Step-by-Step Coding Guide for Item Set V0200A20A: CAA-Return to Community Referral: Triggered

1. Review of Medical Records

• Objective: Gather accurate information regarding the resident’s potential to return to the community and identify if it has triggered a Care Area Assessment (CAA).
• Steps:
  1. Collect Information: Review the resident’s comprehensive medical records, including discharge planning notes, social work assessments, interdisciplinary team notes, and previous assessments.
  2. Identify Community Referral Triggers: Look for documented instances indicating the resident’s ability or desire to return to the community.
  3. Confirm Triggered Status: Verify if these factors have triggered the CAA for return to community referral through the MDS assessment.

2. Understanding Definitions

• CAA (Care Area Assessment): A structured assessment process used to identify areas of concern and guide the development of a care plan.
• Triggered: Indicates that the resident’s situation has met specific criteria during the MDS assessment that necessitates further evaluation through a CAA.

3. Coding Instructions

• Steps:
  1. Identify Triggered Status: Confirm that the resident’s potential or referral for returning to the community has triggered a CAA based on the MDS assessment.
  2. Verify Documentation: Ensure the triggering status is clearly documented in the MDS assessment and relevant social work or discharge planning notes.
  3. Code Appropriately: Code V0200A20A as:
     • 0: No, the CAA was not triggered.
     • 1: Yes, the CAA was triggered.

4. Coding Tips

• Accurate Identification: Ensure the potential or referral for returning to the community has genuinely triggered the CAA based on documented evidence and MDS assessment criteria.
• Consistent Terminology: Use consistent terminology when documenting and coding the triggered status.
• Consult Care Team: If there is any uncertainty, consult with the resident’s care team, including social workers and discharge planners, for clarification.

5. Documentation

• Required:
  • Discharge Planning Notes: Detailed notes documenting the resident’s potential and plans for returning to the community.
  • Social Work Assessments: Include assessments from social workers detailing the resident’s desire and ability to return to the community.
  • MDS Assessment: Document the MDS assessment that indicates the triggered status for return to community referral.

6. Common Errors to Avoid

• Misclassification: Ensure accurate classification by verifying the triggered status through multiple sources.
• Incomplete Documentation: Make sure all relevant details about the resident’s potential for returning to the community and triggered CAA are thoroughly documented.
• Assumptions: Do not assume the triggered status without proper documentation and verification.

7. Practical Application

• Example:
  • Resident Profile: Sarah, a 75-year-old resident, has expressed a desire to return to her home after rehabilitation.
  • Steps:
    1. Review Records: The nurse reviews Sarah’s medical records, including discharge planning notes and social work assessments.
    2. Identify Triggered Status: It is confirmed that Sarah’s potential for returning to the community has triggered a CAA based on the MDS assessment criteria.
    3. Document and Code: The nurse documents the triggered status in Sarah’s records and codes V0200A20A as "1".
  • Outcome: Sarah’s triggered CAA for return to community referral is accurately documented and coded, ensuring proper follow-up and care planning.

Please note that the information provided in this guide for MDS 3.0 Item set V0200A20A 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.