Step-by-Step Coding Guide for C0600. Should the Staff Assessment for Mental Status (C0700 - C1000) be Conducted?

1. Review of Medical Records

• Start by reviewing the resident's medical records thoroughly, including physician's notes, nursing notes, and any mental health professional evaluations. Look for documentation of cognitive function tests, resident behavior, and any noted changes in mental status.

2. Understanding Definitions

• Staff Assessment for Mental Status (C0700 - C1000): A systematic evaluation conducted by the facility staff to assess aspects of a resident's cognitive function, including memory recall, cognitive skills for daily decision-making, and making oneself understood through verbal and non-verbal communication.
• Cognitive Function Tests: Standardized tests used to measure various aspects of cognition, including memory, attention, problem-solving, and language abilities.

3. Coding Instructions

• Code 0 (No): If the Interview for Cognitive Status (BIMS) was completed (responses to C0200 - C0500), code C0600 as 0, indicating the staff assessment should not be conducted.
• Code 1 (Yes): If the BIMS could not be completed because the resident was unable to communicate and a proxy interview was not conducted, or if the BIMS questions were not attempted for any reason, code C0600 as 1, indicating the staff assessment should be conducted.

4. Coding Tips

• Ensure accuracy in determining the need for staff assessment by carefully reviewing the outcomes of the BIMS.
• Consider any temporary factors that might affect the resident’s ability to participate in BIMS, such as acute illness or emotional distress.

5. Documentation

• Document the rationale for the decision on whether the staff assessment for mental status is needed in the resident's care plan.
• Include observations, clinical assessments, and any communication with the resident's family or healthcare provider that influenced the coding.

6. Common Errors to Avoid

• Incorrectly coding C0600 due to failure to attempt the BIMS interview or not considering a proxy interview when appropriate.
• Overlooking relevant medical record information that indicates significant cognitive impairment or communication barriers.

7. Practical Application

• Example Scenario: A resident who has recently experienced a stroke struggles with verbal communication. The BIMS could not be completed due to these communication barriers. The staff decides to proceed with the staff assessment for mental status, documenting the medical condition as the reason for this approach.

The Step-by-Step Coding Guide for item C0600 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.