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CMS Website
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Section E- Mood and Behaviors Patterns
Indicators of depression, anxiety, sad moods that occur once or twice in the past 30 days are not coded Contradictory information found in medical record between various disciplines and what is coded on the MDS
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Section G-Physical Functioning and Structural Problems
Full look back period is not used throughout the 3 shifts ADL coded does not reflect what the resident actually performs
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Section P-Special Treatments and Procedures
Miscalculation of therapy minutes Rounding minutes off to the nearest hundred Coding nursing rehabilitation/restorative care without meeting the specific RAI guideline criteria Miscoding restraints and devices Miscounting physician’s visits and orders
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