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

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

CMS has released the RAI User’s Manual v1.20.1, effective October 1, 2025, with updates across multiple MDS sections. While Sections GG and J bring the most significant changes, every adjustment matters for compliance, reimbursement, and care planning. Here’s what you need to know:

Section A: Administrative Updates

• • “Gender” replaced with “Sex.” (A0810 replaces A0800): Change in terminology only with no item coding changes
  • Transportation item updated: (A1250 retired and replaced with A1255).: Timeline for the look back is now included in the question and updated to be the last 12 months instead of 6 -12 months. Coding simplified to combine transportation for all services, including to and from medical and non- medical services into one response item, which eliminates the confusion in coding

This item is now required to be completed only on the Medicare 5-day MDS for Medicare residents whose admission date is less than 366 days. This means for Long Term resident of the facility who are hospitalized and return to the SNF under their Medicare benefit this question is no longer a required item if they have been resident for 366 days or more. It is also no longer a required item on the End on Medicare Stay MDS (NPE).

Why it matters: CMS is modernizing terminology and making transportation coding more precise to decrease the burden of coding for the IDT Transportation is a SPADES item required to be completed for SNF QRP and these changes align better with transportation issues encountered while living in the community prior to admission and also with a potential impact on discharge planning

Section D: Mood

• • New coding tip for PHQ-2 to 9: a dash may only be used if the resident cannot provide a frequency response.
  • If three or more frequency items are blank or dashed, the interview is not complete.

Why it matters: Dash use is now tightly restricted to avoid incomplete or inaccurate depression screening. Restricting dashes here will also help with SNF QRP reporting compliance.

Section GG: Functional Abilities and Goals

• • Helpers: If two or more helpers are needed, code 01 Dependent.
  • Device Use: Clinical judgment may determine qualifying devices, but therapy-only devices (exoskeletons, parallel bars) cannot be used.
  • Assessment Window: Up to 3 calendar days; dash use should be rare.
  • Specific Tips:
    • Stair mobility may include scooting.
    • Recliners used as beds count for transfers.
    • Footwear includes grip socks or any item covering the foot.
    • Walking can be coded as Dependent if two helpers are required, or Setup assistance if staff only place/remove walker.
    • Bed mobility “lying” may be defined as slightly elevated if that is the resident’s norm.

Why it matters: Section GG coding drives PDPM reimbursement, case mix, and Quality Measures. These clarifications tighten expectations around helpers, devices, and coding consistency.

Section J: Health Conditions – Falls and Injuries

• • Fall Definition Updated: Any unintentional change to a lower surface, including from external force.
  • Intercepted Falls: Still a fall unless during supervised therapy balance testing.
  • Falls During Therapy: If resident lands and is injured, it must be coded as a fall.
  • Injury Updates:
    • Injury (except major): Now includes skin tears, bruises, sprains, pain complaints.
    • Major Injury: Expanded to include fractures, dislocations, organ injuries, crush injuries, etc.
  • Pathological vs. Traumatic Fractures: Pathological fractures (e.g., osteoporosis-related) are not coded as fall injuries.

Why it matters: Fall reporting has direct survey, quality measure, and litigation implications. These clarifications leave less room for interpretation and allow for increased coding consistency.

Section K: Nutrition and Weight

• • Clarified weight loss/gain calculation: only the weights closest to the two time points are used.
  • Visual examples added.
  • New tip: if multiple weights exist, select the one closest to the evaluation point.

Why it matters: Helps standardize weight loss reporting for QMs and care planning.

Section M: Skin Conditions

• • New rules for coding Present on Admission (POA) when ulcers change from stageable to unstageable or vice versa.
  • Example: If an ulcer becomes unstageable for a new reason during the stay, it should still be considered POA.

Why it matters: Prevents miscoding of pressure ulcers that evolve in presentation.

Section N: Medications

• • New tips for coding high-risk medications:
    • Staff should use a consistent resource and be able to identify it.
    • Manufacturer’s package insert may be used.
    • Work with the resident’s pharmacist for confirmation.
  • Flushes to keep IV access patent should not be coded under anticoagulants.

Why it matters: Ensures consistency in classifying medications, with responsibility shifting more directly to the facility and pharmacist.

Section O: Special Treatments

• • O0390 Therapy Services added, replacing most of O0400.
  • Now coded as checkboxes if therapy ≥15 minutes/day on at least one day in last 7 days.
  • O0400 limited to days of respiratory therapy only.
  • O0420 (distinct calendar days of therapy) removed.
  • O0425 Total therapy by discipline and mode of treatment during the Part A stay: This item is unchanged

Why it matters: Therapy reporting is simplified, focusing on whether therapy occurred rather than on detailed minutes. This aligns with CMS’ focus on reducing staff burden for data collection that is no longer relevant since the days and minutes of therapy provided no longer impact reimbursement. The coding of the number of days respiratory was provided at least 15 minutes is still relevant and coded since it impacts the Nursing CMG under PDPM.

Section R: Removed

• • Section R, which was introduced in the draft MDS item-set has been excluded from the Final version of the MDS. Section R focused on health-related social needs (SDOH) including: Living Situation, Food insecurity, Utilities, and Transportation

Why it matters: Streamlines the MDS

Section X & Chapter 5: Data Corrections

• • Added clarification on record deletion.
  • New Data Correction decision tree included.

Why it matters: Facilities now have clearer guidance for correcting errors.

Appendix A: Quality Measures

• • New definition of QMs: Broadened to emphasize outcomes, patient perceptions, and care goals (effective, safe, efficient, patient-centered, equitable, timely).

Why it matters: Reflects a shift from just data collection toward outcome-based quality improvement.

Final Takeaway

The October 1, 2025 MDS changes reflect CMS’s emphasis on precision, consistency, and outcomes.

• • Section GG drives reimbursement and case mix.
  • Section J ensures consistent, defensible fall and injury coding.
  • Other updates refine terminology, calculations, medication classifications, therapy reporting, and QM definitions.

Facilities should begin training and updating documentation processes now to ensure compliance, optimize reimbursement, and prepare staff for survey expectations.

Next Steps:

• • Proactive LTC Consulting is ready to help your facility prepare for compliance with these changes with education, audits, and coding support. Contact us today to learn more about our MDS team QA and mentorship partner plans
  • Access Proactive’s Section GG Toolkit

Written By: