MDS Changes: What You Need to Know!

October 1, 2025 MDS Changes: What You Need to Know!

On August 29, 2025, the Centers for Medicare & Medicaid Services (CMS) released the final version of the MDS 3.0 RAI User’s Manual (v1.20.1), effective October 1, 2025. This version replaces all prior draft editions and finalizes several key changes that nursing facilities must implement. Notably, CMS has removed proposed Section R: Health-Related Social Needs, which had appeared in earlier drafts.

Key Changes at a Glance:

• Section GG (Functional Abilities): Clarified that if two or more helpers are required for an activity, code as “01 – Dependent.” Additional guidance provided for use of assistive devices (e.g., walkers), stair mobility coding (GG0170R/S), walking on uneven surfaces and other ambulation items.
• Section J (Health Conditions): The definition of a fall now includes incidents involving external force."Injury (except major)" now includes skin tears, bruises, sprains, and pain, while "Major Injury" is expanded to include fractures, dislocations, and organ injuries. Pathological fractures are not coded as fall injuries.
• Section M (Skin Conditions): New guidance on coding "Present on Admission" (POA) when ulcers change stage or become unstageable.
• Section N (Medications):Clarified approach to high-risk medication  coding with emphasis on using consistent resources (e.g., package inserts, pharmacists). Additionally, provided confirmation that IV flushes are not coded under anticoagulants.
• Section O (Special Treatments/Programs): O0390 (Therapy Services) is added, replacing most of O0400, and is coded via checkboxes if therapy ≥15 minutes/day on at least one day in the last 7 days. O0400 is now limited to respiratory therapy days, and O0420 (Distinct Calendar Days of Therapy) is removed.

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Why it Matters:

CMS and surveyors are placing increased emphasis on the accuracy of MDS assessments, directly affecting reimbursement, quality measure performance, and survey outcomes.  These changes underscore CMS’s ongoing focus on precision, consistency, and outcome-driven care. To remain compliant, facilities must act now to train staff, update documentation protocols, and ensure assessments reflect the most current guidance.

Resources:

• Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual | CMS  

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