Step-by-Step Coding Guide for Item Set E0100Z: Psychosis - None of the Above

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s mental health status to determine if none of the listed psychosis conditions apply.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including psychiatric evaluations, physician notes, nursing notes, mental health assessments, and previous diagnoses.
  2. Identify Psychosis Documentation: Look for documented instances of psychosis or related symptoms and diagnoses.
  3. Confirm Absence of Conditions: Verify the consistency and accuracy of the documentation to ensure that none of the specified psychosis conditions apply.

2. Understanding Definitions

• Psychosis: A mental disorder characterized by a disconnection from reality, which may include symptoms such as hallucinations, delusions, and disorganized thinking.
• None of the Above: Indicates that the resident does not have any of the listed psychosis conditions as specified in the MDS item set.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm that the resident does not have any documented instances of the specified psychosis conditions based on medical records.
  2. Verify Documentation: Ensure the absence of psychosis conditions is clearly documented in the resident’s records, including psychiatric evaluations and physician notes.
  3. Code Appropriately: Code E0100Z as "1" if the resident has documented evidence of no psychosis conditions listed, and "0" if any of the specified conditions apply.

4. Coding Tips

• Accurate Identification: Ensure that none of the specified psychosis conditions are present and this is supported by comprehensive mental health assessments.
• Consistent Terminology: Use consistent terminology when documenting and coding the resident’s mental health status.
• Consult Mental Health Professionals: If there is any uncertainty, consult with the attending psychiatrist or mental health professional for clarification.

5. Documentation

• Required:
  • Psychiatric Evaluations: Detailed evaluations from a psychiatrist indicating the mental health status of the resident.
  • Physician Notes: Documented assessments and observations by a physician regarding the absence of psychosis.
  • Nursing Notes: Include observations from nursing staff detailing the resident’s behavior and mental status.
  • Mental Health Assessments: Comprehensive assessments that rule out the presence of specified psychosis conditions.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the absence of psychosis conditions through multiple records and evaluations.
• Incomplete Documentation: Make sure all relevant evaluations, physician notes, and nursing observations are included.
• Assumptions: Do not assume the absence of psychosis conditions without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Alice, an 80-year-old resident, is undergoing a mental health assessment to determine the presence of psychosis.
  • Steps:
    1. Review Records: The nurse reviews Alice’s medical records, including psychiatric evaluations and physician notes that indicate no presence of psychosis conditions.
    2. Confirm Absence: It is confirmed that Alice does not have any of the specified psychosis conditions listed.
    3. Document and Code: The nurse documents the findings in Alice’s records and codes E0100Z as "1".
  • Outcome: Alice’s mental health status indicating no psychosis conditions is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set E0100Z 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.