CMS clarifies confusing scoring for ADLs

In March 2013, in an effort to clarify a coding question, the Centers for Medicare & Medicaid Services (CMS) sent a memo to the RAI (Resident Assessment Instrument) state coordinators that surprised many. The memo gave an example of a resident who experienced more than three episodes of Supervision in the look-back period, as well as three or more episodes of a combination of full staff performance, weight-bearing assistance and/or Limited Assistance, “but not three times at any one of these levels” [italics added]. The memo stated:

"Because the threshold of three or more times of Supervision was met, and there were not three or more instances of a single higher level, the correct code in such a scenario would be '1' (indicating Supervision) [italics added]. Consider the following example: Supervision occurred five times in the look back period, while Limited Assistance occurred twice, and Extensive Assistance and Total Assistance each occurred once. In this scenario, the correct code for G01101 would be '1' indicating Supervision, because there were not three or more instances of a single higher level."

The American Association of Nurse Assessment Coordination (AANAC) has heard from many MDS coders expressing their surprise at this interpretation, as a more common understanding of the example above is that the code would be 2, Limited Assistance. This is because that level or higher occurred three times. MDS coders explained to AANAC that when they work through the ADL scoring algorithm on page G-6 of the RAI User’s Manual, they arrive at a different score than CMS does in the example above.

Consider the following example of how the algorithm is commonly used (p. G-6). Example: Supervision 5 times, Limited Assistance 2 times, Extensive Assistance 1 time, Total Assistance 1 time.

Start here:

  • Did the activity occur at least 1 time? Yes
  • Did activity occur 3 or more times? Yes
  • Did resident fully perform the ADL activity without ANY help or oversight from staff every time? No
  • Did resident require full staff performance every time? No
  • Did resident require full staff performance at least 3 times but not every time? No
  • Did resident require a combination of full staff performance and weight bearing assistance 3 or more times? No
  • Did resident require non-weight bearing assistance 3 or more times? No
  • Did resident require a combination of full staff performance/weight bearing assistance and non-weight bearing assistance 3 or more times? Yes

Answer: Code 2, Limited Assistance

The source of the different interpretation is the instructions in the call-out box to the right of the algorithm. The first bullet in the call-out box states, “When an activity occurs three times at any one given level, code that level.” This instruction is also provided on page G-4 in “Instructions for the Rule of Three.” As explained in the CMS memo, using the Rule of Three statements detailed above and not the algorithm results in in a score of “1” Supervision.   

This confusion was one of the topics discussed at the May 2013 AANAC annual conference. Representatives from CMS attended and provided details of their revisions (released May 20) to the RAI User’s Manual. During the question-and-answer session, a conference attendee asked CMS about this coding interpretation.

Ann Spenard, vice president of consulting services for CMS contractor Qualidigm, answered: "At this point, you can’t just follow the algorithm. In fact, if you read the full 17 pages on coding G0110, you will come to the same conclusion that it would’ve been Supervision. You have to understand the Rule of Three and all of the coding guidelines. You cannot use the algorithm in and of itself without reading all the caveats, all of the boxes."

CMS representative Mary Pratt, director of the Division of Chronic and Postacute Care Responsibilities, further explained to the conference attendees that this interpretation is not a new policy and that CMS hopes to simplify the instructions for MDS coders in future RAI User’s Manual updates.

Pratt indicated that CMS desires to work with stakeholders on this issue. “We’re very much interested in getting feedback,” she said. “We want to clarify our policy.”


Davis C. Current ADL coding policy, RAI manual revisions highlight CMS keynote. AANAC LTC Leader2013;May 9:1–4. Retrieved May 19, 2013, from

Kulus J. CMS intends to tweak ADL scoring rule. AANAC LTC Leader 2013;April 18:1–2. Retrieved May 19, 2013, from

Long-term care facility resident assessment instrument user’s manual (version 3.0). Centers for Medicare & Medicaid Services, Baltimore, October 2012. Available at:

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