D0150F1: PHQ Resident Feeling Bad About Self - Presence, Step-by-Step
Step-by-Step Coding Guide for Item Set D0150F1: PHQ Resident Feeling Bad About Self - Presence
1. Review of Medical Records
The initial step in coding for item D0150F1 involves a thorough review of the resident’s medical records. This includes:
- Physician’s Notes: Examine progress notes, history, and physical examination records.
- Diagnosis Lists: Verify the diagnosis/problem list for documented mood disorders or symptoms of depression confirmed by the physician.
- Interdisciplinary Notes: Check notes from nursing, dietary, rehabilitation, and other care team members.
- Behavioral Health Notes: Review any psychiatric or psychological evaluations and treatment notes.
2. Understanding Definitions
Understanding the key definitions related to this item is crucial:
- Feeling Bad About Self: This refers to feelings of worthlessness, self-loathing, or failure. It is an important indicator of mood disorders such as depression.
- PHQ-9: The Patient Health Questionnaire-9 (PHQ-9) is a standardized tool used to screen for depression by assessing the frequency of depressive symptoms over the past two weeks.
3. Coding Instructions
Follow these steps for accurate coding:
- Administer the PHQ-9 Interview: Conduct the Resident Mood Interview (PHQ-2 to 9©) to determine the presence and frequency of depressive symptoms.
- Assess Symptom Presence: Ask the resident if they have been bothered by feeling bad about themselves or feeling like a failure over the past two weeks.
- Use the exact wording from the PHQ-9 to ensure consistency.
- Record the resident's response in Column 1 (Symptom Presence) as follows:
- Code 0 (No): If the resident indicates the symptom is not present.
- Code 1 (Yes): If the resident indicates the symptom is present.
- Code 9 (No Response): If the resident was unable or chose not to complete the assessment.
- Determine Symptom Frequency: If the resident indicates the symptom is present, ask how often they have been bothered by this symptom in the past two weeks.
- Record the frequency in Column 2 (Symptom Frequency) as follows:
- Code 0: Never or 1 day.
- Code 1: 2-6 days (several days).
- Code 2: 7-11 days (half or more of the days).
- Code 3: 12-14 days (nearly every day).
- Record the frequency in Column 2 (Symptom Frequency) as follows:
4. Coding Tips
- Consistency: Ensure the resident’s responses are consistent with other documentation in the medical record.
- Clarity: Clearly explain the response choices to the resident, using a cue card if necessary.
- Neutral Probing: If the resident is uncertain, gently probe with neutral questions to clarify their responses.
- Documentation: Record responses accurately and immediately to avoid errors.
5. Documentation
Accurate documentation is critical for compliance and effective care planning:
- Daily Records: Maintain thorough daily records of the resident’s mood and any changes.
- Care Plans: Update care plans to reflect the presence of depressive symptoms and corresponding interventions.
- Interdisciplinary Communication: Ensure all team members are informed of and document any mood-related findings and their impact on care.
6. Common Errors to Avoid
- Inconsistent Documentation: Avoid discrepancies between the MDS data and other medical records.
- Incomplete Assessments: Ensure all parts of the PHQ-9 are completed unless the resident is unable or unwilling to participate.
- Incorrect Coding: Double-check coding entries for accuracy, especially the presence and frequency columns.
7. Practical Application
Use case studies and scenarios to apply your knowledge:
- Example 1: A resident reports feeling like a failure nearly every day for the past two weeks.
- Coding: D0150F1 (Symptom Presence) would be coded 1 (Yes), and D0150F2 (Symptom Frequency) would be coded 3 (12-14 days).
- Example 2: A resident indicates they have felt bad about themselves for several days over the past two weeks.
- Coding: D0150F1 (Symptom Presence) would be coded 1 (Yes), and D0150F2 (Symptom Frequency) would be coded 1 (2-6 days).
Please note that the information provided in this guide for MDS 3.0 Item set D0150F2 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.
