The Centers for Medicare & Medicaid Services (CMS) has released the final Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) User’s Manual version 1.20.11, which takes effect October 1, 2026.
This year's update is less about introducing a completely new MDS structure and more about refining how existing requirements should be interpreted and coded. That distinction should not minimize its importance. Several of the changes affect areas where small differences in assessment practices or documentation can influence MDS accuracy, quality measures, care planning and Medicare reimbursement.
For nursing homes, the priority is making sure MDS coordinators are not the only people who understand the changes. Wound care, nursing, respiratory services, therapy, social services and other members of the interdisciplinary team may all provide information that ultimately supports MDS coding.
One of the broader changes appears throughout Chapters 1, 2 and 3 of the RAI Manual. CMS clarifies that state or payer requirements do not replace, modify or add to CMS coding requirements for non-Section S MDS items.
Facilities may still have state-specific requirements, particularly within Section S, but federal MDS items must be completed according to the CMS definitions, coding instructions, coding tips and response options.
This clarification reinforces the importance of distinguishing between federal MDS coding requirements and separate payer, state or organizational documentation expectations.
Read more and download the CMS memo.
Chapter 2 now includes additional information addressing resident transfers during a public health emergency.
Emergency waivers and temporary changes in care settings can create questions about assessment timing, transfers and required documentation. The updated guidance gives facilities additional direction for navigating those circumstances when emergency authorities are activated.
While this may not affect routine daily MDS activity, facilities should understand the guidance before an emergency occurs rather than trying to interpret requirements while managing a crisis.
Section A: Ethnicity, Race and Resident Information
CMS updated guidance in Section A, Identification Information, particularly around the reassessment of ethnicity and race. The resident interview icon has also been removed from several items.
These revisions may affect how staff collect and verify demographic information during subsequent assessments. Facilities should review the updated instructions carefully rather than relying on processes developed under previous versions of the RAI Manual.
The larger issue is data consistency. Information collected in Section A contributes to the resident record and to broader CMS data collection efforts, making standardized assessment practices important across the organization.
Sections C and D: Cognitive and Mood Interviews
CMS has clarified what facilities should do when multiple resident interviews are completed during the look-back period, including the Brief Interview for Mental Status (BIMS) in Section C and the Resident Mood Interview in Section D.
For the BIMS, the updated RAI Manual states that when multiple BIMS interviews have been conducted during the look-back period, the MDS should be coded using the interview performed closest to the Assessment Reference Date (ARD).
CMS indicates similar clarification has been incorporated into the mood interview guidance.
This is an important operational reminder for facilities where different clinicians may interact with and assess a resident during the same assessment window. Communication among the interdisciplinary team becomes essential to ensure the correct assessment information reaches the MDS coordinator.
Section M: Important Wound and Skin Coding Clarifications
Some of the more clinically significant revisions are found in Section M, Skin Conditions.
CMS has updated guidance related to pressure ulcers and pressure injuries that were present on admission, subsequently healed and later reopened. The new manual also expands guidance involving advanced wound care dressings, skin substitutes and adhesive bandages.
These changes warrant attention beyond the MDS department. Wound nurses, treatment nurses, clinical leadership and MDS staff need a shared understanding of the terminology being used and the documentation supporting the resident's actual condition.
Inconsistent descriptions of wounds across nursing documentation, treatment records and the MDS can create data integrity concerns. Accurate coding begins with an accurate clinical picture.
Section J: Health Conditions
CMS has also refined guidance affecting health conditions, including shortness of breath and falls.
Industry reviews of the CMS change tables note additional clarification around assessing shortness of breath and the review period used when coding falls following a resident's reentry.
These are areas where assessment timing and documentation matter. Facilities should confirm that clinical teams understand what period is being evaluated and that information about resident events is communicated accurately to the person completing the MDS.
Section O: Isolation and Respiratory Therapy
Section O, Special Treatments, Procedures and Programs, also receives updated guidance.
CMS has refined its criteria related to isolation and skilled respiratory therapy.
Respiratory therapy coding deserves particular attention because the documentation must support whether the service meets MDS requirements. Facilities should review how respiratory services are documented, who is providing the service and whether the record contains the information needed to support the code selected.
The goal is not simply to capture a service because it occurred. The MDS must reflect the service according to the specific CMS definition.
Chapter 6: PDPM and Depression Terminology
CMS revised terminology related to depression signs and symptoms within the Medicare Skilled Nursing Facility Prospective Payment System (SNF PPS).
The update primarily clarifies terminology rather than changing the underlying PDPM classification logic. Even when changes are primarily editorial or clarifying, MDS teams should review them because Chapter 6 remains central to understanding how assessment information feeds into PDPM classifications.
FY 2027 ICD-10 and PDPM Grouper Changes Also Begin October 1
The RAI Manual is not the only MDS-related update facilities need to have on their radar.
CMS has also released PDPM Grouper Version 2.5000 for MDS assessments with a target date on or after October 1, 2026. The update supports the FY 2027 ICD-10 codes and includes 190 clinical category mappings added, 30 removed and 34 modified. CMS also added 18 NTA comorbidities and removed eight.
The ICD-10 database used for I0020B has likewise been updated for codes active beginning October 1.
These technical updates reinforce why facilities should not view MDS accuracy solely as an assessment-completion issue. Diagnosis coding, clinical documentation and PDPM classification are interconnected. A coding change upstream can affect what is ultimately represented in the assessment and reimbursement calculation.
CMS has also released Version 8.0 of the SNF Quality Reporting Program Measure Calculations and Reporting User's Manual for quality measure specifications effective October 1, 2026.
The October changes may look modest when reviewed individually, but they touch several areas with significant clinical, regulatory and financial implications.
Facilities should pay particular attention to whether clinical documentation supports the MDS, whether different members of the interdisciplinary team are applying the same definitions, and whether staff are relying on outdated coding practices that have been clarified by CMS.
MDS accuracy influences much more than reimbursement. The assessment contributes to resident care planning, quality measures, public reporting and the data CMS uses to evaluate nursing home performance. As CMS continues to place greater emphasis on healthcare data, an accurate MDS becomes an important part of both compliance and quality management.
Interpreting a new RAI Manual is one step. Making sure the changes are understood and consistently applied across the facility is another.
Qsource has worked with long-term care providers on MDS requirements and processes for more than two decades. Our MDS consultants are registered nurses, RAC-CT certified and experienced with the Resident Assessment Instrument. Qsource supports facilities with MDS improvement, clinical documentation, PDPM classification review, coding accuracy, quality measure improvement and staff education.
Whether your facility needs help understanding a new requirement, evaluating MDS accuracy or strengthening the connection between clinical documentation and coding, Qsource can provide an experienced outside perspective.
Learn more about Qsource's work with MDS.