atx34 - "mds 3.0/rai: cms updates, frequent coding issues in texas and changes coming in...

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MINIMUM DATA SET (MDS) 3.0/RESIDENT ASSESSMENT

INSTRUMENT (RAI):CMS UPDATES, FREQUENT CODING

ISSUES IN TEXAS AND CHANGES COMING IN 2014!

Cheryl Shiffer, RN, BSN, RAC-CT Center for Policy and Innovation

Texas Department of Aging and Disability Services (DADS)

RAI Panel, Center for Medicare & Medicaid Services (CMS)

Fall 2013

MDS 3.0 OBJECTIVES

•List three or more significant changes that CMS recently made to the MDS 3.0 RAI Manual

•Describe three or more MDS 3.0 items that are frequent coding issues for Texas.

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MDS 3.0 OBJECTIVES

•Apply key clarifications and scenarios to ensure accurate coding of Section G of the MDS

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•Identify at least three changes affecting the MDS 3.0 process in 2014

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CMS UPDATES

CMS updates listed are based on the MDS 3.0 RAI Manual (RAIM3), v1.11

Effective Date: October 1, 2013

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CMS UPDATES

Along with the new version of the RAIM3 is a new version of the data specifications (v1.13.2).

The new specifications removed the “T” (test) value for PRODN_TEST_CD. Test records are no longer accepted by the system.

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CMS UPDATES

New items for the MDS item sets include:

•Items O0400A3A, O0400B3A, and O0400C3A. Co-treatment minutes

Added for reporting co-treatment minutesOnly for Part A, does not apply to Part B

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CMS UPDATES

• Item O0420. Distinct Calendar Days of Therapy

Added to record the number of calendar days The resident received Speech-Language Pathology and Audiology Services, Occupational Therapy or Physical Therapy

For at least 15 minutes a day in past 7 days 7

CMS UPDATES

• Items K0710A1 through K0710B3 (replaced items K0700A and K0700B)

K0710. Percent Intake by Artificial Route Added 3 columns for coding:

1. While NOT a Resident2. While a Resident3. During Entire 7 Days

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CMS UPDATES

Chapter 1, Section 1.8 - Protecting the Privacy of the MDS Data – Adds:

• A revised “Privacy Act Statement – Health Care Records” (RAIM3, pages 1-16 to

1-18)

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CMS UPDATES

Chapter 2, Section 2.6 - Required Omnibus Budget Reconciliation Act (OBRA) Assessments for the MDS – Clarifies:

•Setting the Assessment Reference Date (ARD) for a Discharge assessment is not set prospectively as with other OBRA assessments.

(RAIM3, page 2-36)10

CMS UPDATES

• The ARD (Item A2300) for a Discharge assessment is always equal to the discharge date (Item A2000).

• The ARD may be coded on the assessment any time during the Discharge assessment completion period (i.e., discharge date (A2000) + 14 calendar days).

(RAIM3, page 2-36) 11

CMS UPDATES

Chapter 2, Section 2.9 - MDS Medicare Assessments for SNFs – Clarifies:

•A Change of Therapy (COT) MDS is required:When the most recent assessment used for Part AExcluding an End of Therapy (EOT) MDSHas a sufficient level of rehabilitation therapy to qualify for:

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CMS UPDATES

1. An Ultra High, Very High, High, Medium, or Low Rehabilitation category (even if the final classification index maximizes to a group below Rehabilitation), and

2. The intensity of therapy changes to such a degree it no longer reflect the Resource Utilization Group (RUG) IV classification assigned for a Part A resident based on the most recent assessment used for Medicare payment.


CMS UPDATES

Section 2.9 - MDS Medicare Assessments for SNFs - Coding Tips and Special Populations adds a Note:

•Acknowledging it may not be practicable to conduct the resident interview items on or prior to the ARD for a standalone unscheduled Part A assessment, and

•Allowing facilities to conduct those resident interview sections up to two calendar days after the ARD (A2300).


CMS UPDATES

Section 2.13 - Factors Impacting the SNF Medicare Assessment Schedule – clarifies under Resident Takes a Leave of Absence (LOA) from the SNF:

•An unscheduled Prospective Payment System (PPS) MDS which meets the appropriate standards may have an ARD (A2300) that falls on a LOA day, but…

(RAIM3, page 2-72) 15

CMS UPDATES

•Only if the unscheduled PPS MDS is not combined with a scheduled PPS MDS.

Scheduled PPS MDS must have an ARD that falls on a Medicare Part A benefit day.

(RAIM3, page 2-72)

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CMS UPDATES

Chapter 3, Section G - Item G0110 Activities of Daily Living (ADL) Assistance – extensively revises:

•The “Rule of 3”, and

•The ADL Self-Performance Algorithm, and

•Adds several resident scenarios and rationales for correctly coding those situations.

(RAIM3, pages G-1 to G-22)22

CMS UPDATES

Chapter 3, Section M - Skin Conditions, replaces:

•The MDS Item Set screen shots for several updated items in Section M, and

•References to ‘necrotic tissue’ and instead refers to it as ‘eschar’.

(RAIM3, Section M, throughout)22

CMS UPDATES

Chapter 3, Section O – Special Treatments, Procedures and Programs –clarifies coding the Dates of Therapy:

•When an End of Therapy with Resumption (EOT-R) is completed, the Therapy Start Date (items O0400A5, O0400B5, and O0400C5) on the next PPS assessment is the same as the initial therapy evaluation date.

(RAIM3, page O-17) 22

CMS UPDATES

Chapter 3, Section Z - Item Z0400 - Signatures of Persons Completing the Assessment – adds under Coding Tips and Special Populations:

•If a person who completed a portion of the MDS is not available to sign it, then the person signing the attestation should:

Verify those portions of the MDS that may be verified with the medical record 22

CMS UPDATES

The date signed should be the date the record review was verified.

For sections requiring resident interviews, the person signing the attestation should interview the resident to ensure the accuracy of the information.

The date signed should be the date the interview was validated.

(RAIM3, page Z-7)22

CMS UPDATES

Chapter 5, Section 5.2 - Timeliness Criteria, clarifies:

•The completion timing for the Omnibus Budget Reconciliation Act (OBRA) Admission and Annual assessment is corrected to match the OBRA instructions from Chapter 2 of the RAIM3.

(RAIM3, page 5-2)22

CMS UPDATES

Chapter 6, Section 6.6 - RUG-IV 66-Group Model Calculation Worksheet for SNFs -Situation 2 clarifies:

•If the Z0100A classification for an SOT (Item A0310C = 1), not combined with an OBRA assessment or other PPS assessment, is not in a Rehabilitation Plus Extensive Services group or a Rehabilitation group, then the following adjustment applies:

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CMS UPDATES

The Medicare Non-Therapy RUG-IV group reported in Item Z0150A should be adjusted to AAA (the default group).

• Situation 3 clarifies:If the Z0100A classification for an SOT

OMRA, combined with an OBRA assessment or other PPS assessment, is in a Rehabilitation Plus Extensive Services group or a Rehabilitation group, then no adjustment is made.(RAIM3, page 6-49). 22

OTHER FREQUENT CODING ISSUES IN TEXAS

From page 2-2 of the RAIM3, “If allowed by the State, facilities may have some flexibility in form design …or use a computer generated printout of the RAI as long as the state can ensure that the facility’s RAI in the resident’s record accurately and completely represents the CMS-approved State’s RAI.”

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The state of Texas allows this flexibility as long as the printed assessments:

•Are legible/readable, and•Display all the active items for that type of assessment in the order they are coded, and•Display the answer that the facility selected.

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From page 2-6 of the RAIM3, there are three options for maintaining 15 months of MDS:

•Electronically with electronic signatures•Electronically without electronic signatures (or signatures that do not print or are not safeguarded)•Hard copy

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If MDS are maintained electronically with electronic signatures:

•Facilities must have written policies in place to ensure proper security measures to protect the use of an electronic signature by anyone other than the person to whom the electronic signature belongs.

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If MDS are maintained electronically without electronic signatures (or signatures that do not print or are not safeguarded):

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• Facilities must maintain hard copies of signed and dated CAA(s) completion (Items V0200B-C), correction completion (Items X1100A-E), and assessment completion (Items Z0400-Z0500) data that is resident-identifiable in the resident’s active clinical record.

• No question data is resident-identifiable if Section A is also printed.

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From page 2-7 of the RAIM3, surveyors are directed to review the MDS in the form it is maintained. If electronic, ensure enough terminals and “read-only” access are available.

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From the RAIM3, page 2-6, after the 15-month period RAI information may be thinned from the clinical record and stored in the medical records department, provided that it is easily retrievable if requested by clinical staff, State agency surveyors, CMS, or others.

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From page 2-8 of the RAIM3, Item A2300 - Assessment Reference Date (ARD):

•Refers to the last day of the observation (or “look back”) period ... Since a day begins at 12:00 a.m. and ends at 11:59 p.m., the ARD must also cover this time period.

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• The facility is required to set the ARD on the MDS item set itself or in the facility software within the appropriate timeframe of the assessment type being completed.

• This concept of setting the ARD is used for all assessment types (OBRA and Medicare PPS).

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From page 2-12 of the RAIM3, a Leave of Absence (LOA): Does not require completion of either a Discharge assessment or an Entry record and occurs when a resident has:

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• Temporary home visit of at least one night; or

• Therapeutic leave of at least one night; or

• Hospital observation stay less than 24 hours and the hospital does not admit the patient.

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Hospital observation stay less than 24 hours and the hospital does not admit the patient means:

• From the time the resident left the facility until the time the resident returned was less than 24 hours, and

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• The resident remained in observation and was not admitted, and

• Any hospital observation stay periods while actually at the hospital are irrelevant.

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From page 2-22 of the RAIM3, a Significant Change in Status (SCSA) (A0310A=04) is required to be completed NLT the 14th calendar day after determining a significant change occurred when:

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•The resident will not return to baseline within 2 weeks.

•There are two or more areas of improvement or two or more areas of decline.

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•Scenario: A resident has a change in both self-performance and staff support in Item G0110B Transfer. The resident is newly coded as requiring extensive assistance and one staff member’s support. Prior coding was independent and no staff support.

•If the only change, no SCSA is required.

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•Scenario: A resident has a change in both self-performance and staff support in Item G0110B Transfer and Item G0110H Eating. The resident is newly coded as requiring extensive assistance and one staff member’s support. Prior coding was independent and no staff support.

•This is two areas of change and a SCSA is required.

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An SCSA is also required when a resident elects or revokes Hospice:

•Unless the resident dies or discharges prior to midnight on the 14th calendar day

• Staff should make an entry in the clinical record to reflect why the SCSA was not started or completed.

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From page 2-36 of the RAIM3, a Discharge assessment (A0310F=10 or 11):

•ARD must be set for the day of discharge within 14 days of thedate of discharge

•Must be completed within 14 days of the ARD

•Ensure discharge date in A2000 matches the ARD in A2300 44


From page A-26 of the RAIM3, when a resident on a Medicare Part A stay is discharged:

•The Assessment Reference Date (ARD) of a scheduled Medicare PPS MDS may be adjusted to the day of discharge only when the ARD for the scheduled PPS assessment was set prior to the day of discharge.

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From page I-3 of the RAIM3, Section I Active Diagnoses - Determining Active Diagnoses is a Two Step Process:

1.Determine all physician-documented diagnoses in the last 60 days.2.Determine whether each diagnosis (except UTI) was active in the 7 day look-back period.

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• Active diagnoses have a direct relationship to the resident’s functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring, or risk of death during the look-back period. (RAIM3, page I-4)

• Item I8000 – Do not code HIV/AIDS or related diagnosis (Texas State Law).

• Read The March 2013 The MDS Mentor!47


From page M-7 of the RAIM3, determining if Pressure Ulcers were “present on admission”:

•If the pressure ulcer was unstageable on admission, but becomes staged later, it should be considered as “present on admission” at the stage at which it first becomes staged.

•If it subsequently worsens to a higher stage, that higher stage should not be considered “present on admission.”

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• If a resident who has a pressure ulcer is hospitalized and returns with that pressure ulcer at the same stage, the pressure ulcer should not be coded as “present on admission” because it was present at the facility prior to the hospitalization.

• If a current pressure ulcer worsens to a higher stage during a hospitalization, it is coded at the higher stage upon reentry and should be coded as “present on admission.”

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From page O-1 of the RAIM3, Item O0100. Special Treatments, Procedures and Programs (STPP)

•Facilities may code items the resident performed themselves, independently or after set-up by facility staff.

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Include in column 2. While a resident - the applicable STPP items that occurred during the 14 day look-back while the resident was a resident of the facility.

•Remember: Column 2 includes those items that occurred while the resident was physically present in the facility or that occurred during a Leave of Absence (LOA).

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• Do not code services that were provided solely in conjunction with a surgical procedure or diagnostic procedure, such as IV medications or ventilators.

• Surgical procedures include routine pre- and post-operative procedures.

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From page O-3 of the RAIM3, Item O0100H IV medications - DO NOT include IV fluids (Normal Saline, D5W, etc.)

From page O-4 of the RAIM3, Item O0100M Isolation - DO NOT include wound infections, UTIs or encapsulated pneumonia

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From pages O-4 to O-5 of the RAIM3, Item O0100M Isolation – Code for “single room isolation” only when all of the following conditions are met:

•Note: Never code isolation for wound infections, urinary tract infections or encapsulated pneumonia.

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• Active infection with highly transmissible, epidemiologically significant pathogens.

• Precautions are over and above standard precautions… transmission-based precautions (contact, droplet or airborne) must be in effect.

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• The resident is in a room alone because of active infection and cannot have a roommate.

• The resident must remain in his/her room. All services available in the facility are brought to the resident (e.g. rehab, activities, dining, etc.).

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From Appendix A, page A-19, Item O0400D Respiratory Therapy: Following the state Nursing Practice Act, this therapy must be provided by a respiratory therapist (RT) or a trained nurse.

•The March 2011 issue of

The MDS Mentor explains all the

requirements for coding Item O0400D. 57


Item Z0400 Signatures of Persons Completing the Assessment or Entry/Death Reporting:

•Date for completing interview items is on the ARD or before the ARD (except stand alone unscheduled PPS)

•Date for gathering information for other MDS items is usually after the ARD

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Item Z0400 Signatures of Persons Completing the Assessment or Entry/Death Reporting:•From page Z-7 of the RAIM3, “All staff who completed any part of the MDS must enter their signatures, titles, sections or portion(s) of section(s) they completed, and the date completed.”

•Read the attestation59


From page 5-10 to 5-11 of the RAIM3, a modification request is used to modify most MDS items, including the Target Date:•Entry Date (Item A1600) on an Entry tracking record (Item A0310F = 1)•Discharge Date (Item A2000) on a Discharge/Death in Facility record (Item A0310F = 10, 11, 12),•Assessment Reference Date (Item A2300) on an OBRA or PPS assessment.*

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* : Only correct the ARD when:

•There was a typographical error, and

•The ARD does not reflect the look-back period used to determine the coding of the MDS.

•Monitoring will occur to determine if an ARD is changed and clinical data is also changed (at the same time or in a subsequent modification).

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A Modification Request is also used to correct:

•Type of Assessment (Item A0310)

•Clinical Items (Items B0100-V0200C), including Section O items

Note: Item A0310 can only be modified when the Item Set Code (ISC) of that assessment does not change.

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ACCURATE CODING OF SECTION G

To code ADLs in Item G0110:•Read Section G of the RAIM3•Apply the ADL Algorithm and Rule of 3 on page G-7

•Code 4, total dependence: only if there was full staff performance of an activity with no participation by resident for any aspect of the ADL activity. The resident must be unwilling or unable to perform any part of the activity over the entire 7-day look-back period.

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• Scenario: During the entire 7-day look-back period, the resident required total assistance (4) of two staff (3) to transfer during the day and evening shift. On the night shift, staff coded that the activity did not occur (8).

• G0110B Transfer would reflect the resident required total assistance of two staff every time the activity occurred.

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• Scenario: During the entire 7-day look-back period, the resident required total assistance (4) three times, extensive assistance (3) two times and limited assistance (2) six times in dressing.

• G0110G Dressing would reflect the resident’s self performance was extensive assistance. Total dependence occurred three times but not every time. Staff code extensive.

(RAIM3, page G-4)65


• Code 8, activity did not occur: if, over the 7-day look-back period, the ADL activity (or any part of the ADL) was not performed by the resident or staff at all.

Scenario: ADL self performance is coded as 8 if the ADL was performed only by family or friends, or those either directly or indirectly paid by family or friends, during the entire look-back period.

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From page G-6 and again on page G-7 of the RAIM3, Instructions for the Rule of 3:

•When an ADL activity has occurred three or more times, apply the four steps of the “Rule of 3” (keeping the ADL coding level definitions and the exceptions on page G-5 in mind) to determine the code to enter in Column 1, ADL Self-Performance.

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• These steps must be used in sequence.

• Use the first instruction encountered that meets the coding scenario (e.g., if Step 1 applies, stop and code that level).

• Also, if sub step 3b applies, stop and code that level. Do not apply 3c.

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Instructions for the Rule of 3:

•1. When an activity occurs three or more times at any one level, code that level.

•2. When an activity occurs three or more times at multiple levels, code the most dependent level that occurred three or more times.

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• 3. When an activity occurs three or more times and at multiple levels, but not three times at any one level, apply the following:

a. Convert episodes of full staff performance to weight-bearing assistance when applying the third Rule of 3.

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b. When there is a combination of full staff performance and weight-bearing assistance that total three or more times—code extensive assistance (3).

c. When there is a combination of full staff performance/weight-bearing assistance, and/or non-weight-bearing assistance that total three or more times—code limited assistance (2).

• 4. If none of the above are met, code supervision. 71


Definition of facility staff whose assistance is coded in ADL support provided in Section G:

•Facility employees, agency staff, therapy (PT, OT, ST) whether they are employees or contract staff

Scenario: CNAs provide full staff support but Therapy staff only provides extensive assistance for transfers during the look-back period. Staff would code extensive assistance on the MDS.

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Definition of non-facility staff whose assistance is NOT coded in ADL support provided in Section G:

•Family, friends, sitters, visitors, personal care aides

•EMS/Ambulance, Hospice, Lab, Diagnostic Imaging (X-Ray, Ultrasound, etc.) personnel

•Nursing students/CNA students*73

CHANGES COMING IN 2014

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)

•ICD-10-CM will be used by all providers in every health care setting.

•ICD-10-PCS (Procedure Coding System) will be used only for hospital claims for inpatient hospital procedures.

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• ICD-10-CM and ICD-10-PCS implement October 1, 2014.

• Making the transition to ICD-10 is not optional.

• This transition will affect all covered entities as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

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• Covered entities are required to adopt ICD-10 codes for services provided on or after the October 1, 2014, compliance date.

• For inpatient hospital claims, ICD-10 diagnosis and procedure codes are required for all stays with discharge dates on or after October 1, 2014.


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• Note: The transition to ICD-10 does not directly affect provider use of the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes.


The CMS ICD-10 website is at http://www.cms.gov/icd10

• Each ICD-10-CM code is 3 to 7 characters.• The first must be an alpha character (all letters

except U are used). • The second character is numeric. • Characters 3-7 are either alpha or numeric (alpha

characters are not case sensitive),• With a decimal after the third character.

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Other changes expected in 2014:

• Updated RAIM3 – traditionally April (May) and October

• Updated FY2015 SNF PPS Rules? – Too early to know

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TEXAS MDS RESOURCES

Call Cheryl Shiffer for Clinical Questions:• 210-619-8010

Call Brian Johnson for Technical Questions: • 512-438-2396

• Visit the state MDS web site:

http://www.dads.state.tx.us/providers/MDS/

(Check out The MDS Mentor! & Sign up for e-mails) 80

FINAL THOUGHTS

“When All Else Fails, Read The Instructions”

Ralph Waldo Emerson, Poet, 1803-1882

“If you don't have time to do it right, when will you have time to do it over?”

John Wooden, American Coach, 1910-2010

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atx34 - "mds 3.0/rai: cms updates, frequent coding issues in texas and changes coming in...

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