E0100A: Psychosis - Hallucinations, Step-by-Step

Step-by-Step Coding Guide for E0100A: Psychosis – "Hallucinations"

1. Review of Medical Records

Objective: Determine if the resident experienced hallucinations during the 7-day look-back period, which are symptoms indicating psychosis.

Actions:

• Review the resident's medical records for the last 7 days to see if hallucinations were documented.
• Conduct interviews with staff who interacted with the resident to identify any observed hallucinations.
• Observe the resident during conversations or interactions for any signs of hallucinations.

2. Understanding Definitions

E0100A: Hallucinations are defined as the perception of something that is not actually present. This could involve hearing, seeing, smelling, tasting, or feeling things that others cannot perceive.

Example Scenario:

• Resident A: Reports hearing voices that no one else can hear. This would be coded as E0100A: Hallucinations present.

3. Coding Instructions

Step-by-Step:

• Step 1: Review staff observations and resident interactions over the 7-day look-back period for any reported hallucinations.
• Step 2: If hallucinations were reported or observed, check E0100A.
• Step 3: If no hallucinations were present during the look-back period, do not check this box.

4. Coding Tips

• Behavior-Based Coding: Code based on behaviors observed or expressions by the resident during the look-back period, not solely based on the presence of a medical diagnosis.
• Interview Key Staff: Interview staff from various shifts to ensure a thorough review of the resident’s behavior throughout the week.

5. Documentation

Objective: Clearly document the presence of hallucinations and describe the nature of the hallucination (e.g., auditory, visual) in the resident’s care plan for future follow-up and intervention.

Actions:

• Record specific details about the hallucinations, including the type (auditory, visual, etc.) and frequency.
• Document whether any interventions or treatments have been initiated as a result of the hallucinations.

6. Common Errors to Avoid

• Assuming Without Confirmation: Do not code hallucinations based on assumptions or the resident’s history without clear evidence from the last 7 days.
• Ignoring Staff Input: Be sure to gather input from all staff who interacted with the resident, especially if they are showing symptoms intermittently.

7. Practical Application

Example 1:
A resident reports seeing people in the room that are not present. Staff also noticed the resident talking to these imaginary figures. This should be coded as E0100A: Hallucinations.

Example 2:
A resident hears footsteps when no one is around but dismisses it as background noise after clarification. Since the resident did not hold on to the perception, this would not be coded as hallucination.

Please note that the information provided in this guide for MDS 3.0 Item set E0100A 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.