Step-by-Step Coding Guide for Item Set X1100C: Correction: Attestor Title

1. Review of Medical Records

• Objective: Confirm that the title of the attestor (the individual who signs the MDS, verifying its accuracy and completion) is correctly recorded in the MDS.
• Action: Verify the attestor's professional title by checking it against employment records, professional licenses, or HR files.

2. Understanding Definitions

• Attestor Title: Refers to the professional or official title of the individual attesting to the MDS, which should reflect their credentials and role in the facility.

3. Coding Instructions

• Verify the Title: Ensure that the attestor's title listed in the MDS matches their official title as per employment or professional records.
• Correct the Title in MDS: If discrepancies are found, update the MDS to accurately reflect the correct professional title.

4. Coding Tips

• Accuracy is Crucial: Be exact in verifying the spelling and appropriateness of the professional title to avoid misrepresentations of credentials.
• Consistency Check: Ensure that the title is consistent across all documentation within the facility for the same individual.

5. Documentation

• Comprehensive Record-Keeping: Maintain records of the original title, the evidence used for the correction, and the corrected title.
• Audit Trail: Document the correction process, including who made the correction, when it was made, and the source of the correct information.

6. Common Errors to Avoid

• Using Outdated Titles: Ensure that the title reflects current qualifications and roles, especially after promotions or credential updates.
• Failing to Verify with Reliable Sources: Always use official and reliable sources for verification to avoid incorrect title corrections.
• Overlooking Related Changes: If the attestor’s title changes, ensure this is updated in all relevant areas of the MDS and related records.

7. Practical Application

• Example: It was discovered during an audit that the MDS listed the attestor’s title as "Registered Nurse" when their correct title had been updated to "Nurse Manager" after a recent promotion. The MDS Coordinator confirmed the new title with HR records and the state nursing board, then corrected the title in the MDS. This correction was documented on June 12, 2024, including references to the HR update notification and state board listing for verification, and an entry was made in the facility’s compliance log.

Please note that the information provided in this guide for MDS 3.0 Item set X1100C 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.