Step-by-Step Coding Guide for Item Set X0500: Social Security Number

This guide is designed to ensure the accurate documentation and coding of a resident's Social Security Number (SSN) in the MDS 3.0, specifically in item X0500.

1. Review of Medical Records

• Objective: To locate and confirm the resident's SSN.
• Key Points:
  • Examine the resident's admission paperwork, social security card, or any official document that includes their SSN.
  • Cross-check this information with other documents in the medical record for consistency.

2. Understanding Definitions

• Objective: Define "Social Security Number."
• Key Points:
  • Social Security Number (SSN): A nine-digit number issued to U.S. citizens, permanent residents, and temporary (working) residents under section 205(c)(2) of the Social Security Act. It is used for tracking individuals for social security and other governmental purposes.

3. Coding Instructions

• Objective: Provide guidance on accurately entering the resident's SSN.
• Key Points:
  • Enter the SSN exactly as it appears on the social security card or official documentation, including all nine digits without spaces or dashes.

4. Coding Tips

• Verify the SSN directly from the social security card when possible to minimize errors.
• Be mindful of visually similar numbers (e.g., 0 and 6, 5 and 8) to avoid transcription errors.

5. Documentation

• Objective: Ensure comprehensive documentation related to the resident's SSN.
• Key Points:
  • Clearly note in the resident's file the document used to verify the SSN.
  • If there are discrepancies in the SSN across different documents, document the steps taken to verify the correct number.

6. Common Errors to Avoid

• Incorrectly recording the SSN due to misreading or transcribing numbers.
• Failing to update the SSN in the resident's record if it was initially recorded incorrectly.

7. Practical Application

• Scenario: A new resident, Maria Gonzalez, is admitted to the facility. During the admission process, the administrative staff review her social security card, which lists her SSN as 123-45-6789. The staff member carefully enters her SSN as 123456789 in item X0500 of the MDS and makes a photocopy of the card (if permitted) for the file, noting the date of verification.

The Step-by-Step Coding Guide for item X0500 in MDS 3.0 Section X 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.