Step-by-Step Coding Guide for Item Set D0500D1: PHQ Staff: Feeling Tired/Little Energy - Presence

1. Review of Medical Records

• Objective: Ensure accurate identification and coding of the presence of feeling tired or having little energy as documented in the PHQ-9 Staff Assessment.
• Steps:
  1. Gather Medical Records: Collect all relevant documents including progress notes, physician assessments, and previous PHQ-9 assessments.
  2. Identify Symptoms: Look for documentation that indicates the resident has expressed feelings of tiredness or having little energy.
  3. Verify Consistency: Ensure these symptoms are consistently reported in various parts of the medical records.

2. Understanding Definitions

• Feeling Tired/Little Energy: Refers to a lack of physical or mental energy, leading to fatigue, exhaustion, or a general sense of tiredness.
• PHQ-9 Staff Assessment: A standardized tool used by healthcare providers to screen for the presence and severity of depression in residents.

3. Coding Instructions

• Steps:
  1. Confirm Symptom Presence: Verify that the symptom of feeling tired or having little energy is documented as being present in the PHQ-9 Staff Assessment.
  2. Record Symptom: Enter the presence of the symptom in item set D0500D1 of the MDS form.
  3. Ensure Accuracy: Double-check that the symptom presence is accurately recorded.

4. Coding Tips

• Clear Documentation: Ensure the symptom is clearly documented in the resident's records, including specific instances and descriptions.
• Consistency: Cross-check different parts of the resident's records to ensure the symptom is consistently reported.
• Clarify Ambiguities: If documentation is unclear, seek clarification from the healthcare provider who conducted the assessment.

5. Documentation

• Required:
  • PHQ-9 Staff Assessment: Include the completed assessment form showing the presence of the symptom.
  • Progress Notes: Document any instances where the resident has reported feeling tired or having little energy.
  • Physician Assessments: Include any relevant notes from the physician regarding the symptom.

6. Common Errors to Avoid

• Incorrect Coding: Avoid coding the symptom if it is not clearly documented as present.
• Inconsistent Reporting: Ensure the symptom is reported consistently across all parts of the medical records.
• Incomplete Documentation: Make sure all relevant details and instances of the symptom are documented.

7. Practical Application

• Example:
  • Resident Profile: Mary, a resident in a long-term care facility, frequently reports feeling tired and having little energy.
  • Steps:
    1. Review Records: Gather Mary's progress notes, physician assessments, and previous PHQ-9 assessments.
    2. Confirm Presence: Verify the presence of the symptom in the PHQ-9 Staff Assessment.
    3. Document and Code: Record the presence of the symptom in item set D0500D1 of the MDS form.
    4. Verify Accuracy: Double-check for consistency and accuracy in the documentation.

Please note that the information provided in this guide for MDS 3.0 Item set D0500D1 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.