A0050: Type of Record, Step-by-Step
Step-by-Step Coding Guide for Item Set A0050: Type of Record
1. Review of Medical Records
Before coding the A0050 item, start by thoroughly reviewing the resident's medical records. This review should include:
- Current assessment data: Confirm that the MDS assessment is complete and accurate.
- Previous assessments: Check if there are existing records for the resident that might need to be modified or inactivated.
- Verification of dates: Ensure that key dates such as the Assessment Reference Date (ARD), entry date, or discharge date are accurate.
2. Understanding Definitions
Understanding the options available for A0050 is crucial:
- Code 1: Add New Record: Use when this is the first submission of a record that has not been previously entered into iQIES.
- Code 2: Modify Existing Record: Select this if you need to correct an error in a record that has already been accepted in iQIES.
- Code 3: Inactivate Existing Record: Use this when an already submitted record needs to be removed from the active database due to an error or if it was submitted inappropriately.
3. Coding Instructions
Follow these instructions based on the situation:
-
New Record:
- Code 1 if the assessment is newly completed and has not been submitted before.
- Proceed to A0100 (Facility Provider Numbers).
-
Modify Existing Record:
- Code 2 if you are updating a record already accepted by iQIES.
- Ensure all necessary corrections are made.
- Proceed to A0100 (Facility Provider Numbers).
-
Inactivate Existing Record:
- Code 3 if a record needs to be removed from the system.
- Skip directly to Section X (Type of Provider).
4. Coding Tips
- Check for Duplicates: Always verify that the record you are submitting does not duplicate an existing one. Duplicate records will be rejected.
- Correct Identification: Ensure that all identifying information (e.g., resident name, assessment date) is accurate to avoid "fatal" errors.
- Document Changes: When modifying or inactivating a record, make sure to document the reasons for these actions in the resident’s medical record.
5. Documentation
- Record Keeping: Maintain detailed documentation in the resident’s medical file explaining the rationale behind choosing the specific code for A0050.
- Modification/Inactivation Documentation: If modifying or inactivating a record, clearly document the original error and the steps taken to correct it.
6. Common Errors to Avoid
- Submitting Duplicate Records: Double-check that the record hasn’t been previously submitted with the same details.
- Incorrect Dates: Ensure that the ARD, entry date, and discharge date are accurate.
- Misidentifying Records: Make sure that when modifying or inactivating, the correct original record is targeted.
7. Practical Application
Example 1: Adding a New Record
- A resident named John Doe has just been admitted, and his MDS admission assessment is complete. This is the first submission.
- Code 1 is selected. Proceed to A0100.
Example 2: Modifying an Existing Record
- You discover that Jane Smith’s assessment date was entered incorrectly in the previously submitted record.
- Code 2 is selected. Correct the assessment date and resubmit.
Example 3: Inactivating an Existing Record
- An MDS assessment was mistakenly submitted for the wrong resident, Mark White.
- Code 3 is selected. The record is identified and inactivated in Section X.
Please note that the information provided in this guide for MDS 3.0 Item set A0050 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.
