MDS 3.0 & 802 Roster/ Sample Matrix Cross Reference Identification Information
MDS 3.0 & 802 Roster/ Sample Matrix Cross Reference UT IONS COMP L NCE SOL IA 1|4 Identification Information MDS Item Description MDS Item Resident Characteristics Is this Assessment the First Assessment (OBRA, PPS or Discharge) since the Most Recent Admission/Entry or Reentry? A0310E 22. Admission/Transfer/Discharge Federal OBRA & PPS Entry/Discharge Reporting A0310F 22. Admission/Transfer/Discharge Language A1100 24. Language/Communication A1500 23. Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental Retardation as Defined at 42 CFR 483.45(a)) A1510 23. Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental Retardation as Defined at 42 CFR 483.45(a)) Conditions Related to Intellectual Disability/Developmental Disability (ID/DD) Status A1550 23. Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental Retardation as Defined at 42 CFR 483.45(a)) Entry Date (Date of this Admission/Entry or Reentry into the Facility) A1600 22. Admission/Transfer/Discharge Preadmission Screening and Resident Review (PASRR) Level II Preadmission Screening and Resident Review (PASRR) Conditions Hearing, Speech and Vision MDS Item Description MDS Item Resident Characteristics Hearing B0200 25. Vision/Hearing/Other Assistive Devices Hearing Aid B0300 25. Vision/Hearing/Other Assistive Devices Speech Clarity B0600 24. Language/Communication Makes Self Understood B0700 24. Language/Communication Ability to Understand Others B0800 24. Language/Communication Vision B1000 25. Vision/Hearing/Other Assistive Devices Corrective Lenses B1200 25. Vision/Hearing/Other Assistive Devices Mood MDS Item Description MDS Item Resident Characteristics Total Severity Score D0300 14. Depressive Symptoms Follow-up to D0200I D0350 14. Depressive Symptoms Total Severity Score D0600 14. Depressive Symptoms Follow-up to D0500I D0650 14. Depressive Symptoms Behavior MDS Item Description MDS Item Resident Characteristics Behavioral Symptom — Presence & Frequency E0200 13. Behavioral Symptoms Affecting Others or Self Impact on Resident E0500 13. Behavioral Symptoms Affecting Others or Self Impact on Others E0600 13. Behavioral Symptoms Affecting Others or Self Rejection of Care — Presence & Frequency E0800 13. Behavioral Symptoms Affecting Others or Self Wandering — Presence & Frequency E0900 13. Behavioral Symptoms Affecting Others or Self Wandering — Impact E1000 13. Behavioral Symptoms Affecting Others or Self Functional Status MDS Item Description MDS Item Resident Characteristics Functional Limitation in Range of Motion G0400 21. ROM/Contractures/Positioning Mobility Devices G0600 25. Vision/Hearing/Other Assistive Devices MDS 3.0 & 802 Roster/Sample Matrix Cross Reference 2|4 Bladder and Bowel MDS Item Description MDS Item Resident Characteristics Indwelling Catheter (Including Suprapubic Catheter and Nephrostomy Tube) H0100A 16. Indwelling Urinary Catheter Trial of a Toileting Program H0200A 17. Lo-risk Residents Who Lose Bowel/Bladder Control-Incontinence/Toileting Programs Current Toileting Program or Trial H0200C 17. Lo-risk Residents Who Lose Bowel/Bladder Control-Incontinence/Toileting Programs Urinary Continence H0300 17. Lo-risk Residents Who Lose Bowel/Bladder Control-Incontinence/Toileting Programs Bowel Continence H0400 17. Lo-risk Residents Who Lose Bowel/Bladder Control-Incontinence/Toileting Programs Bowel Toileting Program H0500 17. Lo-risk Residents Who Lose Bowel/Bladder Control-Incontinence/Toileting Programs Active Diagnosis MDS Item Description MDS Item Resident Characteristics Multidrug Resistance Organism (MDRO) I1700 29. Infections Pneumonia I2000 29. Infections Septicemia I2100 29. Infections Tuberculosis I2200 29. Infections Urinary Tract Infection (UTI) (Last 30 Days) I2300 15. Urinary Tract Infection 29. Infections Viral Hepatitis (e.g., Hepatitis A, B, C, D and E) I2400 29. Infections Wound Infection (Other Than Foot) I2500 29. Infections Atrial Fibrillation or Other Dysrhythmias (e.g., Bradycardias, Tachycardias) I3900 10. Falls and/or Falls with Major Injury Coronary Artery Disease (CAD) (e.g., Angina, Myocardial Infarction, Atherosclerotic Heart Disease (ASHD)) I4000 10. Falls and/or Falls with Major Injury I5700 11. 23. Psychoactive Medication with Absence of Condition Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental Retardation as Defined at 42 CFR 483.45(a)) I5800 11. 14. 23. Psychoactive Medication with Absence of Condition Depressive Symptoms Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental Retardation as Defined at 42 CFR 483.45(a)) I5900 11. 14. 23. Psychoactive Medication with Absence of Condition Depressive Symptoms Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental Retardation as Defined at 42 CFR 483.45(a)) I5950 11. 23. Psychoactive Medication with Absence of Condition Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental Retardation as Defined at 42 CFR 483.45(a)) Anxiety Disorder Depression (Other than Bipolar) Manic Depression (Bipolar Disease) Psychotic Disorder (Other than Schizophrenia) MDS 3.0 & 802 Roster/Sample Matrix Cross Reference 3|4 Active Diagnosis cont. MDS Item Description Schizophrenia (e.g., Schizoaffective and Schizophreniform Disorders) Post-traumatic Stress Disorder (PTSD) Additional Active Diagnoses MDS Item Resident Characteristics I6000 11. 23. Psychoactive Medication with Absence of Condition Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental Retardation as Defined at 42 CFR 483.45(a)) I6100 11. 23. Psychoactive Medication with Absence of Condition Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental Retardation as Defined at 42 CFR 483.45(a)) I8000 11. 23. 29. Psychoactive Medication with Absence of Condition Mental Illness (MI) (Non-Dementia) or Intellectual Disability (ID) or Developmental Disability (DD) (Mental Retardation as Defined at 42 CFR 483.45(a)) Infections Health Conditions MDS Item Description MDS Item Resident Characteristics Pain Management J0100 6. Moderate/Severe Pain (Constant or Frequent) Pain Presence J0300 6. Moderate/Severe Pain (Constant or Frequent) Pain Frequency J0400 6. Moderate/Severe Pain (Constant or Frequent) Pain Effect on Function J0500 6. Moderate/Severe Pain (Constant or Frequent) Pain Intensity J0600 6. Moderate/Severe Pain (Constant or Frequent) Should the Staff Assessment for Pain be Conducted? J0700 6. Moderate/Severe Pain (Constant or Frequent) Indicators of Pain J0800 6. Moderate/Severe Pain (Constant or Frequent) Frequency of Indicator of Pain or Possible Pain J0850 6. Moderate/Severe Pain (Constant or Frequent) Fall History on Admission/Entry or Reentry J1700 10. Falls and/or Falls with Major Injury Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), Whichever is More Recent J1800 10. Falls and/or Falls with Major Injury Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), Whichever is More Recent J1900 10. Falls and/or Falls with Major Injury Swallowing/Nutritional Disorder MDS Item Description MDS Item Resident Characteristics Swallowing Disorder K0100 28. Hydration/Swallowing/Oral Health Weight Loss K0300 18. Excessive Weight Loss/Gain Weigh Gain K0310 18. Excessive Weight Loss/Gain Nutritional Approaches K0510 28. Hydration/Swallowing/Oral Health Feeding Tube — Nasogastric or Abdominal (PEG) K05108 27. Special Care (Tube Feeding, Central Lines, Ventilators, O2) Oral/Dental Status MDS Item Description Dental MDS Item L0200 Resident Characteristics 28. Hydration/Swallowing/Oral Health Skin Conditions MDS Item Description MDS Item Resident Characteristics Stage 2 Pressure Ulcers M0300B1 7. Hi-Risk Pressure Ulcers (Stage 2-4) 8. New/Worsened Pressure Ulcers (Stage 2-4) Stage 3 Pressure Ulcers M0300C1 7. Hi-Risk Pressure Ulcers (Stage 2-4) 8. New/Worsened Pressure Ulcers (Stage 2-4) MDS 3.0 & 802 Roster/Sample Matrix Cross Reference 4|4 Skin Conditions cont. MDS Item Description MDS Item Resident Characteristics Stage 4 Pressure Ulcers M0300D1 7. Hi-Risk Pressure Ulcers (Stage 2-4) 8. New/Worsened Pressure Ulcers (Stage 2-4) Unstageable Presure Ulcers Related to Non-removable Dressing/Device M0300E1 7. Hi-Risk Pressure Ulcers (Stage 2-4) Unstageable Pressure Ulcers Related to Slough and/or Eschar M0300F1 7. Hi-Risk Pressure Ulcers (Stage 2-4) Unstageable Pressure Ulcers Related to Suspected Deep Tissue Injury M0300G1 7. Hi-Risk Pressure Ulcers (Stage 2-4) Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or Scheduled PPS) or Last Admission/Entry or Reentry Stage 2 M0800A 8. New/Worsened Pressure Ulcers (Stage 2-4) Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or scheduled PPS) or Last Admission/Entry or Reentry Stage 3 M0800B 8. New/Worsened Pressure Ulcers (Stage 2-4) Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or Scheduled PPS) or Last Admission/Entry or Reentry Stage 4 M0800C 8. New/Worsened Pressure Ulcers (Stage 2-4) Infection of the Foot (e.g., Cellulitis, Purulent Drainage) M1040A 29. Infections Turning/Repositioning Program M1200C 26. ROM/Contractures/Positioning Medications MDS Item Description MDS Item Resident Characteristics Antipsychotic N0410A 11. Psychoactive Medications with Absence of Condition Antianxiety N0410B 11. Psychoactive Medications with Absence of Condition 12. Antianxiety/Hypnotic Medications Antidepressant N0410C 11. Psychoactive Medications with Absence of Condition Hypnotic No410D 11. Psychoactive Medications with Absence of Condition 12. Antianxiety/Hypnotic Medications Special Treatments, Procedures and Programs MDS Item Description MDS Item Resident Characteristics Oxygen Therapy O0100C 27. Special Care (Tube Feeding, Central Lines, Ventilators, O2) Ventilator or Respirator O0100F 27. Special Care (Tube Feeding, Central Lines, Ventilators, O2) Dialysis O0100J 21. Dialysis Hospice Care O0100K2 20. Hospice Isolation for Active Infectious Disease (Does Not Include Standard Precautions) O0100M2 29. Infections Therapies O0400 30. Specialized Rehabilitation (PT, OT, Recrations, Respiratory, Psychological, Speech, Restorative Nursing) or Other Services Restorative Nursing Programs O0500 30. Specialized Rehabilitation (PT, OT, Recrations, Respiratory, Psychological, Speech, Restorative Nursing) or Other Services Restorative Nursing Programs — Splint or Brace Assistance O0500C 25. Vision/Hearing/Other Assistive Devices Medications MDS Item Description Physical Restraints MDS Item P0100 Resident Characteristics 9. Physical Restraints We make improving care easier!® 1917 Garnet Ct. New Lenox, IL 60451 800.648.5190 fax 866.726.7416 promedsupply.com © Professional Medical, Inc. CMS-802 Sample Matrix Cross Reference [11/12]
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