Step-by-Step Coding Guide for Item Set V0100E: Prior Assessment PHQ Resident - Total Mood Severity Score

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s prior PHQ total mood severity score.
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, focusing on previous assessments, including prior PHQ-9 or PHQ-2 assessments.
  2. Identify Previous PHQ Scores: Locate the documented total mood severity scores from previous assessments.
  3. Confirm Details: Verify the consistency and accuracy of the documentation by cross-referencing multiple sources within the medical records.

2. Understanding Definitions

• Total Mood Severity Score: The cumulative score derived from the PHQ-9 or PHQ-2 assessments, indicating the severity of depressive symptoms.
• Key Points:
  • The PHQ-9 is a 9-item questionnaire used to assess the severity of depression, with scores ranging from 0 to 27.
  • The PHQ-2 is a shorter version, focusing on the first two items of the PHQ-9, with scores ranging from 0 to 6.
  • The total mood severity score is a summation of the individual item scores.

3. Coding Instructions

• Steps:
  1. Identify Relevant Documentation: Confirm the prior PHQ total mood severity score based on previous assessments documented in the medical records.
  2. Verify Documentation: Ensure the prior PHQ assessment and the total mood severity score are clearly documented, including the date and context of the assessment.
  3. Code Appropriately: Enter the prior PHQ total mood severity score in item set V0100E. This should be the exact score documented in the prior assessment.

4. Coding Tips

• Accurate Identification: Ensure the prior PHQ assessment and total mood severity score are correctly identified and supported by relevant documentation.
• Consistent Terminology: Use consistent terminology and phrasing when documenting and coding the prior PHQ total mood severity score.
• Consult Previous Assessments: Verify the total mood severity score by cross-checking with previous PHQ assessments in the resident’s medical records.

5. Documentation

• Required:
  • PHQ Assessment Forms: Include completed PHQ-9 or PHQ-2 forms from prior assessments.
  • Nursing Notes: Detailed notes from nursing staff documenting the resident’s mood and any related observations during the prior assessment period.
  • Physician Notes: Documentation from physicians regarding assessments and treatments related to the resident’s mood and depressive symptoms.
  • Care Plans: Include information about the resident’s mental health management plan and any interventions used.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the prior PHQ total mood severity score through multiple records and previous assessments.
• Incomplete Documentation: Make sure all relevant assessment forms, notes, and logs are included.
• Assumptions: Do not assume the prior PHQ total mood severity score without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Alex, a 68-year-old resident, had a PHQ-9 assessment three months ago with a total mood severity score of 15, indicating moderately severe depression.
  • Steps:
    1. Review Records: The nurse reviews Alex’s medical records, including the previous PHQ-9 assessment form that documented a total mood severity score of 15.
    2. Identify Score: It is confirmed that Alex’s prior PHQ-9 assessment score was 15.
    3. Document and Code: The nurse documents the prior PHQ total mood severity score in Alex’s records and codes V0100E as "15".
  • Outcome: Alex’s prior PHQ total mood severity score is accurately documented and coded, ensuring proper follow-up and mental health care planning.

Please note that the information provided in this guide for MDS 3.0 Item set V0100E 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.