Minimum Data Set (MDS) Automation

February, 1998

Information Bulletin 98-1

Minimum Data Set (MDS) Automation

This bulletin addresses the Minimum Data Set (MDS) automation and the Resident Assessment Instrument (RAI).

Regulation Summary

The Federal regulation, designated CFR 42 – 483.20 REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES was published in the Federal Register on December 23, 1997. The regulation establishes a resident assessment instrument for use by long term care facilities participating in the Medicare and Medicaid programs when conducting a periodic assessment of a resident's functional capacity. The resident assessment instrument (RAI) consists of a minimum data set (MDS) of elements, common definitions, and coding categories needed to perform a comprehensive assessment of a long term care facility resident. These regulations establish guidelines for use of the data set and designation of the assessment instrument and requires facilities to have an automated data processing system to encode and transmit data. The provisions contained in these regulations implement statutory requirements. The resident assessment instrument is intended to produce a comprehensive, accurate, standardized, reproducible assessment of each long term care facility resident's functional capacity.

The effective date for this regulation was June 22, 1998. See 42 CFR 483.20 –Resident Assessment at the following web-site:

The following link will provide directions on how to access the MDS regulation and most recent modifications:

This rule requires all federally-certified nursing homes to submit MDS data to their State in an electronically-readable format specified by the federal Centers for Medicare and Medicaid Services (CMS) formerly known as Health Care Financing Administration (HCFA).

Facilities will submit information contained in the MDS for all federally required assessments. This includes:

  • MDS Forms (Sections AA-R, and V, the RAP Summary Form)
  • Quarterly Review Forms
  • Discharge and Reentry Tracking Forms
  • Face Sheet Information

All assessments completed ON or AFTER the effective date of June 22, 1998 must be transmitted. Face Sheet information MUST accompany the first transmission of each resident's assessment.

The provisions contained in this regulation implement federal statutory requirements. Section 4432 of the federal Balanced Budget Act of 1997 (Public Law 105-33) amends Section 1888 of the Social Security Act (the Act), by adding a new subsection (e).

In addition, the federal Balanced Budget Act of 1997 requires HCFA to develop a prospective payment system (PPS) for Medicare payment in skilled nursing facilities (SNFs) that is based on the MDS 2.0 data. Data collection for this effort began on July 1, 1998.

The MDS System

The MDS System is one part of the overall MDS National Automation Project. The purpose of this project is to provide computerized storage, access and analysis of the MDS 2.0 long-term care data on residents in nursing homes across the United States. The MDS System is intended to create a standard, nationwide system for connecting Long Term Care (LTC) facilities to their respective State agencies for the purpose of electronic interchange of data, reports, and other information. The MDS System provides the following functions:

  • Receipt of MDS records from LTC facilities by State agencies
  • Feedback to LTC facilities indicating acknowledgment of the transmission of the data and specifying the status of record validation
  • Storage of MDS records in the database repository within the State agency and the transmission to the national database
  • Report generation on MDS data by State agencies

Facilities must use software capable of encoding MDS records and exporting data files in accordance with HCFA's standard record layout specifications for version 2.0 of the MDS. We strongly encourage facilities to involve their MDS software vendor in the testing process.

If there are any question regarding this bulletin please, call the MDS Help Line at (651) 201-3817 or toll free 1-888-234-1315.

Updated Thursday, March 17, 2011 at 12:46PM