Step-by-Step Coding Guide for Item Set V0100: Items From the Most Recent Prior OBRA or Scheduled PPS Assessment

This guide is designed to assist in accurately coding and documenting items from the most recent prior OBRA (Omnibus Budget Reconciliation Act) or scheduled PPS (Prospective Payment System) assessment, as outlined in V0100 of the MDS 3.0.

1. Review of Medical Records

• Objective: To locate and review items from the most recent prior OBRA or scheduled PPS assessment.
• Key Points:
  • Thoroughly examine the resident's medical records, focusing on the latest completed OBRA or PPS MDS assessments.
  • Identify and note the dates of these assessments to determine the most recent one.

2. Understanding Definitions

• Objective: Clarify the significance of the most recent prior OBRA or scheduled PPS assessment.
• Key Points:
  • OBRA Assessment: Required assessments under the OBRA '87 regulations for all residents in certified nursing facilities.
  • PPS Assessment: Part of the Medicare-required assessments for residents covered under the Medicare Part A PPS.

3. Coding Instructions

• Objective: Guide on how to accurately code items from the latest assessment.
• Key Points:
  • Ensure you are referencing the correct and most recent OBRA or PPS assessment.
  • Carefully transfer relevant information from the previous assessment to the current MDS 3.0 form, as required by V0100 item instructions.

4. Coding Tips

• Double-check the assessment reference date (ARD) to confirm you are using the most recent prior assessment.
• Pay close attention to any changes in resident status or care needs that may have occurred since the last assessment.

5. Documentation

• Document the process of reviewing and coding items from the most recent prior assessment, including any discrepancies or changes noted.
• Ensure that this documentation is easily accessible within the resident's medical records.

6. Common Errors to Avoid

• Using information from an outdated assessment, not the most recent prior OBRA or PPS assessment.
• Inaccurately transferring information or coding items incorrectly based on the previous assessment's findings.

7. Practical Application

• Scenario: A nursing facility staff member is completing the MDS 3.0 for a resident who had an OBRA assessment completed three months prior. The staff member reviews the previous assessment, noting key items such as the resident's cognitive status and ADL performance scores. They carefully ensure that these items are accurately reflected and updated based on the current assessment, documenting any changes or continuity in care needs.

The Step-by-Step Coding Guide for item V0100 in MDS 3.0 Section V is based on the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, Version 1.18.11, dated October 2023. Healthcare guidelines, policies, and regulations can undergo frequent updates. Therefore, healthcare professionals must ensure they are referencing the most current version of the MDS 3.0 manual. This guide aims to assist with understanding and applying the coding procedures as outlined in the referenced manual version. However, in cases where there are updates or changes to the manual after the mentioned date, users should refer to the latest version of the manual for the most accurate and up-to-date information. The guide should not substitute for professional judgment and the consultation of the latest regulatory guidelines in the healthcare field.