Step-by-Step Coding Guide for Item Set D0100: PHQ - Should Resident Mood Interview Be Conducted

1. Review of Medical Records

• Objective: Determine whether the resident's mood interview (PHQ - Patient Health Questionnaire) should be conducted based on a review of their medical records.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including psychological evaluations, nursing notes, physician assessments, and any previous PHQ interviews.
  2. Identify Indicators: Look for indicators that may warrant the mood interview, such as recent changes in behavior, history of depression or anxiety, or other relevant mental health conditions.
  3. Confirm Details: Verify the consistency and relevance of the information across various sources within the medical records.

2. Understanding Definitions

• PHQ: Patient Health Questionnaire, a standard tool used for assessing depression and other mood disorders.
• Mood Interview: An interview conducted to evaluate the resident’s current mood and mental health status.
• Key Points:
  • Relevance: Determine if the resident’s current condition and history suggest the need for a mood interview.
  • Readiness: Assess the resident's ability and willingness to participate in the interview.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm through the medical records if there are indicators suggesting the need for a mood interview.
  2. Verify Documentation: Ensure that the reasons for conducting or not conducting the interview are clearly noted in the records.
  3. Code Appropriately: Enter the appropriate code for item set D0100:
     • 0: No, the resident’s mood interview should not be conducted.
     • 1: Yes, the resident’s mood interview should be conducted.

4. Coding Tips

• Accurate Identification: Ensure the decision to conduct the mood interview is supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the decision.
• Consultation: If there is any uncertainty, consult with the interdisciplinary team to ensure accurate coding.

5. Documentation

• Required:
  • Psychological Evaluations: Detailed evaluations from psychologists or mental health professionals.
  • Nursing Notes: Observations and reports from nursing staff related to the resident’s mood and behavior.
  • Physician Assessments: Assessments from physicians detailing any changes in the resident’s mental health status.
  • Previous PHQ Interviews: Records of any previous PHQ interviews and their outcomes.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the decision through multiple records and notes.
• Incomplete Documentation: Make sure all relevant psychological evaluations, nursing notes, and physician assessments are included to support the decision documented.
• Assumptions: Do not assume the need for a mood interview without proper documentation and verification; always check multiple sources.

7. Practical Application

• Example:
  • Resident Profile: James, a 70-year-old resident, has shown signs of mood changes recently.
  • Steps:
    1. Review Records: The nurse reviews James’s medical records, including psychological evaluations and nursing notes, to find indicators for a mood interview.
    2. Identify Indicators: It is confirmed through the documentation that James has exhibited signs of depression and has a history of anxiety.
    3. Document and Code: The nurse documents the need for a mood interview in James’s records and codes D0100 as "1".
  • Outcome: James’s need for a mood interview 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 D0100 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.