Step-by-Step Coding Guide for Item Set D0150B2: PHQ Resident Mood Interview - Feeling Down, Depressed - Frequency

Step-by-Step Coding Guide for Item Set D0150B2: PHQ Resident Mood Interview - Feeling Down, Depressed - Frequency

1. Review of Medical Records

• Objective: To determine the frequency with which the resident feels down, depressed, or hopeless over the past two weeks.
• Process:
  • Resident Interviews: Conduct the Patient Health Questionnaire (PHQ-9) interview with the resident to assess mood.
  • Nursing and Care Staff Notes: Review notes for observations related to the resident's mood and affect.
  • Mental Health Evaluations: Look at evaluations from mental health professionals regarding depressive symptoms.
  • Medication Records: Check for medications prescribed for depression and any changes in dosages.

2. Understanding Definitions

• PHQ-9: A widely used screening tool to assess the frequency of depression-related symptoms.
• Frequency: Refers to how often the resident has experienced feelings of being down, depressed, or hopeless in the past two weeks.

3. Coding Instructions

• Code D0150B2:
  • 0: Never or 1 day.
  • 1: 2-6 days (several days).
  • 2: 7-11 days (more than half the days).
  • 3: 12-14 days (nearly every day).
• Example: If a resident reports feeling depressed for several days (2-6 days) over the past two weeks, code D0150B2 as '1'.

4. Coding Tips

• Accurate Interviewing: Ensure that the resident understands each question and provide examples if needed.
• Consistent Questioning: Use the exact wording from the PHQ-9 to maintain consistency and reliability.

5. Documentation

• Required Documentation:
  • Interview Notes: Record the resident's responses to each question in the PHQ-9.
  • Care Plan Updates: Include any interventions or changes based on the PHQ-9 results.
  • Observation Records: Document observations from staff that support the resident's self-reported frequency of depressive symptoms.
• Example: "On 05/10/2024, the resident reported feeling down and depressed for several days over the past two weeks. This was documented in the PHQ-9 interview form and the care plan was updated to include increased social activities and regular check-ins by the mental health team."

6. Common Errors to Avoid

• Misinterpretation: Misunderstanding the resident’s response or not using the standardized PHQ-9 wording.
• Inconsistent Documentation: Failing to document the resident's responses accurately or consistently.
• Omission of Context: Not considering factors that might affect the resident’s mood, such as recent changes in health or medication.

7. Practical Application

• Scenario: During a routine assessment, a resident indicates they have felt down and depressed for several days in the past two weeks. This information is documented in the PHQ-9 interview notes and corroborated by nursing staff observations. The care plan is updated to address these feelings with specific interventions. Based on this information, D0150B2 is coded as '1'.

Please note that the information provided in this guide for MDS 3.0 Item set D0150B2 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.