CMS Releases Updated MDS 3.0 Quality Measures User’s Manual

The Centers for Medicare and Medicaid Services (CMS) released the Minimum Data Set (MDS) 3.0 Quality Measures User’s Manual v16.0 on Sept. 20, 2023. This document serves as an update to the specifications used to calculate quality measures that are included in the Nursing Home Quality Initiative (NHQI) effective Oct. 1, 2023. The manual includes a section outlining notable changes to the manual. There are several changes to some measure specifications that CMS describes as “minimal,” while other specifications have “remained intact.”

Measures Affected by Removal of Section G and Re-Specified

• Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay) (CMS ID: N028.03)
• Percent of Residents Whose Ability to Walk Independently Worsened (Long Stay) (CMS ID: N035.04)

Measures Re-Specified by Replacing Old MDS Label with New Label

• Percent of Residents Who Newly Received an Antipsychotic Medication (Short Stay) (CMS ID: N011.03)
• Percent of Residents Who Lose Too Much Weight (Long Stay) (CMS ID: N029.03)
• Percent of Residents Who Have Depressive Symptoms (Long Stay) (CMS ID: N030.03)
• Percent of Residents Who Received an Antipsychotic Medication (Long Stay) (CMS ID: N031.04)
• Prevalence of Antianxiety/Hypnotic Use (Long Stay) (CMS ID: N033.03)
• Percent of Residents Who Used Antianxiety or Hypnotic Medication (Long Stay) (CMS ID: N036.03)

Removal and Addition of Measures

• The NHQI version of the quality measure Percent of Residents Who Made Improvements in Function (Short Stay) (CMS ID: N037.03) will be replaced with the Discharge Function Score measure (CMS ID: S042.01).
• The Percent of High-Risk Residents With Pressure Ulcers (Long Stay) (CMS ID: N015.03) measure will be replaced with the Percent of Residents With Pressure Ulcers (Long Stay) (CMS ID: N045.01).
• The Percent of Low-Risk Residents Who Lose Control of Their Bowel or Bladder (Long Stay) (CMS ID: N025.02) measure will be replaced with the Percent of Residents With New or Worsened Bowel or Bladder Incontinence (Long Stay) (CMS ID: N046.01).

Contact: Susan Chenail, schenail@leadingageny.org, 518-867-8383 ext. 116