Step-by-Step Coding Guide for Item Set X0800: Correction Number

This detailed guide is designed to assist in accurately coding and documenting the Correction Number in MDS 3.0, specifically for item X0800.

1. Review of Medical Records

• Objective: To identify the need for and track the number of corrections made to an MDS assessment.
• Key Points:
  • Examine the resident’s medical records and previous MDS assessments to determine if any prior corrections have been made.
  • Review documentation related to any identified inaccuracies or changes that necessitated a correction to the MDS.

2. Understanding Definitions

• Objective: Define "Correction Number."
• Key Points:
  • Correction Number: A numeric value that represents the sequence of corrections made to a particular MDS assessment. The initial submission is considered "0", and each subsequent correction increments this number by one.

3. Coding Instructions

• Objective: Provide guidance on accurately coding the Correction Number.
• Key Points:
  • If this is the initial submission of the MDS assessment, code as "0".
  • For each correction to the assessment, increase the Correction Number by one from the last submitted Correction Number.

4. Coding Tips

• Keep a log or record of all submissions and corrections to the MDS for each resident to accurately track the Correction Number.
• Verify the Correction Number with the most recent submitted assessment to ensure accuracy before submission.

5. Documentation

• Objective: Ensure thorough documentation related to MDS corrections.
• Key Points:
  • Document the reason for each correction, the date the correction was made, and the resulting Correction Number in the resident’s medical record or a dedicated MDS tracking document.
  • Maintain documentation of communication with CMS or the state MDS coordinator regarding any corrections.

6. Common Errors to Avoid

• Miscounting the Correction Number by failing to accurately track previous submissions and corrections.
• Overlooking the need to document and justify each correction made to the MDS.

7. Practical Application

• Scenario: An MDS coordinator discovers an error in the initially submitted MDS assessment for a resident, Jane Doe, regarding her mobility status. This necessitates a correction. The initial submission was coded with a Correction Number of "0". The coordinator corrects the error, documents the justification for this change, and submits the corrected MDS with a Correction Number of "1".

The Step-by-Step Coding Guide for item X0800 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.