitive function. This includes previous BIMS assessments, physician notes, and any diagnoses of cognitive impairments or mental status changes.

2. Understanding Definitions

• BIMS: A structured interview that evaluates a resident's cognitive status by assessing orientation to year, month, and place, recall ability, and the capacity to attend and concentrate.
• Summary Score: The total points accumulated from the responses in items C0200 to C0400 on the BIMS. The score ranges from 00 to 15, where a higher score indicates better cognitive function.

3. Coding Instructions

• C0200 - C0400: Conduct the interview and record the resident's responses. Points are awarded based on accuracy and immediacy of responses:
  • C0200: Repetition of three words. Score based on the number of words repeated after the first attempt.
  • C0300: Temporal orientation. Points awarded for correctly identifying the current year, month, and location.
  • C0400: Recall. Score based on the number of words correctly recalled without cueing.
• C0500: Sum the points from C0200 to C0400 to get the BIMS Summary Score.

4. Coding Tips

• Ensure the environment is conducive to concentrating, with minimal distractions.
• Use clear, simple language and maintain eye contact to encourage focus.
• Be patient and give the resident adequate time to respond.
• If a resident is unable to complete the interview due to sensory impairments or communication barriers, document these challenges in C0700.

5. Documentation

Accurately document the BIMS Summary Score in the resident's medical record, including the date and time of the assessment. Note any environmental or personal factors that could have influenced the resident's performance.

6. Common Errors to Avoid

• Administering the interview in a noisy or distracting environment which can affect the resident's ability to concentrate.
• Rushing the resident through the interview, potentially leading to lower scores.
• Not considering sensory deficits, such as hearing or vision impairment, that might impede the resident's ability to understand or respond to questions.

7. Practical Application

Consider a scenario where a resident scores 2 points for word recall, 4 points for temporal orientation, and 3 points for word repetition. The BIMS Summary Score (C0500) would be 9. This score suggests moderate cognitive impairment, indicating the need for tailored care interventions to support the resident's cognitive functions.

The Step-by-Step Coding Guide for item C0500 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.