On August 29, 2025, CMS released the final version of the MDS 3.0 RAI User’s Manual (v1.20.1), effective October 1, 2025.
On August 29, 2025, CMS released the final version of the MDS 3.0 RAI User’s Manual (v1.20.1), effective October 1, 2025. This update replaces earlier drafts and locks in key changes that facilities must begin preparing for now. While many revisions were expected, the final release confirms important differences from the draft version, including the removal of Section R on Health-Related Social Needs.
Key Changes at a Glance
Section A – Identification
- A0800 (Gender) removed; replaced by A0810 (Sex).
- A1250 (Transportation) replaced by A1255 (Transportation).
Section D – Mood
- Clarifications to PHQ-9 and mood interview coding.
Section GG – Functional Abilities
- Updated coding tips.
- Clarifications on device use.
Section J – Health Conditions
- New fall definition tied to external force.
- Clarified definitions for falls with injuries and major injuries.
- New coding example: pathological vs. traumatic fracture.
Section K – Swallowing/Nutrition
- Updated instructions for K0300 (Weight Loss) and K0310 (Weight Gain).
- Visual examples included.
- Section M – Skin Conditions
- Clarification on coding pressure ulcers present on admission.
Section N – Medications
- New tips for high-risk medications.
- Must choose a consistent classification resource (package insert, pharmacist, etc.).
- Do not code IV flushes in N0415E (Anticoagulant).
Section O – Special Treatments/Programs
- Updated vaccine links and pneumococcal vaccine guidance.
- O0390 (Therapy Services) added.
- O0400 (Therapies) revised.
- O0420 (Distinct Calendar Days of Therapy) removed.
Section R – Health-Related Social Needs
- Proposed in draft but not included in the final manual.
Why It Matters
With CMS and surveyors applying increased scrutiny to MDS accuracy, even minor errors can now have outsized consequences—impacting reimbursement, quality measure performance, and survey outcomes. These October 1 updates highlight the need for precision, consistent documentation, and interdisciplinary collaboration.
High-Impact Areas to Prioritize
- Billing & Reimbursement: Section GG (Functional Abilities) and Section O (Therapies).
- Survey Deficiencies: Section J (Falls – external force definition and updated major injury criteria) and Section M (Pressure Ulcers – present on admission coding).
Surveyor Lens
Surveyors will be using these updates immediately. Expect them to:
- Compare fall documentation against the new “external force” definition.
- Review falls coded with injury to ensure the revised major injury definition is applied correctly (e.g., distinguishing major injury from minor or no injury, with clear medical record support).
- Validate fracture coding for pathological vs. traumatic causes.
- Closely examine pressure ulcer documentation for present-on-admission vs. acquired status.
- Confirm consistency across CNA notes, nurse documentation, and MDS coding.
Facility Action Steps
To prepare for October 1:
✔ Train staff on new coding definitions (falls, fractures, ulcers, and weight loss/gain).
✔ Update EHR templates to reflect revised item numbers (A0810, A1255) and therapy coding changes.
✔ Audit medication lists for coding consistency, ensuring IV flushes are not miscoded.
✔ Review therapy workflows in light of O0390/O0400 revisions and O0420 removal.
✔ Conduct targeted audits before October 1 to validate coding accuracy and supporting documentation.
How Polaris Group Can Help
Polaris Group offers:
- Compliance consulting and education on RAI Manual updates.
- Mock audits to validate accuracy before survey.
- Outsourced MDS Coordinator (MDSC) services to ensure accurate, timely assessments and ease staffing pressures.
👉 With the October 1 implementation just weeks away, contact Polaris Group today to prepare your team and strengthen your compliance strategy.
