Overview of RAI changes

As of July 15 2010, CMS has released all updated sections of the RAI User’s Manual for the MDS 3.0, except for Appendix F. With no crosswalk to identify the changes between these sections and the previous version of the RAI User’s Manual for the MDS 3.0, many providers are unsure of exactly what changes were made. A list of the major changes to each section included in Chapter 3 of the manual is as follows:

  • Section A: Identification Information
    • Clarification of discharge date: Assessment Reference Date (ARD) and Discharge date must be the same – date the resident leaves the building. 
  • Section B: Hearing, Speech, and Vision
    • Visual aids do not include lens implants.
  • Section C: Cognitive Patterns
    • Minor changes, except for an example of coding the summary score on the BIMS and instructions for aphasia patients to participate in writing, contained in Appendix E.
  • Section D: Mood
    • Preferable to conduct the interview the day before or the day of the ARD, but not mandatory.
  • Section E: Behavior
    • Addition to Rejection of Care: “It is really a matter of resident choice. When rejection/decline of care is first identified, the team then investigates and determines the rejection/decline of care is really a matter of resident’s choice. Education is provided and the resident’s choices become part of the plan of care. On future assessments, this behavior would not be coded in this item.”
    • New definitions of Rejection of Care and Interference with Care.
  • Section F: Preferences for Customary Routine and Activities
    • Minor changes to wording
  • Section G: Functional Status
    • New balance graphic and clarification regarding how to conduct balance test.
    • Range of Motion: Changes to Intent, Steps for Assessment, and Coding Tips.
  • Section H: Bladder and Bowel
    • A one-time catheterization for urine specimen should not be coded as an intermittent catheterization.
  • Section I: Active Diagnoses
    • Diagnosis identification period is 60 days (was 30 days under the previous version of the RAI User’s Manual for the MDS 3.0).
    • Clarification regarding urinary tract infections based on guidelines from the Centers for Disease Control.
  • Section J: Health Conditions
    • Pain interview should be conducted close to the end of the assessment period, preferably the day before or the day of the ARD.
    • Problem Conditions: 
      • Changes to Intent
      • Fever clarified as 2.4 degrees Fahrenheit above baseline. Before baseline is determined, 100.4 degrees Fahrenheit would be considered a temperature.
  • Section K: Swallowing/Nutritional Status
    • Clarification regarding what IV fluids and feedings can be coded in Item K0500, Nutritional Approaches:
      • Parenteral/IV feeding may only be included “when there is supporting documentation that reflects the need for additional fluid intake specifically addressing a nutrition or hydration need. This supporting documentation should be noted in the resident’s medical record according to state and/or internal facility policy.”
      • IV fluids administered solely for the purpose of prevention of dehydration should not be coded in Item K0500A unless there is an active diagnosis of dehydration.
  • Section L: Dietary/Oral Status
    • Minor changes to wording
  • Section M: Skin Conditions
    • Addition to Intent: “Be certain to include in the assessment process, a holistic approach. It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound.”
    • Additions to Planning for Care:
      • “Throughout this section, terminology referring to ‘healed’ vs. ‘unhealed’ ulcers refers to whether or not the ulcer is ‘closed’ vs. ‘open.’ When considering this, recognize that Stage 1, DTI, and unstageable pressure ulcers although ‘closed,’ (i.e. may be covered with tissue, eschar, slough, etc.) would not be considered ‘healed.’”
      • “Facilities should be aware that the resident is at higher risk of having the area of a closed pressure ulcer open up due to damage, injury, or pressure, because of the loss of tensile strength of the overlying tissue. Tensile strength of the skin overlying a closed pressure ulcer is 80% of normal skin tensile strength. Facilities should put preventative measures in place that will mitigate the opening of a closed ulcer due to the fragility of the overlying tissue.”
    • Tools other than Norton and Braden can be used for determination of risk.
    • Revised definitions.
    • Revised/new steps for assessment and coding tips.
    • Added 16 pages of Scenarios for Pressure Ulcer Coding
  • Section N: Medications
    • New coding tips for herbal and alternative medicine products.
  • Section O: Special Treatments, Procedures, and Programs
    • Dextrose 50% and/or Lactated Ringers given intravenously are not considered medications, and should not be coded in Item O0100H, IV Medications.
    • Addition to Therapy Start Date: “This is the date the initial therapy evaluation is conducted regardless if treatment was rendered or not.”
    • Addition to Therapy End Date: “This is the last date the resident received skilled therapy treatment.”
    • Additions to coding tips for minutes of therapy:
      • “The time for the interruption is not considered treatment time and shall not be coded as therapy minutes.”
      • “Minutes reported on the MDS may not match the time reported on a claim.  For example, therapy aide set-up time is recorded on the MDS when it precedes skilled individual therapy; however, the therapy aide time is not included for billing purposes on a therapy Part B claim.”
    • Addition to Non-Skilled Services: “When a resident refuses to participate in therapy, it is important for care planning purposes to identify why the resident is refusing therapy.  However, the time spent investigating the refusal or trying to persuade the resident to participate in treatment is not a skilled service and shall not be included in the therapy minutes.”
    • Clarification regarding coding when a therapy student is involved in treatment.
    • New information regarding Therapy Modalities and Dates of Therapy.
  • Section P: Restraints
    • Minor changes to wording.
  • Section Q: Participation in Assessment and Goal Setting
    • Addition to Participation – Planning for Care: “During care planning meetings, if the resident is present, he or she should be made comfortable and verbal communication should be directly with him or her.”
    • Addition to Discharge Plan – Health-Related Quality of Life: “For residents that have been in the facility for a long time, it is important to discuss with them their interest in talking with local contact agency (LCA) experts about returning to the community. There are improved community resources and supports that may benefit these residents and allow them to return to a community setting.”
    • Addition to Discharge Plan – Planning for Care: “Important progress has been made so that individuals have more choices, care options, and available supports to meet care preferences and needs in the least restrictive setting possible. This progress resulted from the U. S. Supreme Court Olmstead ruling, which states that residents needing long-term care services have a right to receive services in the least restrictive and most integrated setting.”
    • Additions to Discharge Plan – Planning for Care: Minimum discharge instructions.
    • Additions to Discharge Plan – Coding Tips.
    • Additional examples provided.
  • Section V: Care Area Assessment (CAA) Summary
    • Minor changes to wording.
  • Section Z: Assessment Administration
    • With MDS 3.0 implementation on October 1, 2010, the initial Medicare RUG-IV Version Code is “1.0066.”
    • Other minor changes.

You can access the revised sections as well as MDS 3.0 training slides and instructor guides, under the downloads section of CMS’ Web site.

Stay tuned to MDSCentral for a special report from Regulatory Specialist Diane Brown, which will contain more detailed information regarding the changes in all revised Chapters of the RAI User’s Manual for the MDS 3.0.


  1. Debra Thorne

    There is a chart of assessments that can be combined in the RAI Manual Page 2-12&2-13. This chart does not include assessments such as SOT OMRA or EOT OMRA. Would it be possible for a chart to be develped for clarification. I would lke to see more education provided addressing coding of MDS’S.

    Thank you
    Debra Thorne R. N

  2. Shelia

    The following changes were not mentioned:
    1. The new ADL code of “7”
    2. Assessments should be transmitted within 14 days (no longer 30 days) of the completion date;
    3. OBRA assessments are now due 92 days from ARD to ARD and Annual 366 days from ARD

  3. Pennie Bacon

    As a Activity Director I feel we have been belitted in our profession! You have taken section “N” which was not that great to start with then you gave us section “F” which deals with more ADL’s than activities! Do you not recognize how activities benefit residents. Feel free to conatct me for inout on how to improve this.

  4. Hi Pennie,

    I understand your concerns, but we are not responsible for developing the RAI User’s Manual. MDSCentral is a blog designed to provide our visitors with information, tools, analysis, and news related to the SNF PPS system and the MDS 3.0. CMS is responsible for developing the RAI User’s Manual and I would suggesting sending your comments to them. Questions regarding the RAI User’s Manual for the MDS 3.0 can be sent to CMS at the following email address: MDS30Comments@cms.hhs.gov


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