D0150B1: PHQ Resident: Feeling Down, Depressed - Presence, Step-by-Step

Step-by-Step Coding Guide for Item Set D0150B1: PHQ Resident: Feeling Down, Depressed - Presence

1. Review of Medical Records

• Objective: To identify if the resident has expressed feelings of being down or depressed.
• Process:
  • Review psychological assessments, including any Patient Health Questionnaire (PHQ) results that specifically measure depression symptoms.
  • Examine nursing and social services notes for any documentation of the resident expressing feelings of sadness or depression.
  • Consult with the mental health professionals involved in the resident’s care for any clinical observations or treatment notes related to depression.

2. Understanding Definitions

• Feeling Down, Depressed: Refers to the resident's self-reported emotional state involving persistent sadness, melancholy, or a lack of interest in life, which may affect their daily functioning.

3. Coding Instructions

• Code D0150B1:
  • 0: No, the resident does not feel down or depressed.
  • 1: Yes, the resident feels down or depressed.
• Example: If during a routine PHQ assessment, the resident consistently reports feeling down or having little interest in doing things, code D0150B1 as '1'.

4. Coding Tips

• Ensure the assessment is based on the resident’s direct responses to the PHQ or during interactions with staff.
• Re-evaluate periodically as emotional states can change, and code updates may be necessary at each MDS assessment.

5. Documentation

• Required Documentation:
  • Responses from PHQ screenings that indicate the resident’s feelings about depression or mood states.
  • Detailed notes from psychological evaluations or counseling sessions.
  • Interdisciplinary team notes that discuss the resident’s mood and any relevant changes or interventions.
• Documentation should be timely and accurately reflect the resident's current mental health state.

6. Common Errors to Avoid

• Failing to update coding when new information indicates a change in the resident’s emotional well-being.
• Overlooking subtle signs of depression documented in daily care notes but not addressed in formal assessments.
• Relying solely on medication use for depression without considering self-reported mood states or clinical observations.

7. Practical Application

• Scenario: A resident, normally active in social activities, begins to withdraw and expresses feelings of sadness during a monthly care meeting. The social worker administers the PHQ, where the resident reports feeling down nearly every day. This change is documented, discussed in the care planning meeting, and interventions are planned, including referral to a therapist and increased social support. For MDS coding, based on the PHQ results and additional documentation, D0150B1 is coded as '1' to reflect the presence of these feelings.

Please note that the information provided in this guide for MDS 3.0 Item set D0150B1 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.