A1510A: Level II PASRR Conditions - Serious Mental Illness, Step-by-Step

Step-by-Step Coding Guide for A1510A: Level II PASRR Conditions – "Serious Mental Illness"

1. Review of Medical Records

Objective: Determine if the resident has a serious mental illness as identified in a Level II PASRR screening.

Actions:

• Review the resident's PASRR (Preadmission Screening and Resident Review) Level II documentation.
• Verify if the resident was flagged for a serious mental illness by reviewing the diagnosis reports in their medical record.
• Confirm the resident's current mental health status through recent assessments or care plans.

2. Understanding Definitions

A1510A: Serious Mental Illness refers to a condition where the resident has been diagnosed with a significant mental disorder, such as schizophrenia, bipolar disorder, or major depression, based on the Level II PASRR evaluation.

Example Scenario:

• Resident A: Diagnosed with schizophrenia and flagged in the Level II PASRR screening. This would be coded as A1510A: Serious mental illness.

3. Coding Instructions

Step-by-Step:

• Step 1: Review the Level II PASRR documentation to determine if the resident has been diagnosed with a serious mental illness.
• Step 2: If the documentation confirms a diagnosis of a serious mental illness, select A1510A: Yes.
• Step 3: If no such condition is documented or the PASRR indicates no mental illness, code A1510A: No.

4. Coding Tips

• Rely on PASRR Results: Always refer to the PASRR Level II screening for diagnosis of mental illness, as this is the official source of the assessment.
• Keep Up with State Requirements: Some states may have additional PASRR requirements or protocols, so be aware of local regulations when documenting.

5. Documentation

Objective: Accurately record the resident's status regarding serious mental illness as identified in the PASRR Level II screening.

Actions:

• Ensure the PASRR Level II results are accurately reflected in the care plan.
• Include any relevant details regarding the diagnosis and required specialized services or care.

6. Common Errors to Avoid

• Misinterpretation of PASRR Results: Do not code the item based on assumptions. Ensure that the PASRR Level II screening explicitly states the presence of a serious mental illness.
• Failure to Update Records: If the resident's condition changes or a new PASRR review is conducted, ensure that the records are updated accordingly.

7. Practical Application

Example 1:
A resident has been diagnosed with bipolar disorder and is flagged in the PASRR Level II screening. This would be coded as A1510A: Serious mental illness.

Example 2:
A resident is admitted with no history of serious mental illness, as confirmed by the PASRR Level I screening, and no further referral is required. Code this as A1510A: No.

Please note that the information provided in this guide for MDS 3.0 Item set A1510A 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.