Understanding and Coding MDS 3.0 Item V0100F: Prior Assessment PHQ Staff: Total Mood Score

Understanding and Coding MDS 3.0 Item V0100F: Prior Assessment PHQ Staff: Total Mood Score

Introduction

Purpose:
Mental health is a crucial aspect of a resident’s overall well-being in long-term care facilities. Regular assessment of a resident's mood is essential for identifying issues such as depression or anxiety, which can significantly impact their quality of life. The Patient Health Questionnaire (PHQ-9) is a widely used tool for assessing mood and identifying signs of depression. MDS Item V0100F, Prior Assessment PHQ Staff: Total Mood Score, captures the total mood score from the PHQ-9 administered during the resident's prior assessment. This score helps track changes in the resident's mood over time and informs care planning decisions. 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 V0100F?

Explanation:
MDS Item V0100F, Prior Assessment PHQ Staff: Total Mood Score, is located in Section V of the MDS 3.0 and records the total mood score obtained from the PHQ-9 during the previous assessment period. The PHQ-9 is a standardized tool used by staff to evaluate the presence and severity of depression in residents. The total score, which ranges from 0 to 27, is calculated based on the resident’s responses to nine questions about their mood and interest in daily activities over the past two weeks.

This item is essential for monitoring trends in a resident's mood, identifying any deterioration or improvement, and guiding interventions to support the resident’s mental health.

Guidelines for Coding V0100F

Coding Instructions:
To correctly code Item V0100F, follow these steps:

1. Review the Prior PHQ-9 Assessment: Locate the previous MDS assessment in which the PHQ-9 was administered. Identify the total mood score that was recorded at that time.
2. Enter the Total Mood Score: Record the total score from the PHQ-9 in Item V0100F. This score is the sum of the individual scores from the nine questions, with each question scored on a scale from 0 (not at all) to 3 (nearly every day).
3. Verify Accuracy: Ensure that the score entered in Item V0100F matches the score documented in the prior assessment. Accuracy is critical, as this score is used to track changes in the resident’s mood over time and to evaluate the effectiveness of interventions.
4. Document Any Changes: If there is a significant change in the mood 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’s previous MDS assessment included a PHQ-9 administered by the staff, resulting in a total mood score of 15, indicating moderate depression. During the current assessment, the MDS Coordinator needs to document this prior score in Item V0100F. The MDS Coordinator reviews the prior assessment, confirms the score of 15, and accurately enters it into Item V0100F. This score will be used to compare with the current assessment to determine if the resident’s mood has improved, worsened, or remained the same.

Best Practices for Accurate Coding

Documentation:
Maintain thorough documentation of the PHQ-9 assessments and ensure that the total mood score is accurately recorded in the MDS. This documentation should support the coding of Item V0100F and provide a clear record of the resident’s mood over time.

Communication:
Ensure effective communication between the care team regarding changes in the resident’s mood 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 be familiar with the scoring process and understand how to interpret the results to provide appropriate care.

Conclusion

Summary:
MDS Item V0100F is essential for tracking changes in a resident’s mood over time by recording the total mood score from the PHQ-9 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 scores.

Disclaimer

Please note that the information provided in this guide for MDS 3.0 Item V0100F: Prior Assessment PHQ Staff: Total Mood 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.