On-Demand Webinar: Ready or Not - Preparing for the Oct. 1, 2025, MDS Change-Ready or Not - Preparing for the Oct. 1, 2025, MDS Change

Video Transcription

Video Summary

This webinar provided a comprehensive overview of key updates to the Resident Assessment Instrument (RAI) User’s Manual and the Minimum Data Set (MDS) effective October 1, 2025. Notably, anticipated addition of Section R, addressing health-related social needs including transportation and food insecurity, was removed by CMS, resulting in modified timing and coding of the transportation question now located in Section A. A significant update involved changing “gender” (A0800) to “sex” (A0810), with instructions to match social security records to maintain resident identification integrity.<br /><br />Section GG (self-care and mobility) was streamlined, with reductions in examples provided, clarified coding instructions emphasizing clinical judgment, and reinforced definitions regarding assistive devices and helper requirements. Importantly, coding must consider all guidance collectively, not in isolation. Walking and stair assessment definitions were further clarified.<br /><br />Section J underwent substantial changes in the definition of falls, now including incidents caused by overwhelming external force (previously excluded). The definition of major injury was broadened, replacing “closed head injury with altered consciousness” with a more general “head injuries,” provoking concerns about coding due to vagueness. Pathological fractures are distinguished from traumatic fractures based on physician documentation. Coding intercepted falls and therapy-related falls was also clarified.<br /><br />Additional clarifications included coding look-back periods for weight loss/gain, modifications to pharmacological classification coding in medications, and changes to therapy service coding—switching from detailed therapy minutes to checkbox indicators of therapy received for at least 15 minutes on one or more days within seven days.<br /><br />Section X revisions clarified the differences among assessment modifications, inactivations, and manual deletions within iQIES submission processes.<br /><br />The presenters emphasized the importance of clinical judgment, thorough documentation, and adherence to updated guidance, acknowledging evolving surveyor scrutiny and the need for ongoing education. Many detailed questions from participants, particularly on falls and head injury definitions, were addressed with plans for further in-depth discussion in future sessions.

Keywords

Resident Assessment Instrument

RAI User’s Manual

Minimum Data Set

Section R removal

transportation question

gender to sex update

Section GG revisions

falls definition changes

head injury coding

therapy service coding

Section X assessment modifications