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pdfResident
Identifier
Date
MINIMUM DATA SET (MDS) - Version 3.0
RESIDENT ASSESSMENT AND CARE SCREENING
Interim Payment Assessment (IPA) Item Set
Section A - Identification Information
A0050.
Type of Record
Enter Code
A0100.
•
•
•
1.
2.
3.
Add new record → Continue to A0100, Facility Provider Numbers
Modify existing record → Continue to A0100, Facility Provider Numbers
Inactivate existing record → Skip to X0150, Type of Provider
Facility Provider Numbers
A.
B.
C.
National Provider Identifier (NPI):
CMS Certification Number (CCN):
State Provider Number:
A0200.
Type of Provider
Enter Code
Type of provider
•
1. Nursing home (SNF/NF)
•
2. Swing Bed
A0310.
Type of Assessment
Enter Code
A.
Federal OBRA Reason for Assessment
•
•
01.
02.
03.
04.
05.
06.
99.
B.
PPS Assessment
•
PPS Scheduled Assessment for a Medicare Part A Stay
01. 5-day scheduled assessment
PPS Unscheduled Assessment for a Medicare Part A Stay
08. IPA - Interim Payment Assessment
Not PPS Assessment
99. None of the above
•
•
•
•
•
Enter Code
•
•
•
•
•
Enter Code
Enter Code
Admission assessment (required by day 14)
Quarterly review assessment
Annual assessment
Significant change in status assessment
Significant correction to prior comprehensive assessment
Significant correction to prior quarterly assessment
None of the above
E.
Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry
or reentry?
•
•
0.
1.
F.
Entry/discharge reporting
•
01.
10.
11.
12.
99.
•
•
•
•
No
Yes
Entry tracking record
Discharge assessment - return not anticipated
Discharge assessment - return anticipated
Death in facility tracking record
None of the above
A0310 continued on next page
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 1 of 27
Resident
Identifier
Date
Section A - Identification Information
A0310.
Enter Code
A0410.
Type of Assessment - Continued
G.
Type of discharge
•
1.
2.
•
Unit Certification or Licensure Designation
Enter Code
A0500.
•
•
•
C.
Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State
Unit is neither Medicare nor Medicaid certified but MDS data is required by the State
Unit is Medicare and/or Medicaid certified
First name:
B.
Last name:
D.
Middle initial:
Suffix:
Social Security and Medicare Numbers
A.
B.
A0700.
1.
2.
3.
Legal Name of Resident
A.
A0600.
Planned
Unplanned
Social Security Number:
-
-
Medicare Number:
Medicaid Number
Enter “+” if pending, “N” if not a Medicaid recipient
A0810.
Sex
Enter Code
A0900.
•
•
1.
2.
Male
Female
Birth Date
-
-
Month
Day
Year
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 2 of 27
Resident
Identifier
Date
Section A - Identification Information
A1005.
Ethnicity
Are you of Hispanic, Latino/a, or Spanish origin?
↓
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□
A1010.
Check all that apply
A.
No, not of Hispanic, Latino/a, or Spanish origin
B.
Yes, Mexican, Mexican American, Chicano/a
C.
Yes, Puerto Rican
D.
Yes, Cuban
E.
Yes, another Hispanic, Latino/a, or Spanish origin
X.
Resident unable to respond
Y.
Resident declines to respond
Race
What is your race?
↓
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□
□
□
□
□
□
□
□
□
□
□
□
□
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A1110.
Check all that apply
A.
White
B.
Black or African American
C.
American Indian or Alaska Native
D.
Asian Indian
E.
Chinese
F.
Filipino
G.
Japanese
H.
Korean
I.
Vietnamese
J.
Other Asian
K.
Native Hawaiian
L.
Guamanian or Chamorro
M.
Samoan
N.
Other Pacific Islander
X.
Resident unable to respond
Y.
Resident declines to respond
Z.
None of the above
Language
A.
Enter Code
What is your preferred language?
B.
Do you need or want an interpreter to communicate with a doctor or health care staff?
•
0.
1.
9.
•
•
No
Yes
Unable to determine
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
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Resident
Identifier
Date
Section A - Identification Information
A1200.
Marital Status
Enter Code
•
•
•
•
•
A1300.
Never married
Married
Widowed
Separated
Divorced
Optional Resident Items
A.
B.
C.
D.
A2300.
1.
2.
3.
4.
5.
Medical record number:
Room number:
Name by which resident prefers to be addressed:
Lifetime occupation(s) - put “/” between two occupations:
Assessment Reference Date
Observation end date:
-
-
Month
Day
Year
A2400.
Medicare Stay
Enter Code
A.
Has the resident had a Medicare-covered stay since the most recent entry?
•
•
0.
1.
B.
Start date of most recent Medicare stay:
No → Skip to B0100, Comatose
Yes → Continue to A2400B, Start date of most recent Medicare stay
-
-
Month
C.
Day
Year
End date of most recent Medicare stay - Enter dashes if stay is ongoing:
-
-
Month
Day
Year
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 4 of 27
Resident
Identifier
Date
Look back period for all items is 7 days unless another time frame is indicated
Section B - Hearing, Speech, and Vision
B0100.
Comatose
Enter Code
Persistent vegetative state/no discernible consciousness
•
0. No → Continue to B0700, Makes Self Understood
•
1. Yes → Skip to GG0130, Self-Care
B0700.
Makes Self Understood
Enter Code
Ability to express ideas and wants, consider both verbal and non-verbal expression
•
0. Understood
•
1. Usually understood - difficulty communicating some words or finishing thoughts but is able if prompted or given time
•
2. Sometimes understood - ability is limited to making concrete requests
•
3. Rarely/never understood
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 5 of 27
Resident
Identifier
Date
Section C - Cognitive Patterns
C0100.
Should Brief Interview for Mental Status (C0200–C0500) be Conducted?
Attempt to conduct interview with all residents
Enter Code
0.
1.
•
•
No (resident is rarely/never understood) → Skip to and complete C0700–C1000, Staff Assessment for Mental Status
Yes → Continue to C0200, Repetition of Three Words
Brief Interview for Mental Status (BIMS)
C0200.
Enter Code
Repetition of Three Words
Ask resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three.
The words are: sock, blue, and bed. Now tell me the three words.”
Number of words repeated after first attempt
•
0. None
•
1. One
•
2. Two
•
3. Three
After the resident’s first attempt, repeat the words using cues (“sock, something to wear; blue, a color; bed, a piece of furniture”).
You may repeat the words up to two more times.
C0300.
Temporal Orientation (orientation to year, month, and day)
Ask resident: “Please tell me what year it is right now.”
A. Able to report correct year
Enter Code
0.
1.
2.
3.
•
•
•
•
Ask resident: “What month are we in right now?”
B. Able to report correct month
Enter Code
0.
1.
2.
•
•
•
0.
1.
•
•
C0400.
Ask resident: “Let’s go back to an earlier question. What were those three words that I asked you to repeat?”
If unable to remember a word, give cue (something to wear; a color; a piece of furniture) for that word.
A. Able to recall “sock”
0.
1.
2.
•
•
•
B.
Enter Code
•
C.
Enter Code
•
•
•
C0500.
Enter Score
No - could not recall
Yes, after cueing (“something to wear”)
Yes, no cue required
Able to recall “blue”
0.
1.
2.
•
•
Incorrect or no answer
Correct
Recall
Enter Code
Missed by > 1 month or no answer
Missed by 6 days to 1 month
Accurate within 5 days
Ask resident: “What day of the week is today?”
C. Able to report correct day of the week
Enter Code
Missed by > 5 years or no answer
Missed by 2–5 years
Missed by 1 year
Correct
No - could not recall
Yes, after cueing (“a color”)
Yes, no cue required
Able to recall “bed”
0.
1.
2.
No - could not recall
Yes, after cueing (“a piece of furniture”)
Yes, no cue required
BIMS Summary Score
Add scores for questions C0200–C0400 and fill in total score (00–15)
Enter 99 if the resident was unable to complete the interview
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
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Resident
Identifier
Date
Section C - Cognitive Patterns
C0600.
Should the Staff Assessment for Mental Status (C0700–C1000) be Conducted?
Enter Code
•
•
0.
1.
No (resident was able to complete Brief Interview for Mental Status) → Skip to D0100, Should Resident Mood Interview
be Conducted?
Yes (resident was unable to complete Brief Interview for Mental Status) → Continue to C0700, Short-term Memory OK
Staff Assessment for Mental Status
Do not conduct if Brief Interview for Mental Status (C0200–C0500) was completed
C0700.
Enter Code
C1000.
Enter Code
Short-term Memory OK
Seems or appears to recall after 5 minutes
•
0. Memory OK
•
1. Memory problem
Cognitive Skills for Daily Decision Making
Made decisions regarding tasks of daily life
•
0. Independent - decisions consistent/reasonable
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1. Modified independence - some difficulty in new situations only
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2. Moderately impaired - decisions poor; cues/supervision required
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3. Severely impaired - never/rarely made decisions
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
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Resident
Identifier
Date
Section D - Mood
D0100.
Should Resident Mood Interview be Conducted?
Enter Code
D0150.
•
•
0.
1.
No (resident is rarely/never understood) → Skip to and complete D0500–D0600, Staff Assessment of Resident
Mood (PHQ-9-OV)
Yes → Continue to D0150, Resident Mood Interview (PHQ-2 to 9 ©)
Resident Mood Interview (PHQ-2 to 9 ©)
Say to resident: “Over the last 2 weeks, have you been bothered by any of the following problems?”
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
If yes in column 1, then ask the resident: “About how often have you been bothered by this?”
Read and show the resident a card with the symptom frequency choices. Indicate response in column 2, Symptom Frequency.
1. Symptom Presence
2. Symptom Frequency
•
0. No (enter 0 in column 2)
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0. Never or 1 day
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1. Yes (enter 0–3 in column 2)
•
1. 2–6 days (several days)
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9. No response (leave column 2 blank)
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2. 7–11 days (half or more of the days)
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3. 12–14 days (nearly every day)
•
Enter Scores in Boxes
A.
Little interest or pleasure in doing things
B.
Feeling down, depressed, or hopeless
1. Symptom
Presence
2. Symptom
Frequency
If both D0150A1 and D0150B1 are coded 9, OR both D0150A2 and D0150B2 are coded 0 or 1, END the PHQ interview; otherwise, continue.
C.
Trouble falling or staying asleep, or sleeping too much
D.
Feeling tired or having little energy
E.
Poor appetite or overeating
F.
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
G.
Trouble concentrating on things, such as reading the newspaper or watching television
H.
Moving or speaking so slowly that other people could have noticed.
Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
I.
Thoughts that you would be better off dead, or of hurting yourself in some way
D0160.
Enter Score
Total Severity Score
Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 27.
Enter 99 if unable to complete interview (i.e., Symptom Frequency is blank for 3 or more required items).
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 8 of 27
Resident
Identifier
Date
Section D - Mood
D0500.
Staff Assessment of Resident Mood (PHQ-9-OV*)
Do not conduct if Resident Mood Interview (D0150–D0160) was completed
Over the last 2 weeks, did the resident have any of the following problems or behaviors?
If symptom is present, enter 1 (yes) in column 1, Symptom Presence.
Then move to column 2, Symptom Frequency, and indicate symptom frequency.
1. Symptom Presence
2. Symptom Frequency
•
0. No (enter 0 in column 2)
•
0. Never or 1 day
•
1. Yes (enter 0–3 in column 2)
•
1. 2–6 days (several days)
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•
2. 7–11 days (half or more of the days)
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•
3. 12–14 days (nearly every day)
Enter Scores in Boxes
A.
Little interest or pleasure in doing things
B.
Feeling or appearing down, depressed, or hopeless
C.
Trouble falling or staying asleep, or sleeping too much
D.
Feeling tired or having little energy
E.
Poor appetite or overeating
F.
Indicating that they feel bad about self, are a failure, or have let self or family down
G.
Trouble concentrating on things, such as reading the newspaper or watching television
H.
Moving or speaking so slowly that other people have noticed.
Or the opposite - being so fidgety or restless that they have been moving around a lot more than usual
I.
States that life isn’t worth living, wishes for death, or attempts to harm self
J.
Being short-tempered, easily annoyed
D0600.
Enter Score
1. Symptom
Presence
2. Symptom
Frequency
Total Severity Score
Add scores for all frequency responses in Column 2, Symptom Frequency. Total score must be between 00 and 30.
Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 9 of 27
Resident
Identifier
Date
Section E - Behavior
E0100.
↓
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□
□
Potential Indicators of Psychosis
Check all that apply
A.
Hallucinations (perceptual experiences in the absence of real external sensory stimuli)
B.
Delusions (misconceptions or beliefs that are firmly held, contrary to reality)
Z.
None of the above
Behavioral Symptoms
E0200.
Behavioral Symptom - Presence and Frequency
Note presence of symptoms and their frequency
Coding:
•
0. Behavior not exhibited
•
1. Behavior of this type occurred 1 to
3 days
•
2. Behavior of this type occurred 4 to 6
days, but less than daily
•
3. Behavior of this type occurred daily
↓
Enter Codes in Boxes
A. Physical behavioral symptoms directed toward others (e.g., hitting, kicking,
pushing, scratching, grabbing, abusing others sexually)
B. Verbal behavioral symptoms directed toward others (e.g., threatening others,
screaming at others, cursing at others)
C. Other behavioral symptoms not directed toward others (e.g., physical symptoms
such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing
in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like
screaming, disruptive sounds)
E0800.
Rejection of Care - Presence and Frequency
Enter Code
Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the
resident’s goals for health and well-being? Do not include behaviors that have already been addressed (e.g., by discussion or care
planning with the resident or family), and determined to be consistent with resident values, preferences, or goals.
•
0. Behavior not exhibited
•
1. Behavior of this type occurred 1 to 3 days
•
2. Behavior of this type occurred 4 to 6 days, but less than daily
•
3. Behavior of this type occurred daily
E0900.
Wandering - Presence and Frequency
Enter Code
Has the resident wandered?
•
0. Behavior not exhibited
•
1. Behavior of this type occurred 1 to 3 days
•
2. Behavior of this type occurred 4 to 6 days, but less than daily
•
3. Behavior of this type occurred daily
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 10 of 27
Resident
Identifier
Date
Section GG - Functional Abilities - OBRA/Interim
GG0130. Self-Care (Assessment period is the ARD plus 2 previous calendar days)
Code the resident’s usual performance for each activity using the 6-point scale. If an activity was not attempted, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident’s
performance is unsafe or of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
If activity was not attempted, code reason:
•
06.
Independent - Resident completes the activity by themself with no assistance from a helper.
•
07. Resident refused
•
05.
Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity.
Helper assists only prior to or following the activity.
•
•
04.
Supervision or touching assistance - Helper provides verbal cues and/or
touching/steadying and/or contact guard assistance as resident completes activity.
Assistance may be provided throughout the activity or intermittently.
09. Not applicable - Not attempted and
the resident did not perform this activity
prior to the current illness, exacerbation,
or injury
•
•
03.
Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts,
holds, or supports trunk or limbs, but provides less than half the effort.
10. Not attempted due to environmental
limitations (e.g., lack of equipment,
weather constraints)
•
02.
Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts
or holds trunk or limbs and provides more than half the effort.
•
88. Not attempted due to medical condition
or safety concerns
•
01.
Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the
activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.
5. OBRA/
Interim
Performance
Enter Codes in Boxes
A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is
placed before the resident.
B. Oral hygiene: The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures
into and from the mouth, and manage denture soaking and rinsing with use of equipment.
C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If
managing an ostomy, include wiping the opening but not managing equipment.
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 11 of 27
Resident
Identifier
Date
Section GG - Functional Abilities - OBRA/Interim
GG0170. Mobility (Assessment period is the ARD plus 2 previous calendar days)
Code the resident’s usual performance for each activity using the 6-point scale. If an activity was not attempted, code the reason.
Coding:
Safety and Quality of Performance - If helper assistance is required because resident’s
performance is unsafe or of poor quality, score according to amount of assistance provided.
Activities may be completed with or without assistive devices.
If activity was not attempted, code reason:
•
06.
Independent - Resident completes the activity by themself with no assistance from a helper.
•
07. Resident refused
•
05.
Setup or clean-up assistance - Helper sets up or cleans up; resident completes activity.
Helper assists only prior to or following the activity.
•
•
04.
Supervision or touching assistance - Helper provides verbal cues and/or
touching/steadying and/or contact guard assistance as resident completes activity.
Assistance may be provided throughout the activity or intermittently.
09. Not applicable - Not attempted and
the resident did not perform this activity
prior to the current illness, exacerbation,
or injury
•
•
03.
Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts,
holds, or supports trunk or limbs, but provides less than half the effort.
10. Not attempted due to environmental
limitations (e.g., lack of equipment,
weather constraints)
•
02.
Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts
or holds trunk or limbs and provides more than half the effort.
•
88. Not attempted due to medical condition
or safety concerns
•
01.
Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the
activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.
5. OBRA/
Interim
Performance
Enter Codes in Boxes
B. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed.
C. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no
back support.
D.
Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed.
E.
Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair).
F.
Toilet transfer: The ability to get on and off a toilet or commode.
I.
Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If interim performance is
coded 07, 09, 10, or 88 → Skip to H0100, Appliances
J.
Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns.
K. Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space.
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
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Resident
Identifier
Date
Section H - Bladder and Bowel
H0100.
↓
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□
□
Appliances
Check all that apply
C.
Ostomy (including urostomy, ileostomy, and colostomy)
D.
Intermittent catheterization
Z.
None of the above
H0200.
Urinary Toileting Program
Enter Code
C.
Current toileting program or trial - Is a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training)
currently being used to manage the resident’s urinary continence?
•
0.
1.
•
No
Yes
H0500.
Bowel Toileting Program
Enter Code
Is a toileting program currently being used to manage the resident’s bowel continence?
•
0. No
•
1. Yes
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 13 of 27
Resident
Identifier
Date
Section I - Active Diagnoses
I0020.
Indicate the resident’s primary medical condition category
Enter Code
Indicate the resident’s primary medical condition category that best describes the primary reason for admission
•
01. Stroke
•
02. Non-Traumatic Brain Dysfunction
•
03. Traumatic Brain Dysfunction
•
04. Non-Traumatic Spinal Cord Dysfunction
•
05. Traumatic Spinal Cord Dysfunction
•
06. Progressive Neurological Conditions
•
07. Other Neurological Conditions
•
08. Amputation
•
09. Hip and Knee Replacement
•
10. Fractures and Other Multiple Trauma
•
11. Other Orthopedic Conditions
•
12. Debility, Cardiorespiratory Conditions
•
13. Medically Complex Conditions
I0020B. ICD Code
Active Diagnoses in the last 7 days
Check all that apply.
Diagnoses listed in parentheses are provided as examples and should not be considered as all-inclusive lists
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□
□
□
□
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□
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□
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□
Gastrointestinal
I1300.
Ulcerative Colitis, Crohn’s Disease, or Inflammatory Bowel Disease
Infections
I1700.
Multidrug-Resistant Organism (MDRO)
I2000.
Pneumonia
I2100.
Septicemia
I2500.
Wound Infection (other than foot)
Metabolic
I2900.
Diabetes Mellitus (DM) (e.g., diabetic retinopathy, nephropathy, and neuropathy)
Neurological
I4300.
Aphasia
I4400.
Cerebral Palsy
I4500.
Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke
I4900.
Hemiplegia or Hemiparesis
I5100.
Quadriplegia
I5200.
Multiple Sclerosis (MS)
I5300.
Parkinson’s Disease
I5500.
Traumatic Brain Injury (TBI)
Nutritional
I5600.
Malnutrition (protein or calorie) or at risk for malnutrition
Active Diagnoses in the last 7 days continued on next page
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 14 of 27
Resident
Identifier
Date
Section I - Active Diagnoses
Active Diagnoses in the last 7 days - Continued
□
□
□
Pulmonary
I6200.
Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease (e.g., chronic bronchitis and
restrictive lung diseases such as asbestosis)
I6300.
Respiratory Failure
None of Above
I7900.
None of the above active diagnoses within the last 7 days
Other
□
I8000.
Additional active diagnoses
Enter diagnosis on line and ICD code in boxes. Include the decimal for the code in the appropriate box.
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 15 of 27
Resident
Identifier
Date
Section J - Health Conditions
Other Health Conditions
J1100.
↓
□
□
J1550.
↓
□
□
□
Shortness of Breath (dyspnea)
Check all that apply
C.
Shortness of breath or trouble breathing when lying flat
Z.
None of the above
Problem Conditions
Check all that apply
A.
Fever
B.
Vomiting
Z.
None of the above
J2100.
Recent Surgery Requiring Active SNF Care
Enter Code
Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay?
•
0. No
•
1. Yes
•
8. Unknown
Surgical Procedures
Complete only if J2100 = 1
↓
□
□
□
□
□
□
□
□
□
□
□
□
□
Check all that apply
Major Joint Replacement
J2300.
Knee Replacement - partial or total
J2310.
Hip Replacement - partial or total
J2320.
Ankle Replacement - partial or total
J2330.
Shoulder Replacement - partial or total
Spinal Surgery
J2400. Involving the spinal cord or major spinal nerves
J2410.
Involving fusion of spinal bones
J2420.
Involving Iamina, discs, or facets
J2499. Other major spinal surgery
Other Orthopedic Surgery
J2500. Repair fractures of the shoulder (including clavicle and scapula) or arm (but not hand)
J2510.
Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot)
J2520.
Repair but not replace joints
J2530.
Repair other bones (such as hand, foot, jaw)
J2599. Other major orthopedic surgery
Surgical Procedures continued on next page
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 16 of 27
Resident
Identifier
Date
Section J - Health Conditions
Surgical Procedures - Continued
Complete only if J2100 = 1
↓
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Check all that apply
Neurological Surgery
J2600. Involving the brain, surrounding tissue or blood vessels (excludes skull and skin but includes cranial nerves)
J2610.
Involving the peripheral or autonomic nervous system - open or percutaneous
J2620.
Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices
J2699. Other major neurological surgery
Cardiopulmonary Surgery
J2700.
Involving the heart or major blood vessels - open or percutaneous procedures
J2710.
Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords - open or endoscopic
J2799.
Other major cardiopulmonary surgery
Genitourinary Surgery
J2800. Involving genital systems (such as prostate, testes, ovaries, uterus, vagina, external genitalia)
J2810.
Involving the kidneys, ureters, adrenal glands, or bladder - open or laparoscopic (includes creation or removal of
nephrostomies or urostomies)
J2899. Other major genitourinary surgery
Other Major Surgery
J2900. Involving tendons, ligaments, or muscles
J2910.
Involving the gastrointestinal tract or abdominal contents from the esophagus to the anus, the biliary tree, gall
bladder, liver, pancreas, or spleen - open or laparoscopic (including creation or removal of ostomies or percutaneous
feeding tubes, or hernia repair)
J2920.
Involving the endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, or thymus - open
J2930.
Involving the breast
J2940. Repair of deep ulcers, internal brachytherapy, bone marrow or stem cell harvest or transplant
J5000. Other major surgery not listed above
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 17 of 27
Resident
Identifier
Date
Section K - Swallowing/Nutritional Status
K0100.
↓
□
□
□
□
□
Swallowing Disorder
Signs and symptoms of possible swallowing disorder
Check all that apply
A.
Loss of liquids/solids from mouth when eating or drinking
B.
Holding food in mouth/cheeks or residual food in mouth after meals
C.
Coughing or choking during meals or when swallowing medications
D.
Complaints of difficulty or pain with swallowing
Z.
None of the above
K0300.
Weight Loss
Enter Code
Loss of 5% or more in the last month or loss of 10% or more in last 6 months
•
0. No or unknown
•
1. Yes, on physician-prescribed weight-loss regimen
•
2. Yes, not on physician-prescribed weight-loss regimen
K0520.
Nutritional Approaches
Check all of the following nutritional approaches that apply
2. While Not a Resident
Performed while NOT a resident of this facility and within the last 7 days
3. While a Resident
Performed while a resident of this facility and within the last 7 days
Only check column 2 if resident entered (admission or reentry) IN THE LAST
7 DAYS. If resident last entered 7 or more days ago, leave column 2 blank.
Check all that apply
•
A.
Parenteral/IV feeding
•
B.
Feeding tube (e.g., nasogastric or abdominal (PEG))
•
C.
Mechanically altered diet - require change in texture of food or liquids
(e.g., pureed food, thickened liquids)
•
Z.
None of the above
K0710.
2. While Not
a Resident
□
□
□
Percent Intake by Artificial Route
3. While a
Resident
□
□
□
□
Complete K0710 only if Column 2 and/or Column 3 are checked for K0520A and/or K0520B
2. While a Resident
Performed while a resident of this facility and within the last 7 days
3. During Entire 7 Days
Performed during the entire last 7 days
Enter Codes
A.
•
•
•
B.
•
•
Proportion of total calories the resident received through parenteral or tube feeding
1.
2.
3.
25% or less
26–50%
51% or more
Average fluid intake per day by IV or tube feeding
1.
2.
500 cc/day or less
501 cc/day or more
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
2. While a
Resident
3. During
Entire 7 Days
Page 18 of 27
Resident
Identifier
Date
Section M - Skin Conditions
Report based on highest stage of existing ulcers/injuries at their worst; do not “reverse” stage
M0210.
Unhealed Pressure Ulcers/Injuries
Enter Code
Does this resident have one or more unhealed pressure ulcers/injuries?
•
0. No → Skip to M1030, Number of Venous and Arterial Ulcers
•
1. Yes → Continue to M0300, Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
M0300.
Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage
B.
Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as
an intact or open/ruptured blister
Enter Number
C.
1.
Number of Stage 3 pressure ulcers
Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.
Often includes undermining and tunneling
Enter Number
F.
Number of Stage 2 pressure ulcers
Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but
does not obscure the depth of tissue loss. May include undermining and tunneling
Enter Number
D.
1.
1.
Number of Stage 4 pressure ulcers
Unstageable - Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar
Enter Number
M1030.
Enter Number
M1040.
↓
□
□
□
□
□
□
□
1.
Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar
Number of Venous and Arterial Ulcers
Enter the total number of venous and arterial ulcers present
Other Ulcers, Wounds and Skin Problems
Check all that apply
Foot Problems
A.
Infection of the foot (e.g., cellulitis, purulent drainage)
B.
Diabetic foot ulcer(s)
C.
Other open lesion(s) on the foot
Other Problems
D.
Open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion)
E.
Surgical wound(s)
F.
Burn(s) (second or third degree)
None of the Above
Z.
None of the above were present
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 19 of 27
Resident
Identifier
Date
Section M - Skin Conditions
M1200.
↓
□
□
□
□
□
□
□
□
□
□
Skin and Ulcer/Injury Treatments
Check all that apply
A.
Pressure reducing device for chair
B.
Pressure reducing device for bed
C.
Turning/repositioning program
D.
Nutrition or hydration intervention to manage skin problems
E.
Pressure ulcer/injury care
F.
Surgical wound care
G.
Application of nonsurgical dressings (with or without topical medications) other than to feet
H.
Applications of ointments/medications other than to feet
I.
Application of dressings to feet (with or without topical medications)
Z.
None of the above were provided
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 20 of 27
Resident
Identifier
Date
Section N - Medications
N0350.
Insulin
Enter Days
A.
Insulin injections
Record the number of days that insulin injections were received during the last 7 days or since admission/entry or reentry if
less than 7 days
Enter Days
B.
Orders for insulin
Record the number of days the physician (or authorized assistant or practitioner) changed the resident’s insulin orders
during the last 7 days or since admission/entry or reentry if less than 7 days
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 21 of 27
Resident
Identifier
Date
Section O - Special Treatments, Procedures, and Programs
O0110.
Special Treatments, Procedures, and Programs
Check all of the following treatments, procedures, and programs that were performed
b. While a Resident
Performed while a resident of this facility and within the last 14 days
Check all that apply
Cancer Treatments
•
A1. Chemotherapy
•
B1. Radiation
□
□
Respiratory Treatments
•
C1. Oxygen therapy
•
D1. Suctioning
•
E1.
Tracheostomy care
•
F1.
Invasive Mechanical Ventilator (ventilator or respirator)
Other
•
H1. IV Medications
•
I1.
Transfusions
•
J1.
Dialysis
•
M1. Isolation or quarantine for active infectious disease (does not include standard body/fluid precautions)
None of the Above
•
Z1.
D.
Therapies
□
□
□
□
Respiratory Therapy
Enter Number of Days
□
□
□
□
□
None of the above
O0400.
b. While a
Resident
• 2.
Days - record the number of days this therapy was administered for at least 15 minutes a day in the last 7 days
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 22 of 27
Resident
Identifier
Date
Section O - Special Treatments, Procedures, and Programs
O0500.
Restorative Nursing Programs
Record the number of days each of the following restorative programs was performed for at least 15 minutes a day in
the last 7 calendar days (enter 0 if none or less than 15 minutes daily)
Technique
↓
Number of Days
A. Range of motion (passive)
B. Range of motion (active)
C. Splint or brace assistance
Training and Skill Practice In:
↓
Number of Days
D. Bed mobility
E. Transfer
F. Walking
G. Dressing and/or grooming
H. Eating and/or swallowing
I.
Amputation/prostheses care
J. Communication
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 23 of 27
Resident
Identifier
Date
Section X - Correction Request
Complete Section X only if A0050 = 2 or 3
Identification of Record to be Modified/Inactivated
The following items identify the existing assessment record that is in error. In this section, reproduce the information EXACTLY as it appeared on
the existing erroneous record, even if the information is incorrect.
This information is necessary to locate the existing record in the National MDS Database.
X0150.
Type of Provider (A0200 on existing record to be modified/inactivated)
Enter Code
Type of provider
•
1. Nursing home (SNF/NF)
•
2. Swing Bed
X0200.
Name of Resident (A0500 on existing record to be modified/inactivated)
A.
C.
X0310.
X0400.
Last name:
Sex (A0810 on existing record to be modified/inactivated)
Enter Code
First name:
•
•
1.
2.
Male
Female
Birth Date (A0900 on existing record to be modified/inactivated)
-
-
Month
X0500.
Day
Year
Social Security Number (A0600A on existing record to be modified/inactivated)
-
-
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 24 of 27
Resident
Identifier
Date
Section X - Correction Request
X0600.
Type of Assessment (A0310 on existing record to be modified/inactivated)
Enter Code
A.
Federal OBRA Reason for Assessment
•
•
01.
02.
03.
04.
05.
06.
99.
B.
PPS Assessment
•
•
PPS Scheduled Assessment for a Medicare Part A Stay
01. 5-day scheduled assessment
PPS Unscheduled Assessment for a Medicare Part A Stay
08. IPA - Interim Payment Assessment
Not PPS Assessment
99. None of the above
F.
Entry/discharge reporting
•
01.
10.
11.
12.
99.
•
•
•
•
•
Enter Code
•
•
•
•
Enter Code
•
•
•
•
X0700.
Admission assessment (required by day 14)
Quarterly review assessment
Annual assessment
Significant change in status assessment
Significant correction to prior comprehensive assessment
Significant correction to prior quarterly assessment
None of the above
Entry tracking record
Discharge assessment - return not anticipated
Discharge assessment - return anticipated
Death in facility tracking record
None of the above
Date on existing record to be modified/inactivated
A.
Assessment Reference Date (A2300 on existing record to be modified/inactivated) - Complete only if X0600B = 08
-
-
Month
Day
Year
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 25 of 27
Resident
Identifier
Date
Section X - Correction Request
Correction Attestation Section
Complete this section to explain and attest to the modification/inactivation request
X0800.
Enter Number
X0900.
↓
□
□
□
□
□
X1050.
↓
□
□
X1100.
Correction Number
Enter the number of correction requests to modify/inactivate the existing record, including the present one
Reasons for Modification
Complete only if Type of Record is to modify a record in error (A0050 = 2)
Check all that apply
A.
Transcription error
B.
Data entry error
C.
Software product error
D.
Item coding error
Z.
Other error requiring modification
If “Other” checked, please specify: _____________________________________________________________________________
Reasons for Inactivation
Complete only if Type of Record is to inactivate a record in error (A0050 = 3)
Check all that apply
A.
Event did not occur
Z.
Other error requiring inactivation
If “Other” checked, please specify: _____________________________________________________________________________
RN Assessment Coordinator Attestation of Completion
A.
B.
Attesting individual’s first name:
Attesting individual’s last name:
C.
Attesting individual’s title:
D.
Signature
E.
Attestation date
-
-
Month
Day
Year
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 26 of 27
Resident
Identifier
Date
Section Z - Assessment Administration
Z0100.
Medicare Part A Billing
A.
B.
Z0400.
Medicare Part A HIPPS code:
Version code:
Signature of Persons Completing the Assessment or Entry/Death Reporting
I certify that the accompanying information accurately reflects resident assessment information for this resident and that I collected or
coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance
with applicable Medicare and Medicaid requirements. I understand that this information is used as a basis for ensuring that residents receive
appropriate and quality care, and as a basis for payment from federal funds. I further understand that payment of such federal funds and
continued participation in the government-funded health care programs is conditioned on the accuracy and truthfulness of this information, and
that I may be personally subject to or may subject my organization to substantial criminal, civil, and/or administrative penalties for submitting false
information. I also certify that I am authorized to submit this information by this facility on its behalf.
Signature
Title
Sections
Date Section Completed
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Z0500.
A.
Signature of RN Assessment Coordinator Verifying Assessment Completion
Signature:
B.
Date RN Assessment Coordinator
signed assessment as complete:
-
-
Month
Day
Year
Legal Notice Regarding MDS 3.0 - Copyright 2011 United States of America and interRAI. This work may be freely used and distributed solely within the United
States. Portions of the MDS 3.0 are under separate copyright protections; Pfizer Inc. holds the copyright for the PHQ-9; Confusion Assessment Method. © 1988, 2003,
Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8. Question on transportation has been derived from
the national PRAPARE® social drivers of health assessment tool (2016), for which the National Association of Community Health Centers (NACHC) holds the
copyright. Pfizer Inc., the Hospital Elder Life Program, LLC, and NACHC have granted permission to use these instruments in association with the MDS 3.0. All
rights reserved.
MDS 3.0 Interim Payment Assessment (IPA) Version 1.20.1 Effective 10/01/2025
Page 27 of 27
| File Type | application/pdf |
| File Title | MDS 3.0 Interim Payment Assessment (IPA) Item Set |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2025-07-15 |
| File Created | 2024-10-31 |