CMS MDS 3.0 RAI Manual v1.20.11: Key October 2026 Changes for Skilled Nursing Providers
CMS has released the final MDS 3.0 RAI User’s Manual v1.20.11, effective October 1, 2026.
This year’s update is not a major overhaul of the MDS. Most of the changes are refinements, corrections, and clarifications. But several of them are important enough that MDS, clinical reimbursement, quality, and interdisciplinary teams should take a closer look before the new fiscal year begins.
The updates touch resident interviews, assessment processes, skin conditions, isolation, respiratory therapy, and Medicare SNF reimbursement guidance.
One clarification in particular deserves attention: CMS added clearer language around the difference between federal MDS coding requirements and separate state or payer requirements.
Celtic Consulting Founder and CEO Maureen McCarthy walks through several of the changes and why they matter for nursing home providers in the accompanying video.
Quick answers from the October 2026 RAI Manual update
Here are a few of the changes at a glance:
- Multiple BIMS completed? Use the BIMS conducted closest to the Assessment Reference Date, or ARD.
- Multiple Resident Mood Interviews completed? Use the interview conducted closest to the ARD.
- A pressure ulcer or injury healed and later reopened? It should not be coded as present on admission.
- An advanced wound care dressing or skin substitute was applied to a pressure ulcer? That does not make it a surgical wound.
- Skilled respiratory therapy minutes? At least 15 minutes of skilled treatment must occur on a single day for that day to count.
- State or payer requirements? They do not replace, modify, or add to CMS coding requirements for federal MDS items outside Section S.
What changed in the October 2026 MDS 3.0 RAI Manual?
The updated Manual includes changes across multiple chapters and sections, including Chapters 1, 2, 3, and 6 and Sections A, C, D, M, and O.
Some of the key areas providers should have on their radar include:
- State and payer requirements versus federal MDS coding requirements
- Resident transfers during a public health emergency
- Ethnicity and race reassessment guidance in Section A
- Multiple BIMS and Resident Mood Interviews during the look-back period
- Pressure ulcer and pressure injury guidance in Section M
- Isolation and skilled respiratory therapy coding in Section O
- Updates affecting Medicare SNF PPS guidance
CMS also released chapter and section change tables that identify the specific revisions.
Can state or payer requirements change CMS coding requirements for federal MDS items?
No. CMS clarified that state or payer requirements do not replace, modify, or add to CMS coding requirements for federal MDS items outside of Section S.
Here is where the distinction matters.
States may require additional state-specific items in Section S. They may also add federal comprehensive assessment items to Quarterly or PPS item sets. But if those are federal MDS items, the CMS definitions, coding instructions, coding tips, and response options still apply.
CMS reinforces the same point in Chapter 3: non-Section S MDS items are coded according to the definitions and instructions in the RAI Manual, and separate state or payer requirements do not change those federal coding instructions.
Celtic’s perspective
We are very pleased to see CMS establish clearer guardrails in this area.
Celtic has spent a great deal of time working with providers and advocating alongside state and national associations for greater clarity, particularly as providers navigate increasingly intensive state Medicaid audit expectations.
States and payers can still have separate requirements within their own programs. What this update makes clearer is that those requirements do not change the CMS-defined coding criteria for federal MDS items.
For facilities, that means coding decisions should continue to be supported by the clinical record and follow the applicable RAI Manual instructions, while teams also understand whether an additional audit expectation is coming from a separate state or payer requirement.
What changed for resident transfers during a public health emergency?
Chapter 2 now includes additional guidance for resident transfers during a public health emergency.
When the President declares a disaster or emergency and the Secretary of Health and Human Services declares a public health emergency and invokes Section 1135 waiver authority, CMS will identify which requirements are being waived or modified, who those changes apply to, and under what circumstances.
The Manual also points providers to applicable CMS, State Agency, and Medicare Administrative Contractor guidance during a declared emergency.
In plain terms, the guidance gives facilities more direction on where to look when an emergency affects normal assessment requirements or processes.
What changed in Section A for ethnicity and race?
CMS added more specific guidance about when prior ethnicity and race responses may be carried forward and when the resident should be asked again.
For A1005, Ethnicity, if it has been less than one year since the resident was asked about their ethnicity, the prior response may be used on a subsequent assessment.
If it has been one year or more, the facility should go back to the New Admission process and ask the resident about their ethnicity again.
The same one-year approach applies to A1010, Race. If the resident was asked less than a year ago, the prior response may be used. If a year or more has passed, the resident should be asked again.
That gives teams a much more defined timeframe for when reassessment is needed.
Which BIMS should be coded if multiple BIMS interviews are completed?
Use the BIMS conducted closest to the Assessment Reference Date, or ARD.
If multiple Brief Interviews for Mental Status are completed during the look-back period, CMS now directs facilities to code the MDS using the BIMS performed closest to the ARD.
That removes some of the uncertainty when more than one BIMS exists in the same look-back period.
Which Resident Mood Interview should be coded if more than one is completed?
Use the Resident Mood Interview conducted closest to the ARD.
CMS applies the same approach to multiple Resident Mood Interviews, or PHQ-2 to 9 interviews. If more than one is completed during the look-back period, use the interview completed closest to the ARD for MDS coding.
Again, the clarification gives teams a more specific rule to follow when multiple interviews are present.
Is a pressure ulcer or injury still “present on admission” if it healed and later reopened?
No.
Under the updated Section M guidance, if a pressure ulcer or injury was documented as present on admission, later healed, and then reopened, it should not be coded as present on admission. This is a reversal from prior guidance.
Celtic Insight
The key word here is healed. If a pressure ulcer was present on admission but subsequently healed, a later reopening is no longer coded as present on admission. That is a change from the prior guidance, and it would be easy for a team to carry forward the original admission status out of habit.
I would encourage facilities to review how wound healing and reopening are documented and communicated to the MDS nurse. The record should make the timeline clear: when the original wound healed, when the area reopened, and what was found at that time. This is also a good opportunity to update any wound tracking tools or coding references that still reflect the old instruction.
Does an advanced wound care dressing or skin substitute make a pressure ulcer a surgical wound?
No.
CMS clarifies that applying an advanced wound care dressing or skin substitute to a pressure ulcer is not considered a surgical procedure, graft, or flap.
If one of those products is applied to a pressure ulcer, the associated wound care is coded under M1200E, Pressure ulcer/injury care, rather than surgical wound care.
CMS also clarifies that adhesive bandages and wound-closure strips do not count as dressings for several Section M items, including pressure ulcer/injury care, surgical wound care, and application of dressings to the feet.
When can isolation be coded in Section O?
The updated Section O guidance focuses on residents who have an active infection with a highly transmissible or epidemiologically significant pathogen and require transmission-based precautions and single-room isolation.
The criteria described in the updated Manual include that:
- The resident has an active infection with a highly transmissible or epidemiologically significant pathogen.
- Precautions are above and beyond standard precautions.
- The resident is alone in a room and is not cohorted.
- The resident remains in the room with services brought directly to them.
The revised guidance also removes prior wording that specifically referenced pathogens acquired through a contact, droplet, or airborne route.
Celtic Insight
One area I would watch closely is room placement. A resident who is cohorted with another resident does not meet the single-room criterion, even if both residents are on transmission-based precautions. I would also make sure the infection preventionist, nursing team, and MDS nurse are communicating when precautions or room arrangements change. A diagnosis or an isolation order alone does not tell the whole story for MDS coding.
What respiratory therapy time counts on the MDS?
Only the time a respiratory therapist or respiratory nurse spends with the resident counts toward the 15-minute daily threshold.
That time can include evaluation or assessment, treatment administration and monitoring, and setup and removal of treatment equipment.
CMS also spells out what does not count.
Time is not included when a resident self-administers treatment or receives a nebulizer treatment or maintenance-level/prophylactic incentive spirometry without clinically indicated or medically necessary supervision by a respiratory therapist or respiratory nurse.
Administration of metered-dose or dry-powder inhalers is also excluded from respiratory therapy minutes.
The Manual further clarifies that only skilled therapy time should be recorded on the MDS. If part of a treatment is skilled and part is not, only the portion requiring the skills, knowledge, and judgment of a qualified therapist may be counted.
Can respiratory therapy minutes be combined across multiple days?
No. The resident must receive at least 15 minutes of skilled respiratory therapy on a single day for that day to count.
CMS provides an example that makes this especially clear.
A resident receives 10 minutes of skilled respiratory therapy on one day, seven minutes on another, and 13 minutes on a third. Although that adds up to more than 15 minutes overall, O0390D would not be checked because the resident never received at least 15 minutes of skilled respiratory therapy on any one day.
For O0400, CMS similarly defines a day of respiratory therapy as 15 minutes or more of skilled treatment during that day.
Celtic Insight
This is where documentation matters. I would want to see why the resident needed the skills and judgment of a qualified respiratory therapist or respiratory nurse, what was assessed or treated, the resident’s response, and the skilled time provided each day. If a treatment includes both skilled and routine portions, the record should distinguish them. That gives the MDS nurse a sound basis for coding and helps the team avoid counting routine treatments simply because they appear on a respiratory treatment record.
What should skilled nursing providers review before October 1, 2026?
Before the October 1 effective date, providers should review both the updated Manual and the applicable chapter and section change tables.
A few areas are especially worth checking:
- Current MDS coding and interview workflows
- Section A reassessment processes for ethnicity and race
- BIMS and Resident Mood Interview coding when multiple interviews occur
- Section M guidance related to reopened pressure ulcers and advanced wound care products
- Section O isolation criteria
- Skilled respiratory therapy documentation and coding
- The distinction between federal MDS coding requirements and separate state or payer expectations
- FY2027 education, auditing, and reimbursement resources affected by the updated guidance
The changes may be largely refinements and clarifications, but in several places CMS is giving providers much more specific direction about how an item should be coded.
That is exactly why these updates are worth more than a quick scan of the change table.
Where can providers find the final MDS 3.0 RAI User’s Manual v1.20.11?
CMS publishes the current MDS 3.0 RAI User’s Manual, change tables, and supporting materials on its Minimum Data Set Resident Assessment Instrument Manual webpage.
Version 1.20.11 becomes effective October 1, 2026.
Providers should review both the updated Manual and the applicable chapter and section change tables.
Celtic Consulting works with skilled nursing providers on MDS coding, clinical reimbursement, documentation, audit readiness, and related compliance and reimbursement issues. If your team is sorting through what the October 2026 RAI Manual updates mean for your current practices, we can help make the guidance easier to understand and translate it into practical next steps.
