A1005A: Ethnicity - No, not of Hispanic, Latino/a, or Spanish origin, Step-by-Step

Step-by-Step Coding Guide for A1005A: Ethnicity – "No, not of Hispanic, Latino/a, or Spanish origin"

1. Review of Medical Records

Objective: Assess the resident’s ethnicity to determine if they identify as Hispanic, Latino/a, or of Spanish origin. This information helps in understanding demographic trends and ensuring personalized care.

Actions:

• Review the resident's demographic details recorded in their admission documents.
• Interview the resident directly or consult with family members, caregivers, or legally authorized representatives if the resident cannot respond.
• Confirm ethnicity data based on the resident’s self-report, as this item is intended to capture self-identified ethnic origins.

2. Understanding Definitions

A1005: Ethnicity refers to the resident’s identification with Hispanic, Latino/a, or Spanish origin. This includes persons of Mexican, Puerto Rican, Cuban, or other Spanish cultures, regardless of race.

Example Scenarios:

• Resident A: The resident identifies as not having Hispanic, Latino/a, or Spanish ancestry. This would be coded as A1005A: "No, not of Hispanic, Latino/a, or Spanish origin."
• Resident B: The resident’s family confirms they are not of Hispanic, Latino/a, or Spanish origin due to a medical condition preventing them from responding. This would also be coded as A1005A: No.

3. Coding Instructions

Step-by-Step:

• Step 1: Ask the resident if they identify as Hispanic, Latino/a, or of Spanish origin.
• Step 2: If the resident does not identify as such, select "No" for A1005A.
• Step 3: If the resident is unable to respond and no family member or representative is available, document X: Resident unable to respond.
• Step 4: If the resident declines to answer, code as Y: Resident declines to respond.

4. Coding Tips

• Self-Identification: Ensure that ethnicity is based on the resident’s self-identification, not assumptions or medical records unless the resident is unable to respond.
• Multiple Responses: The resident may select multiple ethnicities. However, if they affirmatively state that they are not of Hispanic, Latino/a, or Spanish origin, code A1005A as "No."

5. Documentation

Objective: Accurately document the resident’s ethnicity based on their own identification or a family member’s response when necessary.

Actions:

• Ensure that the resident’s self-reported ethnicity is clearly documented in the medical record.
• If a family member provides the response on behalf of the resident, document their input accordingly.

6. Common Errors to Avoid

• Incorrectly Coding Assumptions: Avoid assuming ethnicity based on physical appearance, last name, or other indicators without confirmation from the resident or a family member.
• Incomplete Documentation: Ensure that the resident’s ethnicity is clearly documented, especially in cases where they are unable to respond or decline to answer.

7. Practical Application

Example 1:
A resident who is of European descent states they are not of Hispanic or Latino/a origin. This would be coded as A1005A: "No".

Example 2:
A resident who is unresponsive due to a medical condition and has no family available to provide information is coded as X: Resident unable to respond.

Please note that the information provided in this guide for MDS 3.0 Item set A1005A 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.