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DiraChart MDS item reference
J0100ASection Jv1.20.1Manual page J-1
Pain: received scheduled pain med regimen
This item is referenced against CMS MDS source materials. Verify coding against the current CMS RAI Manual, item set instructions, and facility documentation before submission.
Quick coding
Answer Codes
Use the item-specific response choices below when structured codes apply.
Response format: Coded response
1
yes
Manual page J-1Item-specific instructions
Coding Guidance
Review what the item asks, how to choose the response, and what should be verified before submission.
Steps for Assessment
1. Review medical record to determine if a pain regimen
exists.
2. Review the medical record and interview staff and direct
caregivers to determine what, if any, pain management
interventions the resident received any time during the last
5 days. Include information from all disciplines.
Coding Instructions
for J0100A-C
Determine all interventions for pain provided to the resident
any time in the last 5 days. Answer these items even if the
resident currently denies pain.
Coding Instructions for J0100A, Been on a
Scheduled Pain Medication Regimen
•
Code 0, no: if the medical record does not contain
documentation that a scheduled pain medication was
received.
•
Code 1, yes: if the medical record contains documentation that a scheduled pain
medication was received.
Coding Instructions for J0100B, Received PRN Pain Medication
•
Code 0, no: if the medical record does not contain documentation that a PRN
medication was received or offered.
•
Code 1, yes: if the medical record contains documentation that a PRN medication was
either received OR was offered but declined.
DEFINITIONS
SCHEDULED PAIN
MEDICATION REGIMEN
Pain medication order that
defines dose and specific
time interval for pain
medication administration.
For example, “once a day,”
“every 12 hours.”
PRN PAIN
MEDICATIONS
Pain medication order that
specifies dose and indicates
that pain medication may be
given on an as needed basis,
including a time interval,
such as “every 4 hours as
needed for pain” or “every 6
hours as needed for pain.”
NON-MEDICATION PAIN
INTERVENTION
Scheduled and implemented
nonpharmacological
interventions include, but are
not limited to, biofeedback,
application of heat/cold,
massage, physical therapy,
nerve block, stretching and
strengthening exercises,
chiropractic, electrical
stimulation, radiotherapy,
ultrasound and acupuncture.
Herbal or alternative
medicine products are not
included in this category.
J0100: Pain Management (cont.)
Coding Instructions for J0100C, Received Non-medication
Intervention for Pain
•
Code 0, no: if the medical record does not contain documentation that a non-
medication pain intervention was received.
•
Code 1, yes: if the medical record contains documentation that a non-medication pain
intervention was scheduled as part of the care plan and it is documented that the
intervention was actually received and assessed for efficacy.
Coding Tips
•
Code only pain medication regimens without PRN pain medications in J0100A. Code
receipt of PRN pain medications in J0100B.
•
For J0100B code only residents with PRN pain medication regimens here. If the resident
has a scheduled pain medication J0100A should be coded.
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