Accurate measurement of cognitive-based functioning is an essential area within the forthcoming Patient-Driven Payment Model. Specifically, the case-mix methodology for speech pathology includes impacts associated with documented impairments in Section C: Cognitive Patterns of the Minimal Data Set.

Cognitive functioning can be a difficult measure to obtain, engaging your communities’ speech language pathologists in coding practices can assist with accuracy. Furthermore, getting it right requires us to consider impacts of the environment, medical complexities that can mirror and complicate cognitive declines, and the need for assessors to have the skill sets needed to frame questions in a manner that allows for an accurate overall measure.

To begin, let’s review how the RAI Manual defines the overall intent of Section C: Cognitive Patterns:

The items in this section are intended to determine the resident’s attention, orientation and ability to register and recall new information. These items are crucial factors in many care-planning decisions. 

Specifically, regarding Section C the following areas are being used as determiners for speech-language pathology case mix under PDPM:

Brief Interview of Mental Status (BIMS)
C0200 Repetition of Three Words
C0300 Temporal Orientation
C0400 Recall

Staff Interview
C0700 Short Term Memory OK
C0800 Long Term Memory OK
C0900 Memory/Recall Ability
C1000 Cognitive Skills for Daily Decision Making

So how can we effectively obtain measures of these areas?

To begin, assessors must set up the environment appropriately. Some considerations are as follows:
•  Ensure adequate lighting, reduce environment distracts from a visual and auditory stand point, and provide the individual with glasses and hearing aids as appropriate.
•  Language: Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication.
•Alternative options: If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language or cue cards. 

Secondly, assessors need to understand impacts of differential diagnosis as root cause of change to develop effective plans of care.

For example, clinical presentation of cognitive change may be due to a decline in overall attention, orientation and memory. Additionally, declines can occur due to infection, recent anesthesia, and polypharmacy.

Finally, assessors need to have the knowledge of scoring methodology for the BIMS and Staff Interview as follows:

Brief Interview of Mental Status (BIMS)

C0200: Repetition of Three Words
Say to the resident: “I am going to say three words for you to remember. Please repeat the words after I have said all three. The words are: sock, blue and bed.  Now tell me the three words.”

Number of words repeated after first attempt
1. None
2. One 
3. Two
4. Three

After the resident’s first attempt to repeat the words using cues >

C0300:  Temporal orientation
Ask the resident the following questions without providing cues
A.  Please tell me what year it is right now?
    1.  Missed by >5 years or no answer
    2.  Missed by 2-5 years
    3.  Missed by 1 years
    4.  Correct

B. What month are we in right now?
    1.  Missed by > 1 month
    2.  Missed by 6 days to 1 month
    3.  Accurate within 5 days

C.  What day of the week is today?
    1.  Incorrect or no answer
    2.  Correct

C0400: Recall
Ask the resident the following: “Let’s go back to an earlier question. What were those three words that I asked you to repeat?”
    1.  Able to recall “sock”
    2.  Able to recall “blue”
    3.  Able to recall “bed”

All codes on the following scale:
    1.  No, could not recall
    2.  Yes, after cueing
    3.  Yes, no cue required.

Staff Interview
C0700 Short Term Memory OK
C0800 Long Term Memory OK
C0900 Memory/Recall Ability
C1000 Cognitive Skills for Daily Decision Making

Renee Kinder, MS, CCC-SLP, RAC-CT, is Director of Clinical Education for Encore Rehabilitation and is the Silver Award winner in the 2018 American Society of Business Publishing Editors competition for the Upper Midwest Region in the Service/How To Blogs category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).