The Five Most Important Updates to This Year's MDS Process and RAI Manual

CMS updates the RAI Manual every year, with coding changes, clarifications, and corrections. Version 1.20.11 took effect October 1, 2026, replacing the October 2025 version, 1.20.1. Some of what changed is a genuine shift in how a situation should be coded. Some of it clarifies language that was already there but easy to read more than one way. Below are the five updates most likely to affect day-to-day coding decisions, compared side by side with what the manual said before, what changed, and what each means for the team completing the assessment.

1. Healed pressure injuries that reopen

Before: M0300 allowed an injury that was documented on admission, later closed, and then reopened at the same stage to still be coded as present on admission.

What changed: M0300 now says an injury that was documented on admission, subsequently healed, and later reopened should not be coded as present on admission.

What it means for MDS nurses: Review the dated wound history and confirm whether healing was documented before the injury reopened. Do not automatically carry forward the original present-on-admission designation. This is a substantive coding change, not a clarification. For example, an injury present on admission that fully heals and later reopens at the same stage no longer qualifies under the old same-stage instruction. This does not apply to a wound that never healed in the first place.

Source: CMS RAI Manual v1.20.11, Section M, M0300, p. M-9, step 10.

2. Selecting among multiple resident interviews

Before: The BIMS and resident mood interview instructions did not include explicit guidance on which interview to use when more than one was conducted within the look-back period.

What changed: When multiple BIMS or resident mood interviews fall within the look-back period, staff should use the interview conducted closest to the assessment reference date, or ARD.

What it means for MDS nurses: Check the dates of every qualifying interview within the look-back period and select the one closest to the ARD, documenting that choice clearly in the assessment workflow. This is not a basis for choosing the highest, lowest, or most favorable score, and it does not require facilities to conduct additional interviews.

Source: CMS RAI Manual v1.20.11, Section C, C0200 to C0500, p. C-6; Section D, D0150, p. D-7.

3. Skilled respiratory therapy and counted time

Before: Only skilled therapy time qualified for counted minutes, and respiratory guidance already excluded self-administered nebulizer treatments performed without therapist or respiratory-nurse supervision. The 15-minute daily threshold already existed.

What changed: The manual now explicitly addresses nebulizer treatments and maintenance or preventive incentive spirometry that residents self-administer or receive without clinically indicated or medically necessary supervision by a respiratory therapist or respiratory nurse, with new examples reinforcing the skilled-service requirement. It also directs staff to complete O0400 only when O0390D is checked and to apply the O0390 therapy coding guidance.

What it means for MDS nurses: Review what was actually provided, why skilled supervision was clinically necessary, and how the qualifying time was determined. Staff presence and elapsed minutes alone do not establish skilled therapy. Under the new examples, routine incentive spirometry for a stable resident does not qualify. That does not mean all maintenance therapy is excluded: skilled maintenance therapy can still qualify when the required professional skills are necessary, and the 15-minute threshold itself is not new.

Source: CMS RAI Manual v1.20.11, Section O, O0390, pp. O-23 and O-32 to O-33; O0400, p. O-34.

4. Advanced wound dressings and skin substitutes

Before: The manual distinguished pressure-ulcer care from surgical wound care, including surgical closure involving a flap or graft.

What changed: The manual now states that applying an advanced dressing or skin substitute to a pressure ulcer is not itself a surgical procedure, graft, or flap. That care is classified under M1200E rather than M1200F, and explicit exclusions for adhesive bandages and wound closure strips are added under M1200E, M1200F, and M1200I. The exclusion under M1200G already existed.

What it means for MDS nurses: Check the actual procedure and treatment record before selecting pressure-ulcer care or surgical-wound-care items. Using an advanced wound product does not automatically make a wound surgical. Keep the bandage exclusion tied to the named categories rather than applying it to every MDS wound item.

Source: CMS RAI Manual v1.20.11, Section M, M0210, p. M-6; M1040, p. M-35; M1200, pp. M-40 to M-41.

5. Federal coding instructions and payer requirements

Before: The manual used broader language about additional state requirements and following state requirements alongside federal ones.

What changed: The update states explicitly that state or payer requirements do not change CMS definitions, instructions, tips, or response options for items outside Section S. Section S remains reserved for state-specific items, and states may still require additional assessments.

What it means for MDS nurses: Apply the CMS item instructions when selecting an MDS response, and keep payer or coverage documentation tasks separate from that coding decision. Review internal checklists that may blur the two. This does not mean insurers can no longer request documentation, and it does not mean state assessment requirements have disappeared.

Source: CMS RAI Manual v1.20.11, Chapter 1, p. 1-10; Chapter 2, p. 2-49; Chapter 3, p. 3-1.

Why these five

These five updates were selected for their effect on coding decisions, evidence review, and everyday MDS work, not because CMS ranked them this way. Some, like the pressure injury reopening rule, are substantive changes that alter a coding outcome in a defined situation. Others, like the respiratory therapy, wound dressing, and federal coding updates, are clarifications that spell out how existing items should already be applied. The interview selection update adds an explicit instruction, which CMS describes as a clarification, and determines which assessment result the team uses going forward.

Several other manual updates, including changes to race and ethnicity reassessment, isolation wording, shortness of breath assessment, and depression terminology, are not covered in this breakdown. They may still be relevant to specific items your facility completes regularly, so it is worth reviewing the relevant sections of the full RAI Manual rather than assuming this article captures every revision. The manual is linked throughout this article.

Practical recommendations

These are practical next steps, not official CMS instructions:

• Review the RAI Manual instructions for each item discussed above, using the page references linked in this article.
• Update internal education materials, cheat sheets, and templates that still reference the prior version's language.
• Continue to use the official RAI Manual for individual coding decisions. This article is a summary, not a substitute for the manual itself, and coding questions specific to a resident's record should go through your facility's normal clinical review process.