Understanding and Coding MDS 3.0 Item A1510B: "Level II PASRR Conditions: Intellectual Disability"

Understanding and Coding MDS 3.0 Item A1510B: "Level II PASRR Conditions: Intellectual Disability"

Introduction

Purpose:

MDS 3.0 Item A1510B, "Level II PASRR Conditions: Intellectual Disability," is a critical component of the resident assessment process, focusing on individuals who may have an intellectual disability (ID). This item is used to document whether a resident has been identified as having an intellectual disability through the PASRR (Preadmission Screening and Resident Review) Level II evaluation. Proper coding of this item ensures that residents with ID receive the appropriate care and services tailored to their specific needs.

What is MDS Item A1510B?

Explanation:

MDS Item A1510B captures whether the resident has been diagnosed with an intellectual disability as determined by a PASRR Level II evaluation. The PASRR process is a federally mandated requirement to screen individuals before admission to Medicaid-certified nursing facilities to ensure that those with serious mental illness (SMI), intellectual disabilities, or related conditions are identified and provided with necessary services.

Intellectual disability, in the context of PASRR, refers to a condition characterized by significant limitations in both intellectual functioning and adaptive behavior, originating before the age of 18. Identifying and documenting this condition through the PASRR Level II evaluation is essential for developing an individualized care plan that addresses the resident’s specific needs.

Guidelines for Coding A1510B

Coding Instructions:

1. Confirm PASRR Level II Evaluation: Determine if the resident has undergone a PASRR Level II evaluation and whether they have been diagnosed with an intellectual disability as part of this evaluation.

2. Response Coding:

   • Code 0 if the resident has not been identified as having an intellectual disability through the PASRR Level II evaluation.
   • Code 1 if the resident has been identified as having an intellectual disability through the PASRR Level II evaluation.

3. Documentation: Ensure that the PASRR Level II documentation is included in the resident's medical record, detailing the diagnosis of intellectual disability and any specialized services recommended or provided as a result.

Example Scenario:

Ms. Green, a resident admitted to a long-term care facility, was evaluated through the PASRR Level II process due to her history of developmental delays. The evaluation confirmed that she has an intellectual disability. For MDS Item A1510B, this would be coded as 1 to indicate the presence of an intellectual disability.

Best Practices for Accurate Coding

Documentation:

• Maintain detailed documentation of the PASRR Level II evaluation, including the diagnosis of intellectual disability and any recommended specialized services or interventions. Ensure this information is easily accessible to the care team.

Communication:

• Facilitate communication between the interdisciplinary team, including social workers, mental health professionals, and caregivers, to ensure that the resident’s care plan is aligned with the PASRR findings and recommendations.

Training:

• Train staff on the importance of recognizing and documenting intellectual disabilities within the PASRR process. Staff should be aware of the specific care needs and services required for residents with intellectual disabilities.

Conclusion

Summary:

Accurately coding MDS Item A1510B is essential for ensuring that residents with intellectual disabilities receive the appropriate care and services. Proper documentation and coordination among staff are key to maintaining compliance with federal regulations and enhancing the quality of care for residents with intellectual disabilities.

Click here to see a detailed Step-by-Step on how to complete this item set.

Reference

This information is based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024, Page 2-6.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item A1510B: "Level II PASRR Conditions: Intellectual Disability" was originally based on the CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. 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.