Step-by-Step Coding Guide for Item Set D0150D2: PHQ Result - Feeling Tired/Little Energy - Frequency

1. Review of Medical Records

• Objective: Confirm that the resident's reports or clinical observations of feeling tired or having little energy are accurately recorded in their medical records.
• Action: Examine clinical notes, psychological evaluations, and other relevant health assessments where symptoms of fatigue or low energy might be documented.

2. Understanding Definitions

• PHQ Result - Feeling Tired/Little Energy - Frequency: This measures the frequency of the resident’s feelings of tiredness or having little energy, as part of the Patient Health Questionnaire (PHQ) depression scale, which assesses mental health conditions.

3. Coding Instructions

• Assessment through PHQ-9: Use the PHQ-9 questionnaire to determine how often the resident has felt this way over the last two weeks.
• Correct Coding of Frequency:
  • 0 = "Not at all"
  • 1 = "Several days"
  • 2 = "More than half the days"
  • 3 = "Nearly every day"
• Enter the appropriate code based on the resident's response into the MDS.

4. Coding Tips

• Consistency with Clinical Observations: Ensure the resident’s self-report aligns with clinical observations and notes made by healthcare providers.
• Reevaluation: Consider regular reevaluation as mental health can fluctuate, affecting the frequency of reported symptoms.

5. Documentation

• Accurate Recording: Document the resident's responses and any relevant clinical observations that support the coding.
• Audit Trail: Maintain detailed records of assessments and interviews that justify the coded frequency.

6. Common Errors to Avoid

• Misinterpretation: Ensure that responses are not misinterpreted or recorded under the wrong frequency due to miscommunication or rushed assessments.
• Inconsistency: Avoid inconsistencies between different sections of the MDS or other medical records that might suggest data entry errors.

7. Practical Application

• Example: During a routine assessment, Mr. John Smith, a resident, reported feeling tired "more than half the days" over the last two weeks during his PHQ-9 interview. This information was cross-referenced with nurse's notes indicating observations of Mr. Smith appearing lethargic on several recent occasions. The MDS Coordinator coded his response as 2 for D0150D2, consistent with both his self-report and clinical observations. This coding was then reviewed in a team meeting to ensure all staff were aware and could adjust care plans accordingly.

Please note that the information provided in this guide for MDS 3.0 Item set D0150D2 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.