By: Marilyn Ramirez, MSN, RN. RAC-CTA
The Centers for Medicare & Medicaid Services (CMS) has released MDS 3.0 RAI User’s Manual Version 1.20.11, effective October 1, 2026.
While this update does not include sweeping changes to the MDS, it contains several important clarifications and corrections. For MDS coordinators, reimbursement specialists, and clinical leaders, some of these seemingly small changes could have a meaningful impact on MDS accuracy, PDPM reimbursement, state Medicaid programs, and audit outcomes.
Here are some of the key changes providers should understand.
Federal RAI Guidance Comes First
One of the most significant clarifications addresses the relationship between state-specific requirements and federal MDS coding guidance.
CMS reinforced that federal MDS items must be coded according to CMS-established item definitions, coding instructions, coding tips, and response options. States may establish additional requirements, including requiring federal comprehensive assessment items on Quarterly or PPS assessments, but they cannot redefine how a federal MDS item is coded.
This distinction is important. The MDS is a clinical assessment, and clinicians attest to the accuracy of the information reported.
If a state has additional Medicaid reimbursement requirements, those requirements cannot result in a federal MDS item being coded contrary to RAI Manual guidance.
The takeaway: Code the MDS according to the RAI Manual. State-specific reimbursement methodology must work from an accurately coded assessment rather than redefine federal MDS coding requirements.
Respiratory Therapy: 15 Minutes Alone Is Not Enough
CMS also refined guidance related to skilled respiratory therapy.
The 15-minute threshold is not new. What CMS has clarified is the type of service that qualifies as respiratory therapy.
A respiratory-related treatment does not automatically qualify simply because staff spend 15 minutes providing the treatment. The service must require the skills and knowledge of qualified personnel.
Facilities should look beyond the minutes and evaluate:
- What respiratory service was actually provided?
- Did it require skilled knowledge and intervention?
- Was it reasonable and necessary for the resident?
- Is the service supported by the resident’s treatment plan?
- Does the clinical documentation support both the service and the reported time?
This is particularly important because respiratory therapy may affect the resident’s PDPM Nursing classification when all applicable criteria are met.
The key message: 15 minutes is a threshold—it is not the definition of skilled respiratory therapy.
Special Care High: Pulmonary Conditions Clarified
CMS also made an important clarification within the Special Care High PDPM Nursing category.
Previous Chapter 6 language created questions because it referenced COPD when addressing certain pulmonary conditions combined with shortness of breath while lying flat.
CMS has now expanded the language to include asthma, chronic obstructive pulmonary disease, or chronic lung disease and shortness of breath when lying flat.
This clarification is particularly important when reviewing PDPM classification and supporting documentation.
CMS also clarified guidance for J1100. When a resident reports avoiding an activity—such as lying flat—because it causes shortness of breath, the resident does not have to actually perform the activity simply to demonstrate the symptom.
Facilities should ensure both the applicable pulmonary diagnosis and shortness of breath are clearly supported within the clinical record.
BIMS and PHQ: Which Interview Should You Code?
CMS addressed another common operational question involving multiple resident interviews.
If more than one BIMS or PHQ-2 to 9 interview is completed during the applicable look-back period, the interview completed closest to the Assessment Reference Date (ARD) should be coded.
This reinforces the importance of communication among interdisciplinary team members and appropriate ARD management.
Facilities should review their processes to ensure staff do not automatically use the first interview completed when multiple interviews exist.
Race and Ethnicity: Less Repetitive Interviewing
CMS also added flexibility regarding race and ethnicity information.
Facilities do not have to repeatedly ask residents these questions on every applicable assessment. When the resident has been asked within the previous year, the prior response may be used according to the updated guidance.
This should help reduce unnecessary repetitive interviewing while maintaining accurate demographic information.
Depression and Toileting Program Clarifications
Chapter 6 also includes revised terminology surrounding the depression end split within the PDPM Nursing component, clarifying the terminology related to signs and symptoms of depression.
CMS additionally clarified requirements surrounding toileting programs.
Programs reported under H0200C and H0500 do not require documentation of days and minutes in the same manner as restorative nursing programs used for certain PDPM classifications.
This is an important reminder not to add requirements that CMS does not require. Facilities should evaluate each MDS and PDPM criterion against the actual RAI Manual instructions rather than relying solely on longstanding facility practices.
Other Changes Worth Reviewing
Additional updates include:
- Chapter 2: Added information regarding resident transfers during a public health emergency.
- Section M: Updated guidance for pressure ulcers/injuries that were present on admission, subsequently closed, and later reopened.
- Section O: Clarified guidance and coding examples related to respiratory therapy.
- Chapter 6: Updated terminology and guidance related to PDPM Nursing classification.
What Should Facilities Do?
Although CMS characterizes many of these updates as clarifications and corrections, providers should not dismiss them as insignificant.
When CMS clarifies an area of the RAI Manual, it often highlights an area where interpretation or implementation has been inconsistent.
Facilities should use the October 1 update as an opportunity to review current practices, provide targeted education, and conduct internal audits—particularly around respiratory therapy, Special Care High, state-specific MDS requirements, BIMS/PHQ interviews, toileting programs, and supporting documentation.
Most importantly, the update reinforces a fundamental principle of MDS accuracy:
The RAI Manual drives MDS coding.
State reimbursement systems, payer requirements, software prompts, historical facility practices, and previous audit interpretations do not replace CMS coding guidance.
Likewise, documentation of a service does not automatically mean the service meets an MDS definition. Respiratory therapy is an excellent example: documenting 15 minutes is not enough if the underlying service does not meet the requirements for skilled respiratory therapy.
These may be described as minor changes, but their impact can extend well beyond the MDS itself—affecting PDPM reimbursement, Medicaid reimbursement, audit outcomes, and compliance.
As October 1 approaches, the message for providers is straightforward: review the changes, educate your teams, audit your current practices, and make sure what is coded on the MDS is supported by both the resident’s clinical record and the current RAI Manual.