Step-by-Step Coding Guide for Item Set D0600: PHQ Staff: Total Mood Severity Score

Step-by-Step Coding Guide for Item Set D0600: PHQ Staff: Total Mood Severity Score

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident's mood and psychological well-being.
• Steps:
  1. Collect Information: Review the resident's medical records, including nursing notes, psychological evaluations, and previous assessments.
  2. Identify Mood-Related Documentation: Look for documented evidence of mood disturbances, including previous PHQ-9 scores.
  3. Review Medication Records: Check for any medications prescribed for mood disorders.

2. Understanding Definitions

• PHQ-9 (Patient Health Questionnaire-9): A nine-item questionnaire used to screen for the presence and severity of depression.
• Total Mood Severity Score: The cumulative score of all nine items on the PHQ-9, which reflects the overall severity of the resident’s depressive symptoms.
• Scoring Ranges:
  • 0-4: None
  • 5-9: Mild
  • 10-14: Moderate
  • 15-19: Moderately severe
  • 20-27: Severe

3. Coding Instructions

• Steps:
  1. Conduct the PHQ-9 Assessment: Administer the PHQ-9 questionnaire to the resident or review the most recent PHQ-9 assessment conducted by staff.
  2. Calculate Total Score: Sum the scores of all nine items on the PHQ-9 to get the total mood severity score.
  3. Code Appropriately: Enter the total mood severity score in item D0600 based on the sum of the PHQ-9 items.

4. Coding Tips

• Accurate Scoring: Ensure each item on the PHQ-9 is scored correctly, based on the resident’s responses.
• Consistency: Use the same method for scoring and calculating the total mood severity score each time.
• Clarify Responses: If the resident’s responses are unclear, ask follow-up questions to ensure accurate scoring.

5. Documentation

• Required:
  • PHQ-9 Questionnaire: Include the completed PHQ-9 questionnaire in the resident’s records.
  • Score Calculation: Document how the total score was calculated from the individual item scores.
  • Assessment Notes: Include any relevant notes from the assessment process, such as resident’s behavior or additional comments.

6. Common Errors to Avoid

• Incorrect Scoring: Ensure that each item is scored according to the PHQ-9 guidelines.
• Incomplete Assessment: Do not leave any items on the PHQ-9 blank; ensure all questions are answered.
• Misinterpretation of Scores: Be familiar with the scoring ranges to accurately interpret the total mood severity score.

7. Practical Application

• Example:
  • Resident Profile: Jane, an 80-year-old resident, completed the PHQ-9 questionnaire.
  • Steps:
    1. Administer PHQ-9: The nurse administers the PHQ-9 questionnaire to Jane.
    2. Calculate Score: Jane’s responses result in the following scores: 2, 3, 1, 2, 1, 0, 2, 3, 1. The total mood severity score is 15.
    3. Document and Code: The nurse documents the total score in Jane’s records and codes D0600 as "15".
  • Outcome: Jane’s total mood severity score is accurately documented and coded, facilitating appropriate follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set D0600 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.