Section C on the MDS

MDS Coding for BIMS Refusals

Accuracy in Minimum Data Set (MDS) coding is vital for reflecting the true cognitive status of a resident and ensuring compliance with federal regulations. According to the RAI User’s Manual, specific steps must be followed when a resident refuses to participate in the Brief Interview for Mental Status (BIMS).

Handling Resident Refusal

When a resident is able to participate but chooses not to, the interview is considered incomplete. The manual provides clear instructions on how to document this scenario to avoid coding errors that could impact reimbursement or quality measures:

• Coding Responses: If the resident refuses to answer a specific question, that item should be coded as 0.
• Summary Score: For a refused interview, the BIMS Summary Score (C0500) must be coded as 99. This indicates the interview was not completed.
• Dashes vs. Zeros: Dashes should generally be avoided if the resident simply refused. Coding the items as 0 and then entering 99 for the total score triggers the requirement to proceed to the Staff Assessment of Mental Status (C0700 through C1000).

Staff Assessment Requirements

The Staff Assessment is mandatory whenever the BIMS is not completed (score of 99). This ensures that the resident's cognitive status is still captured through clinical observation of daily patterns and decision-making. Relying on the regional MDS coordinator's guidance to code zeros throughout ensures the software correctly identifies the interview as attempted but unsuccessful, provided the final score reflects the 99 code.

For further details on regulatory compliance and professional standards, consulting the Boards of Nursing can provide additional oversight on documentation expectations for licensed staff.

Has the facility recently updated its internal policy regarding the use of dashes in the MDS software?