Step-by-Step Coding Guide for Item Set D0160: PHQ Res: Total Mood Severity Score

1. Review of Medical Records

• Objective: To accurately gather information to calculate the resident’s total mood severity score using the PHQ-9 Resident Mood Interview.
• Steps:
  1. Collect PHQ-9 Data: Gather all previous PHQ-9 assessments completed by the resident.
  2. Verify Responses: Cross-check the responses with nursing notes, care plans, and any other relevant documentation to ensure consistency.
  3. Interview Notes: Review detailed notes from interviews conducted with the resident, paying attention to their reported symptoms and frequency.

2. Understanding Definitions

• PHQ-9 (Patient Health Questionnaire-9): A validated tool used to screen for the presence and severity of depression.
• Total Mood Severity Score: The cumulative score derived from the PHQ-9, indicating the overall severity of the resident's mood symptoms.

3. Coding Instructions

• Steps:
  1. Administer the PHQ-9: Conduct the PHQ-9 interview with the resident, ensuring to ask each of the nine questions regarding mood symptoms.
  2. Score Each Item: Score each item on the PHQ-9 based on the resident’s responses:
     • 0: Not at all
     • 1: Several days
     • 2: More than half the days
     • 3: Nearly every day
  3. Calculate Total Score: Add the scores for each of the nine items to get the total mood severity score, which can range from 0 to 27.
  4. Record the Score: Document the total mood severity score in item set D0160 in the MDS system.

4. Coding Tips

• Ensure Accuracy: Double-check the scoring for each item to ensure the total score is accurate.
• Resident Engagement: Engage with the resident empathetically during the PHQ-9 interview to ensure honest and accurate responses.
• Consistency: Ensure that the responses recorded during the PHQ-9 interview are consistent with other documentation and observations in the resident’s medical records.

5. Documentation

• Required:
  • PHQ-9 Forms: Completed forms from the resident’s interviews.
  • Interview Notes: Detailed notes from the PHQ-9 interview.
  • Nursing Notes: Observations and notes from nursing staff regarding the resident’s mood and behavior.
  • Care Plans: Any care plans addressing mood or depression-related issues.

6. Common Errors to Avoid

• Incorrect Scoring: Miscalculating the total mood severity score by incorrectly scoring individual items.
• Incomplete Interviews: Failing to complete all nine items of the PHQ-9.
• Inconsistent Documentation: Recording responses that are inconsistent with other documented observations or notes.

7. Practical Application

• Example:

  • Resident Interview: Ms. Jane Doe, an 80-year-old female resident, completes the PHQ-9 interview. Her responses are as follows:
    • Little interest or pleasure in doing things: Nearly every day (3)
    • Feeling down, depressed, or hopeless: More than half the days (2)
    • Trouble falling/staying asleep, or sleeping too much: Several days (1)
    • Feeling tired or having little energy: More than half the days (2)
    • Poor appetite or overeating: Nearly every day (3)
    • Feeling bad about yourself – or that you are a failure or have let yourself or your family down: Not at all (0)
    • Trouble concentrating on things, such as reading the newspaper or watching television: Several days (1)
    • Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual: Not at all (0)
    • Thoughts that you would be better off dead, or thoughts of hurting yourself in some way: Not at all (0)
  • Total Mood Severity Score Calculation:
    • Total Score = 3 + 2 + 1 + 2 + 3 + 0 + 1 + 0 + 0 = 12
  • Documentation: Record the total mood severity score of 12 in item set D0160.

• Illustration:

  • Include a chart or table showing how to score each item on the PHQ-9 and calculate the total mood severity score.

Please note that the information provided in this guide for MDS 3.0 Item set D0160 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.