3.0 Medical Necessity and Level of Care Assessment(MN/LOC)Item by Item GuideSeptember 2019Item by Item Guide to the 3.0 MN/LOC –September 2019Page 1

3.0 Medical Necessity and Level of Care Item by Item GuideTable of ContentsOVERVIEW TO THE 3.0 MN/LOC ITEM BY ITEM GUIDE . 6Overview . 6Medical Necessity and Level of Care Assessment Purpose . 7RUG Training. 7When to Complete and Submit an Assessment . 7How to Complete and Submit an Assessment . 8Physician’s Signature . 8Assessment Retention . 8Coding Conventions . 8SECTION A: IDENTIFICATION INFORMATION . 10A0310: Type of Assessment . 10A0500: Legal Name of Individual . 10A0600: Social Security and Medicare Numbers . 11A0700: Medicaid Number . 12A0800: Gender . 13A0900: Birth Date . 13A1000: Race/Ethnicity . 14A1100: Language . 14A1300: Optional Individual Items. 15A1550: Conditions Related to Intellectual and Developmental Disability Status . 16A2300: Assessment Date . 17SECTION B: HEARING, SPEECH, AND VISION. 18B0100: Comatose . 18B0200: Hearing . 19B0300: Hearing Aid . 21B0600: Speech Clarity . 22B0700: Makes Self Understood . 23B0799 Modes of Expression . 24B0800: Ability to Understand Others . 25B1000: Vision . 27B1200: Corrective Lenses . 28SECTION C: COGNITIVE PATTERNS . 30C0100: Should Brief Interview for Mental Status Be Conducted? . 30C0200-C0500: Brief Interview for Mental Status (BIMS) . 32C0200: Repetition of Three Words . 35C0300: Temporal Orientation (Orientation to Year, Month, and Day) . 38C0400: Recall . 41Item by Item Guide to the 3.0 MN/LOC –September 2019Page 2

C0500: BIMS Summary Score . 44C0600: Should the Caregiver Assessment for Mental Status (C0700-C1000) Be Conducted? 45C0700-C1000: Caregiver Assessment of Mental Status Item . 47C0700: Short-term Memory OK . 48C0800: Long-term Memory OK . 49C0900: Memory/Recall Ability. 51C1000: Cognitive Skills for Daily Decision Making . 52C1310: Signs and Symptoms of Delirium (from CAM ) . 55SECTION D: MOOD . 60D0100: Should Individual Mood Interview Be Conducted? . 61D0200: Individual Mood Interview (PHQ-9 ) . 62D0300: Total Severity Score . 67D0500: Caregiver Assessment of Individual Mood (PHQ-9-OV ) . 69D0600: Total Severity Score . 72SECTION E: BEHAVIOR . 73E0100: Potential Indicators of Psychosis . 74E0200: Behavioral Symptom—Presence & Frequency . 76E0300: Overall Presence of Behavioral Symptoms . 78E0500: Impact on Individual . 78E0600: Impact on Others. 81E0800: Rejection of Care—Presence & Frequency . 83E0900: Wandering—Presence & Frequency . 86E1000: Wandering—Impact . 87E1100: Change in Behavior or Other Symptoms . 88SECTION G: FUNCTIONAL STATUS. 91G0110: Activities of Daily Living (ADL) Assistance . 91G0120: Bathing . 108G0300: Balance During Transitions and Walking . 111G0400: Functional Limitation in Range of Motion . 119G0600: Mobility Devices . 121G0900: Functional Rehabilitation Potential . 123SECTION H: BLADDER AND BOWEL . 126H0100: Appliances . 126H0200: Urinary Toileting Program . 128H0300: Urinary Continence . 130H0400: Bowel Continence . 132H0500: Bowel Continence Program . 134H0600: Bowel Patterns. 135SECTION I: ACTIVE DIAGNOSES. 137Active Diagnoses in the Last 7 Days . 137Item by Item Guide to the 3.0 MN/LOC –September 2019Page 3

SECTION J: HEALTH CONDITIONS . 149J0100: Pain Management . 149J0200: Should Pain Assessment Interview Be Conducted? . 152J0300-J0600: Pain Assessment Interview . 153J0300: Pain Presence . 155J0400: Pain Frequency . 157J0500: Pain Effect on Function . 158J0600: Pain Intensity . 160J0700: Should the Caregiver Assessment for Pain be Conducted? . 162J0800: Indicators of Pain . 164J0850: Frequency of Indicator of Pain or Possible Pain . 167J1400: Prognosis . 170J1550: Problem Conditions . 172J1700: Fall History . 173J1900: Number of Falls in the last 6 months with or without Injury . 177J2000: Prior Surgery. 179SECTION K: SWALLOWING/NUTRITIONAL STATUS. 181K0100: Swallowing Disorder . 181K0200: Height and Weight . 183K0300: Weight Loss . 185K0310: Weight Gain . 187K0510: Nutritional Approaches . 188K0710: percent Intake by Artificial Route . 191K0710A, Proportion of Total Calories the Individual Received through Parental or TubeFeedings . 191K0710B, Average Fluid Intake per Day by IV or Tube Feeding . 192SECTION L: ORAL/DENTAL STATUS. 194L0200: Dental . 194SECTION M: SKIN CONDITIONS . 197M0100: Determination of Pressure Ulcer/Injury Risk . 197M0150: Risk of Pressure Ulcers/Injuries . 199M0210: Unhealed Pressure Ulcers/Injuries. 199M0300: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage . 202Steps for completing M0300A–G . 202M0300A: Stage 1 Pressure Ulcers/Injuries . 203M0300B: Stage 2 Pressure Ulcers . 204M0300C: Stage 3 Pressure Ulcers/Injuries . 205M0300D: Stage 4 Pressure Ulcers/Injuries . 207M0300E: Unstageable Pressure Ulcers/Injuries Due to Non-removable Dressing/Device . 208M0300F: Unstageable Pressure Ulcers Due to Slough and/or Eschar . 210Item by Item Guide to the 3.0 MN/LOC –September 2019Page 4

M0300G: Unstageable Pressure Injuries Due to Suspected Deep Tissue Injury . 211M1030: Number of Venous and Arterial Ulcers . 213M1040: Other Ulcers, Wounds and Skin Problems . 214M1200: Skin and Ulcer/Injury Treatments . 218SECTION N: MEDICATIONS . 222N0300: Injections . 222N0350: Insulin . 223N0410: Medications Received . 225SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS . 230O0100: Special Treatments, Procedures, and Programs . 230O0400: Therapies . 235O0500: Restorative Nursing Programs . 243O0600: Physician Examinations . 247O0700: Physician Orders . 248SECTION P: RESTRAINTS AND ALARMS . 250SECTION Q: PARTICIPATION IN ASSESSMENT AND GOAL SETTING . 259Q0100: Participation in Assessment . 259Q0300: Individual’s Overall Expectation . 260SECTION Z: ASSESSMENT ADMINISTRATION. 262Z0500: Signature of RN Completing Assessment . 262Section LTC Medicaid Information . 264S1. Medicaid Information . 264S2. Claims Processing Information . 264S3. Primary Diagnosis . 266S4. For DADS use only . 266S5. Licenses . 266S6. Additional MN Information . 268S7. Physician’s Evaluation and Recommendation . 270S9. Medications . 272S10. Comments . 277S11. Advance Care Planning. 278S12. LAR Address. 279Appendix I – RUG Items . 280Appendix II – Revisions Table . 283Item by Item Guide to the 3.0 MN/LOC –September 2019Page 5

OVERVIEW TO THE 3.0 MN/LOC ITEM BY ITEM GUIDEOverviewThis guide is to be used in conjunction with the Medical Necessity and Level of CareAssessment (MN/LOC Assessment). A blank copy of the MN/LOC can be found here. TheMN/LOC Assessment includes the following sections: Section A: Identification Information Section B: Hearing, Speech, and Vision Section C: Cognitive Patterns Section D: Mood Section E: Behavior Section G: Functional Status Section H: Bladder and Bowel Section I: Active Diagnosis Section J: Health Conditions Section K: Swallowing/Nutritional Status Section L: Oral/Dental Status Section M: Skin Conditions Section N: Medications Section O: Special Treatments, Procedures, and Procedures Section P: Restraints Section Q: Participation in Assessment and Goal Setting Section Z: Assessment Administration LTC Medicaid Information: Texas Specific ItemsThis guide provides information to facilitate an accurate and uniform assessment focused on: Intent. The reason(s) for including this set of assessment items in the MN/LOC. Item Display. To facilitate accurate individual assessment using the MN/LOC, eachassessment section is accompanied by screen shots, which display the item from theMN/LOC 3.0 item set. Item Rationale. The purpose of assessing this aspect of an individual’s clinical or functionalstatus. Health-related Quality of Life. How the condition, impairment, improvement, or declinebeing assessed can affect an individual’s quality of life, along with the importance ofcaregiver understanding the relationship of the clinical or functional issue related to qualityof life. Planning for Care. How assessment of the condition, impairment, improvement, or declinebeing assessed can contribute to appropriate care planning. Steps for Assessment. Sources of information and methods for determining the correctresponse for coding each MN/LOC item. Coding Instructions. The proper method of recording each response, with explanations ofindividual response categories. Coding Tips and Special Populations. Clarifications, issues of note, and conditions to beItem by Item Guide to the 3.0 MN/LOC –September 2019Page 6

considered when coding individual MN/LOC items. Examples. Case examples of appropriate coding for most MN/LOC sections/items.Additional layout issues to note include: Resource Utilization Group (RUG) fields are identified with . In addition Appendix I listsall the RUG fields. Important definitions are included in each section. Pediatric Tips are included in each section as appropriate. All look-back periods are 7 days unless otherwise noted below the item.Medical Necessity and Level of Care Assessment PurposeThe MN/LOC is used by the following Community Programs: Community First Choice (CFC)Program, Medically Dependent Children Program (MDCP), Program of All-Inclusive Care forthe Elderly (PACE), and the Home and Community Based Services STAR PLUS WaiverHome and Community-based Services (SPW HCBS) to: Supply current information that is used by medical professionals at Texas Medicaid &Healthcare Partnership (TMHP) to determine medical necessity (MN) for individuals. MN isthe determination that an individual requires the services (supervision, assessment, planning,and intervention) of licensed nurses in an institutional setting to carry out a physician’splanned regimen for total care. A determination that an individual meets MN is required foran individual to participate in CFC, MDCP, PACE, and SPW HCBS. Determine the Resource Utilization Group (RUG). A RUG is a systematic approach tocategorize the care needs of an individual. The Texas Medicaid & Healthcare Partnership(TMHP) automated system uses a mathematical algorithm established by Centers forMedicare & Medicaid Services (CMS) to calculate a RUG value. This algorithm is used in allcases to automatically generate a RUG based on the information entered on the MN/LOCAssessment by the assessing nurse. The RUG is used to establish the service plan cost limitin MDCP and SPW HCBS.RUG TrainingRUG training must be completed every two years in order to complete and submit assessments.After training is completed, the nurse’s license number is registered with the TMHP. Licensenumbers associated with the assessment are verified to confirm training requirements have beenmet. The RUG training will be effective for a two-year period.To enroll in the course, access the following to Complete and Submit an AssessmentUse the MN/LOC Assessment to submit assessment information necessary for TMHP todetermine:1) Medical necessity; and 2) RUGItem by Item Guide to the 3.0 MN/LOC –September 2019Page 7

How to Complete and Submit an AssessmentMedical Necessity and Level of Care Assessments can only be submitted on the TMHP LTCOnline Portal. TMHP’s LTC Online Portal can be accessed via TMHPconducts community service waiver program workshops that detail how to create an account foraccess to the TMHP LTC Online Portal. Details can be found at receives a monthly feed of valid registered nurse (RN) license numbers from the TexasBoard of Nursing. Depending on dates, a nurse can renew the license timely, but if done close tothe end of the expiration month, it could result in TMHP not receiving information of therenewal until the following month. In order to avoid this possibility, and ensure MN/LOCAssessments can be submitted on the TMHP LTC Online Portal, it is recommended that nursesrenew their license a month prior to the expiration date.Physician’s SignatureA Physician’s Signature page can be generated and printed from the TMHP LTC Online Portalfor Initial, Annual, and Significant Change in Status Assessments. A physician’s signature isrequired when submitting an Initial Assessment (when 01 is selected as the Reason forAssessment in Field A0310). Initial Assessments cannot be submitted unless the physician hassigned the statement on the Physician Signature Page certifying the applicant requires NursingFacility services or alternative community based services under the supervision of an MD/DO. Aphysician’s signature is optional for Annual and Significant Change in Status Assessments.Assessment RetentionKeep the electronic and/or handwritten assessment with appropriate original signatures in theindividual’s record in accordance with all applicable Department of Aging and DisabilityServices (DADS) record retention rules and your agency’s policies.Coding ConventionsThere are several standard conventions to be used when completing the MN/LOC Assessment, asfollows. The standard look-back period for the MN/LOC 3.0 is 7 days, unless otherwise stated as inthe following sections: D, I, J, K, O, and Long Term Care Medicaid Information (LTCMI). The Assessment Date (A2300) establishes the endpoint for all look-back periods. Responses entered on the LTMCI must not conflict with the responses entered on othersections of the MN/LOC Assessment. There are a few instances in which scoring on one item will govern how scoring is completedfor one or more additional items. The instructions direct the assessor to “skip” over the nextitem (or several items) and go on to another. This is called a skip pattern. When youencounter a skip pattern, leave the item blank and move on to the next item as directed (e.g.,item B0100, Comatose, directs the assessor to skip to item G0110, Activities of DailyItem by Item Guide to the 3.0 MN/LOC –September 2019Page 8

Living Assistance, if B0100 is answered code 1, yes. The intervening items from B0200F0800 would not be coded. If B0100 were recorded as code 0, no, then the assessor wouldcontinue with item B0200).Use a check mark for boxes where the instructions state to “check all that apply,” if specifiedcondition is met; otherwise these boxes remain blank.Use a numeric response (a number or pre-assigned value) for blank boxes (e.g., D0350,Safety Notification).When recording month, day, and year for dates, enter two digits for the month and the day,and four digits for the year.Some MN/LOC 3.0 items allow a dash (-) value to be entered. A dash value indicates that anitem was not assessed.NONE OF ABOVE is a response item to several items. Check this item where none of theresponses apply; it should not be used to signify lack of information about the item.Item by Item Guide to the 3.0 MN/LOC –September 2019Page 9

SECTION A: IDENTIFICATION INFORMATIONIntent: The intent of this section is to obtain key information to uniquely identify the individualand the reason for assessment.A0310: Type of Assessment Item RationaleAllows identification of needed assessment content.Coding Instructions for A0310, Type of AssessmentEnter the Reason for Assessment:01. Initial Assessment- An Initial Assessment is completed when an individual is admitted to aCommunity Program. Please refer to the specific Community Program handbook or rules todetermine if an MN/LOC must be completed for individuals transitioning from a NursingFacility (NF) to a specific Community Program. In some instances, the MN and RUGdetermined by the Nursing Facility (NF) assessment (the Minimum Data Set [MDS]) may bevalid for the Community Program. .03. Annual Assessment- An Annual Assessment is required yearly. It must be submitted up to 90days prior to the end of the service plan. Rejection of an Annual Assessment will occur if it issubmitted more than 90 days prior to the service plan end date.04. Significant Change in Status Assessment (SCSA) – For the purposes of this assessmentprocess, a significant change is a decline in an individual’s condition that could potentiallyincrease their current Resource Utilization Group (RUG) value. A SCSA does not apply forPACE. For MDCP and SPW refer to the program handbook to determine if a SCSA must beauthorized prior to submission on the TMHP LTC Online Portal.A0500: Legal Name of IndividualItem by Item Guide to the 3.0 MN/LOC –September 2019Page 10

DefinitionsLegal Name - The individual’s name as it appears on the Medicaid card. If the individual is notenrolled in the Medicaid program, use the name as it appears on a government issued document(i.e., driver’s license, birth certificate, social security card).Item Rationale Allows identification of the individualAlso used for matching of recordsSteps for Assessment1. Ask the individual, caregiver, or legally authorized representative (LAR).2. Check the individual’s name on his or her Medicaid card, or if not in the program, checkother government-issued document.Coding InstructionsUse printed letters. Enter in the following order:A. First NameB. Middle Initial (if the individual has no middle initial, leave Item A0500B blank; if theindividual has two or more middle names, use the initial of the first middle name)C. Last NameD. Suffix (e.g., Jr./Sr.)A0600: Social Security and Medicare NumbersDefinitionsSocial Security Number- A tracking number assigned to an individual

Item by Item Guide to the 3.0 MN/LOC –September 2019 Page 6 OVERVIEW TO THE 3.0 MN/LOC ITEM BY ITEM GUIDE Overview This guide is to be used in conjunction with the Medical Necessity and Level of Care Assessment (MN/LOC Assessment). A blank copy of the MN/LOC can be found here. The MN