Step-by-Step Coding Guide for Item Set D0150E2: PHQ Resident: Poor Appetite or Overeating - Frequency

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s experience with poor appetite or overeating and its frequency.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including nursing notes, dietary logs, and previous assessments.
  2. Identify Eating Patterns: Look for documented instances where the resident’s eating habits indicate poor appetite or overeating.
  3. Confirm Details: Verify the consistency of these eating patterns through various sources within the medical records.

2. Understanding Definitions

• Poor Appetite or Overeating: Refers to significant changes in eating habits where the resident either eats very little (poor appetite) or eats excessively (overeating).
• Frequency: The regularity with which these eating habits occur, typically measured over the past two weeks.

3. Coding Instructions

• Steps:
  1. Conduct the Interview: During the PHQ (Patient Health Questionnaire) interview, ask the resident how often they have experienced poor appetite or overeating in the past two weeks.
  2. Record the Response: Note the resident’s response using the following frequency scale:
     • 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)
  3. Code Appropriately: Enter the corresponding code in item set D0150E2 based on the resident’s response.

4. Coding Tips

• Accurate Interviewing: Ensure the environment is conducive to a focused interview, free from distractions.
• Clarify Question: Make sure the resident understands the question about poor appetite or overeating.
• Consistent Terminology: Use consistent terminology and phrasing when conducting the interview and documenting the response.

5. Documentation

• Required:
  • Interview Notes: Record the exact question asked and the resident’s verbatim response regarding poor appetite or overeating.
  • Assessment Records: Document the resident’s eating patterns and their frequency in the assessment records.
  • Care Plans: Include the resident’s eating habits in the care plan to ensure it is considered in their daily routine and nutritional management.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the resident’s response through direct questioning.
• Incomplete Documentation: Make sure all relevant details about the resident’s eating habits are thoroughly documented.
• Assumptions: Do not assume the resident’s eating habits without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Mary, a 75-year-old resident, is being interviewed about her eating habits over the past two weeks.
  • Steps:
    1. Conduct Interview: The nurse asks Mary, “Over the last two weeks, how often have you had poor appetite or been overeating?”
    2. Record Response: Mary responds, “I’ve had poor appetite on nearly every day.”
    3. Document and Code: The nurse documents Mary’s response and codes D0150E2 as "3".
  • Outcome: Mary’s experience with poor appetite is accurately documented and coded, ensuring proper follow-up and inclusion in her care plan.

Please note that the information provided in this guide for MDS 3.0 Item set D0150E2 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.