E0100B: Psychosis - Delusions, Step-by-Step

Step-by-Step Coding Guide for E0100B: Psychosis – "Delusions"

1. Review of Medical Records

Objective: Determine if the resident experienced delusions in the last 7 days, as part of identifying potential psychosis.

Actions:

• Review the resident’s medical record for any documentation of delusional thoughts or behavior.
• Interview staff who observed the resident during the 7-day look-back period for any signs of delusions.
• Observe the resident directly or through structured interviews to assess if they are expressing fixed false beliefs.

2. Understanding Definitions

E0100B: Delusions refers to a fixed false belief held by the resident that persists even in the face of evidence to the contrary. Examples include beliefs that someone is trying to harm them when there is no threat or that they are in danger despite reassurance to the contrary.

Example Scenario:

• Resident A: Believes they are still employed and insists they must go to work every day, despite being retired for many years. This belief persists even when staff gently remind them of their retirement. This would be coded as E0100B: Delusions.

3. Coding Instructions

Step-by-Step:

• Step 1: Review all available documentation and interview staff regarding the resident’s behavior over the past 7 days.
• Step 2: If the resident exhibited a fixed false belief that persisted despite evidence to the contrary, select E0100B.
• Step 3: If no delusional behavior was observed, skip to the next relevant section.

4. Coding Tips

• Clarify False Beliefs: Ensure that the belief is genuinely false and not merely misunderstood or based on partial information.
• Resident Response to Reassurance: If the resident accepts a reasonable alternative explanation, do not code the behavior as a delusion.

5. Documentation

Objective: Clearly record any instances of delusional thoughts, providing details on how often the behavior occurred and the nature of the delusion.

Actions:

• Document the specific nature of the delusion and how the resident reacted when presented with evidence to the contrary.
• Record how long the belief persisted and whether it caused distress or interfered with care.

6. Common Errors to Avoid

• Assuming Intent: Do not confuse delusions with forgetfulness or cognitive impairment where the resident simply cannot recall certain facts.
• Missing Documentation: Ensure that all delusional episodes are documented clearly, even if the resident only exhibited them briefly during the 7-day period.

7. Practical Application

Example 1:
A resident firmly believes they are being followed by unknown people, despite staff assuring them otherwise. This would be coded as E0100B: Delusions.

Example 2:
A resident initially expresses a false belief about a deceased relative visiting them but quickly accepts an explanation that the relative has passed away. This would not be coded as a delusion.

Please note that the information provided in this guide for MDS 3.0 Item set E0100B 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.