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
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CMS-802 Sample Matrix Cross Reference [11/12]