New or worsened bowel or bladder incontinence (N046.02)

The long-stay bowel and bladder measure no longer asks whether a low-risk resident is incontinent. It asks whether continence got worse between two assessments. If your tracker still has a “low-risk loss of bowel or bladder control” column, that measure has been gone since October 2023.

The low-risk measure is retired

CMS replaced the old measure when MDS version 1.18.11 removed section G and moved function to section GG. The QM User’s Manual v16.0, effective October 1, 2023, said so directly:

The current version is N046.02, in the QM User’s Manual v18.0. N025 isn’t in v17.0 or v18.0 at all.

Where N046.02 is used

• Care Compare: yes. Five-Star: no. It is a long-stay MDS measure outside the rating.
• Texas QIPP scores it as Component 3, Metric 3 for state fiscal year 2027. See Texas QIPP, explained.
• Florida’s QIP scores it as one of its MDS measures. See Florida QIP, explained.
• New York’s NHQI scores it in its 2025 methodology.

What puts a resident in the numerator

CMS compares H0400 (bowel) and H0300 (bladder) on the target assessment with the same items on the prior assessment. Any one of these moves puts the resident in:

Bowel and bladder are not treated alike. On the bowel side, any first accident counts: 0 to 1 is a new case. On the bladder side, “occasionally incontinent” is grouped with continent, so 0 to 1 is not a case. The bladder has to reach frequently (2) or always (3).

Who is left out

• Residents whose target assessment is an OBRA Admission or a PPS 5-Day.
• Residents with no prior assessment to compare against.
• Residents who are comatose, have an indwelling catheter (H0100A) or have an ostomy (H0100C) on the prior or the target assessment, or who have any of those items missing.
• Residents not in the numerator with H0300 or H0400 missing on either assessment.

Which two assessments are compared

The target is the resident’s latest qualifying assessment (OBRA, PPS 5-Day or OBRA discharge), dated no more than 120 days before the episode ends or the quarter closes. The prior is the latest qualifying assessment 46 to 165 days before the target. Anything closer than 46 days is skipped over.

That makes this a comparison measure, not a history measure. There is no look-back scan. A resident counts in the quarter their target shows the decline against the prior. On the next pair, if continence holds at the new level, there is no new or worsened case and the resident is out.

Risk adjustment

N046.02 is one of the few measures CMS risk-adjusts. The manual lists it among six:

In plain words, the adjusted rate expects more new incontinence in residents with severe cognitive impairment on the target assessment, and in residents who were dependent (or for whom the activity wasn’t attempted) on the prior assessment for sit to lying, sit to stand, or walking 10 feet (wheeling 50 feet, for wheelchair users). Accurate section GG coding on the prior assessment feeds straight into what CMS expects of your building.

Common coding mistakes

• Excusing the laxative accident. One incontinent stool in 7 days is code 1 on H0400, and it doesn’t matter why.
• Miscounting bladder episodes. Frequently incontinent (2) is seven or more episodes in the 7-day look-back with at least one continent void. Six episodes is occasionally (1). That one-episode difference decides whether a resident who was occasionally incontinent becomes a new bladder case.
• Coding from the flow sheet alone. The RAI Manual’s steps are the record, the resident (or family, if the resident can’t report reliably) and the direct care staff on all shifts.
• Getting code 9 wrong. Not rated (9) is only for a resident who, for the entire 7 days, had a catheter or ostomy, no urine output (bladder), or no bowel movement (bowel). It isn’t for a resident whose continence is simply hard to judge.

SuperQM compares each resident’s H0300 and H0400 with the prior assessment CMS will use, so a new case is visible before the quarter closes.