V0100D: Prior Assessment BIMS Summary Score, Step-by-Step
Step-by-Step Coding Guide for Item Set V0100D: "Prior Assessment BIMS Summary Score"
1. Review of Medical Records
- Objective: Ensure that the BIMS (Brief Interview for Mental Status) summary score from the prior assessment is accurately documented.
- Actions:
- Access the resident’s previous MDS assessment and locate the BIMS summary score (C0500).
- Review any relevant cognitive assessments or notes that support the previous BIMS score.
- Ensure that the BIMS score accurately reflects the resident’s cognitive status at the time of the previous assessment.
2. Understanding Definitions
- V0100D: Prior Assessment BIMS Summary Score: This item records the BIMS summary score from the previous MDS assessment. The BIMS is a structured cognitive assessment used to screen for cognitive impairment, with scores ranging from 00 (severe cognitive impairment) to 15 (cognitively intact).
- BIMS Summary Score: The total score obtained by adding up the responses to the BIMS questions (C0200-C0400). This score helps in assessing the resident’s cognitive function.
3. Coding Instructions
- Step-by-Step:
- Step 1: Identify the most recent prior MDS assessment where the BIMS was conducted.
- Step 2: Locate the total BIMS score recorded in item C0500 of the previous assessment.
- Step 3: Enter this score into the V0100D field in the current MDS assessment.
- Step 4: If the BIMS was not completed in the prior assessment or if the score was 99 (indicating the interview was not completed), enter "99" in the V0100D field.
4. Coding Tips
- Accuracy: Ensure the BIMS summary score entered is exactly as recorded in the prior assessment’s C0500 field.
- Consistent Documentation: Cross-reference with other sections of the MDS to confirm that cognitive assessments are consistently documented.
- Handling Missing Scores: If no BIMS score was available in the prior assessment, document this clearly and ensure that the current cognitive assessment reflects any changes.
5. Documentation
- Objective: Maintain clear and accurate records to support the BIMS summary score and track cognitive changes over time.
- Actions:
- Ensure the prior assessment’s BIMS score is documented in a way that allows easy reference in future assessments.
- Document any changes in the resident’s cognitive status that may have occurred since the last assessment, providing context for any score changes.
6. Common Errors to Avoid
- Incorrect Score Transcription: Entering an incorrect score from the prior assessment can lead to inaccurate tracking of cognitive changes and potential care plan issues.
- Overlooking Prior Assessments: Ensure that you refer to the correct previous assessment, especially if multiple assessments were conducted close in time.
- Inconsistent Documentation: Avoid discrepancies between the recorded BIMS scores and the overall cognitive assessment documented in the resident’s records.
7. Practical Application
- Example 1: A resident previously scored 10 on the BIMS, indicating moderate cognitive impairment. This score is entered in V0100D for the current MDS assessment to reflect the prior assessment’s findings. The care team uses this information to track cognitive changes and adjust interventions accordingly.
- Example 2: A resident’s prior assessment had a BIMS score of 99 due to the resident’s inability to complete the interview. The V0100D field is coded as "99," and the current assessment includes alternative measures to assess the resident’s cognitive status.
Please note that the information provided in this guide for MDS 3.0 Item set V0100D 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.
