The CMS Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual
webpage was updated recently to include two important announcements:
1. Changes to Chapter 3, Section I, of the MDS 3.0 RAI Manual v1.17.1R. In July 2022. In July 2022, CMS revised pages that clarify the need for a detailed evaluation and appropriate diagnostic information to support a diagnosis, such as for a mental disorder, prior to coding the diagnosis on the MDS. It also clarifies the steps that may be necessary when a resident has potentially been misdiagnosed. An example of when a diagnosis should not be coded in Section I due to lack of a detailed evaluation and appropriate diagnostic information to support the diagnosis has also been added to this section.
The coding tips on page I-12, the manual now states:
In situations where practitioners have potentially misdiagnosed residents with a condition for which there is a lack of appropriate diagnostic information in the medical record, such as for a mental disorder, the corresponding diagnosis in Section I should not be coded, and a referral by the facility and/or the survey team to the State Medical Boards or Boards of Nursing may be necessary.
The revised manual pages are I-12 and I-16 and are marked with the footer “October 2019 (R).”
The errata document begins with a table that lists all identified revisions and the pages to which they have been applied. Following the table are the actual corrected replacement pages for insertion into the printed manual.
2. Changes to Appendix B of the MDS RAI Manual. CMS updated the list of State RAI Coordinators, MDS Automation Coordinators, RAI Panel members, and CMS locations and contacts for the states of California, Georgia, and Nebraska.