Certified Inpatient Coding (CIC) Practice Exam

What is the standardized primary screening and assessment tool for residents in Medicare or Medicaid-certified long-term care facilities?

1. UHDDS

2. MDS

3. PEPPER

4. HIPAA

The correct answer is: MDS

The standardized primary screening and assessment tool for residents in Medicare or Medicaid-certified long-term care facilities is the Minimum Data Set (MDS). The MDS is a comprehensive assessment completed for each resident in long-term care, which includes a range of clinical and functional information. It is essential in assessing the health status of residents, informing care planning, and determining reimbursement levels for facilities under Medicare and Medicaid programs. The MDS allows for the collection of standardized information that helps enhance the quality of care in nursing homes. It enables facilities to identify the needs of residents accurately and to develop appropriate care plans tailored to those needs. Additionally, the data gathered through the MDS are used for quality improvement initiatives, regulatory compliance, and research. In contrast, other options serve different purposes: The Uniform Hospital Discharge Data Set (UHDDS) is mainly used for hospital patient discharge records; PEPPER (Program for Evaluating Payment Patterns Electronic Reports) is a tool used to review data for patterns in billing; and HIPAA (Health Insurance Portability and Accountability Act) pertains to privacy and security regulations for health information, rather than being a screening or assessment tool for long-term care facilities.