Understanding and Coding MDS 3.0 Item V0100E: Prior Assessment PHQ Resident: Total Mood Severity Score

Understanding and Coding MDS 3.0 Item V0100E: Prior Assessment PHQ Resident: Total Mood Severity Score

Introduction

Purpose:
Monitoring the mental health of residents in long-term care settings is essential to ensure their overall well-being. The Patient Health Questionnaire (PHQ-9) is a key tool used to assess a resident’s mood and identify symptoms of depression. MDS Item V0100E, Prior Assessment PHQ Resident: Total Mood Severity Score, records the total mood severity score from the PHQ-9 administered during the resident’s previous assessment. This score helps track changes in the resident's mood over time and guides interventions aimed at improving their mental health. This article provides detailed guidance on how to correctly code this item to ensure accurate documentation and compliance with CMS standards.

What is MDS Item V0100E?

Explanation:
MDS Item V0100E, Prior Assessment PHQ Resident: Total Mood Severity Score, is located in Section V of the MDS 3.0 and captures the total mood severity score from the PHQ-9 that was self-administered by the resident during the prior assessment. The PHQ-9 consists of nine questions that assess the frequency of depressive symptoms over the past two weeks, with each question scored from 0 (not at all) to 3 (nearly every day). The total score, which ranges from 0 to 27, provides an indication of the severity of the resident’s mood disturbances, with higher scores indicating more severe depression.

This item is essential for tracking the resident’s mood over time, evaluating the effectiveness of interventions, and informing ongoing care planning.

Guidelines for Coding V0100E

Coding Instructions:
To correctly code Item V0100E, follow these steps:

1. Review the Prior PHQ-9 Assessment: Access the previous MDS assessment where the resident self-administered the PHQ-9. Identify the total mood severity score that was recorded.
2. Enter the Total Mood Severity Score: Record the total score from the resident’s self-administered PHQ-9 in Item V0100E. This score is the sum of the responses to the nine questions, reflecting the severity of depressive symptoms.
3. Verify Accuracy: Ensure that the score entered in Item V0100E matches the score documented in the prior assessment. Accuracy is critical, as this score is used to track changes in the resident’s mood and to assess the need for ongoing or adjusted interventions.
4. Document Any Changes: If there is a significant change in the mood severity score from the prior assessment to the current assessment, ensure that this change is documented and addressed in the resident’s care plan.

Example Scenario:
A resident self-administered the PHQ-9 during a prior MDS assessment, resulting in a total mood severity score of 12, indicating moderate depression. During the current assessment, the MDS Coordinator needs to document this prior score in Item V0100E. The MDS Coordinator reviews the previous assessment, confirms the score of 12, and accurately enters it into Item V0100E. This score will be compared with the current assessment to determine if the resident’s mood has improved, worsened, or remained the same, guiding further care planning.

Best Practices for Accurate Coding

Documentation:
Maintain thorough documentation of the PHQ-9 assessments and ensure that the total mood severity score is accurately recorded in the MDS. This documentation should support the coding of Item V0100E and provide a clear record of the resident’s mood severity over time.

Communication:
Ensure effective communication between the care team regarding changes in the resident’s mood severity score. This information is critical for making informed decisions about the resident’s care plan and any necessary adjustments to interventions.

Training:
Provide regular training to staff on the administration of the PHQ-9 and the importance of accurate scoring. Staff should understand how to guide residents in self-administering the questionnaire and how to interpret the results to provide appropriate care.

Conclusion

Summary:
MDS Item V0100E is essential for tracking changes in a resident’s mood severity over time by recording the total mood severity score from the PHQ-9 self-administered during the previous assessment. By accurately coding this item and monitoring trends in the resident’s mood, healthcare professionals can ensure that the resident’s mental health needs are addressed, supporting high-quality care and compliance with CMS regulations. Following the guidelines and best practices outlined in this article will help maintain the integrity of your facility’s documentation and improve resident outcomes.

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

Reference

CMS's Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.19.1, October 2024. Refer to [Chapter 4, Page 4-30] for detailed guidelines on the CAA process and the importance of documenting prior assessment mood severity scores.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item V0100E: Prior Assessment PHQ Resident: Total Mood Severity Score 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.