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MDS OCTOBER 2014 CAROL SIEM, MSN, RN, BC, GNP, RAC-CT QIPMO Clinical Educator

Seriously Current manual version 1.12 can be found at:

http://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html An Errata document is already being put together to fix the errors in the manual that was just released. Pg. numbers incorrect on the Track change info making it nearly impossible to see the changes in the manual from track changes Changes in paragraphs such as additions or changes in formatting were not highlighted Only because my computer was dying. The above web site does have the highlighted changes

2014 Version Overview 

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New questions Revised questions Revision of some of the “rules” New examples Formatting changes References to nursing home is now “facility”

Computer Updates 

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Be sure you have received the updates from your software regarding the new form version 1.12.0 After October 1 your computer must have the Operating System of Windows 7 and that the Browser is Internet Explorer V 9.0. –

This is a computer issue, not MDS software

Chapter 1 

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Section 1.1 pg. 1.5: Reinforces the purpose of the manual is to have an individualized care plan Section 1.1 pg. 1-6 The CAA resources provided as a courtesy, they are not mandatory and is not an all inclusive list nor are they endorsed by CMS

Chapter 2 

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Pg. 2.2 The CMS State approved RAI staff is now a link in Appendix B and not the actual list. Pg. 2.6 The demographic information (Items A050-A1600) must stay in the active chart until the resident is discharged return not anticipated or is discharged return anticipated but does not return within 30 days

Chapter 2 

Another bullet (4 total now) has been added to the definition of a Discharge on page 2-10. The new one is: –

Resident is transferred from a Medicareand/or Medicaid certified bed to a non certified bed

Chapter 2 

Item Set Discussion 2-10 - 2-12: Clarifies –

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Quarterly Item Set: It can be used for a plain quarterly or qtrly combined with PPS assessment or a Discharge PPS Item Set: It can be used for a scheduled PPS, or an OMRA and or a discharge There is no longer an option to choose Readmission/Return Assessment. Begin with a Medicare 5 day. Medicare assessments will always begin with a Medicare 5 day after a discharge.

Sig Change and Hospice  

Pg. 2-21 Don’t over think or over work it – –

Admitted with hospice then the admission assessment will show hospice (O0100 K) Hospice comes on board or stops before admission completed  

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Add it or adjust ARD to accommodate when hospice has the papers signed going on or coming off This saves you from doing an Admission assessment then a Sig change Time frame for ARD must still be within the admission requirements

Chapter 2 

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Pg. 2-27 Removed an example for doing a PASSR Pg. 2-28: Documentation of identification of the following needs to be in the clinical record progress notes –

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Significant error Significant change (current page 2-21)

Chapter 2 

Reminders: –

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Pg. 2-29: Qtrly. assessment started, went to hospital and returned 2 days later. If no sig change needed, complete the assessment that had been started and completion is done by day 14 after the original ARD Pg. 2-30: Dies during the assessment process. Place whatever is done with the MDS in the chart with a note on why it was not completed. Complete Death in Facility record ARD always drives the due date for the next ARD

Chapter 2 Coding A1700 = 1 

Entry Tracking marked as Admission pg 2-33 –

Some examples were removed. 

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Readmitted after discharge prior to completion of Admission assessment For swing bed facilities, the Entry tracking record will always be coded 1, Admission, since these providers do not complete an OBRA Admission Assessment

Now Entry Tracking Record 

Mark Admission when – –

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Is admitted for the first time to this facility Is readmitted after a discharge reutn not anticipated Is readmitted after a discharge return anticipated when return was not within 30 days page 2 - 33-32

Chapter 2 Coding A1700 = 2 Reentry 

Entry tracking is coded Reentry every time a person: –

Is readmitted to this facility, and was discharged return anticipated from this facility, and returned within 30 days of discharge

Chapter 2 Discharge – return not anticipated 

Important point for homes which have certified beds and non certified beds in their building and a resident leaves the certified to a non certified bed. Code as follows: – A0310F Discharge return not anticipated – A2000 Date of move to new room – A2100 Location: Another nursing home or swing bed – There is an example of coding this on page 2-35 in the New Manual

Chapter 2 Discharges 

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Pg. 2-36: ARD for discharge is not set prospectively. May be coded on the assessment anytime during completion period (i.e. discharge date + 14 days) Discussion on the use of “-” when unable to determine response. May combine discharge with other assessments when indicated Unplanned should be completed the best you can

Chapter 2 PPS 

On page 2-41: reminder: –

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Medicare unscheduled assessment in a scheduled assessment window cannot be followed by the scheduled assessment later in the window. Must be combined with an ARD appropriate to the unscheduled assessment. You can a completed scheduled assessment followed by unscheduled assessment in the same window. The unscheduled may supersede the scheduled assessment in regards to payment Ex: Day 13: 14 day ARD then missed therapy on day 14, 15, &16 so EOT done which will over rule the 14 day 

Chapter 2 

All references in the manual regarding the readmission/return assessment have been removed.

Chapter 2 COT 

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Must have a RUG before a COT can be done Except with the next slide a COT may only be completed when a resident is currently classified into a Rehab therapy RUG regardless of whether or not resident is classified into this group for payment based on the most recent assessment

Chapter 2 COT 

COT OMRA may be completed when a resident is not currently classified into a therapy RUG IF Both of the following conditions are met 1.

2.

Was classified into a therapy RUG on a prior assessment during the current Med A stay No discontinuation of therapy services (planned or unplanned occurred between Day 1 of COT that classified resident into non therapy RUG

COT EXAMPLE Day 30: RUA Day 37 RUA minutes but only 4 distinct days so does not qualify Nursing RUG then for the next 7 days based on what was obtained with the COT Day 44 MAY complete a COT OMRA on this date to get back to therapy RUG NOTE: Under these circumstances, completing the COT OMRA may be considered optional

Transition to October 

According to the FY 2015 final rule, discontinuation of therapy under the revised EOT OMRA policy "refers to the planned or unplanned discontinuation of all rehabilitation therapies for 3 or more consecutive days."

Transition 

The COT OMRA which would be used to reclassify the resident into a RUG-IV therapy group from a RUG-IV non-therapy group, pursuant to the rules associated with this policy outlined in the FY 2015 SNF final rule (79 FR 45647 through 45649) and in the Minimum Data Set, Version 3.0 (MDS 3.0) manual, must have an ARD set for on or after October 1, 2014.

Chapter 2 

To combine a scheduled assessment and the COT, Day 7 of the COT MUST be in the window of setting the scheduled assessment

Chapter 2 

Every time someone leaves the facility on Med A and returns on Med A the Medicare schedule will be restarted with a 5 day assessment

Chapter 2 

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Scheduled PPS assessments, the ARD must be on a day that the facility can bill (They were in the building at midnight) Unscheduled PPS assessments can be set if the resident was not in the building at midnight

Chapter 3 

On the form itself there are some wording changes such as: – –

Nursing home Facility Provider A0410 Unit Certification or Licensure Designation submission requirement

A 0410 Unit Certification or Licensure Designation Submission Requirement (cont.) We are to submit those residents who are in a Medicare and/or Medicaid certified unit/bed Payer source is not the determinant by which this which item is to be coded

A0410 

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Code 1 Unit is neither Medicare or Medicaid certified and MDS data is not federal nor state required by the State submission If submitted it will be rejected Code 2 Unit is neither Medicare nor Medicaid certified but MDS data is required by the State (not marked in MO) Code 3 Unit is Medicare and/or Medicaid certified

A 1600 Entry Date 

Most recent admission/entry or reentry into this facility

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Entry Date Definition: The initial date of admission to the facility or the date the resident most recently returned to your facility after being discharged.

1700 Type of Entry 

Code 1, admission/entry: removed the category of discharged prior to completion of admission assessment –

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Resident has never been admitted to facility Resident was there and D/C’d return not anticipated Resident was there and D/C’d return anticipated and did not return

1700 Type of Entry 

Code 2, reentry, when all 3 of the following occurred prior to this entry, the resident was: – – –

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Admitted to this facility AND Discharged return anticipated AND Returned to facility within 30 days of discharge This coding is for both Swing bed facilities and nursing homes.

A 1900 Date 

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New Question/Item Date this episode of care in the facility began Rationale: To document this episode of care in this facility began The Admission Date may be the same as the Entry date for the entire stay (i.e. if the resident is never discharged)

C 1300 

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The CAM: There is a new disclaimer that essentially says that the CAM contains unauthorized portions, unauthorized modifications of and incorrect references to. Bottom line: The version we use was never approved by the original founders and they disclaim all responsibility for and liabilities with respect to any use, publication, or implementation of this protocol Interpretation: CMS got their hands slapped

Section E 

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Hallucinations can be both auditory and visual In the example regarding elopement: the sentence regarding the alarm system was removed. The alarms have nothing to do with the fact that she is no longer attempting to exit

G0110 

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CMS has written out in the text the definitions of the ADL’s and not just on the sample form In description of Locomotion off unit: has added “If facility has only one floor” how resident moves to and from distant areas on the floor. If in wheelchair, self sufficiency once in chair.

G0110 

In the example on page G-19 it talks about the resident who could not do her hair 3 of the last 7 days. The answer extensive assistance did not change but the rationale did in that brushing and styling her hair is a sub task for personal hygiene

H0200 

In the example on page H-6, regarding when a resident is on a trial of a toileting program, the answer hasn’t changed but it has been abbreviated

J0100 

In the definition of Non Medication Pain Intervention they have added: “Herbal or alternative medicinal products are not included in this category

Section K 

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Posted definitions of Parental/IV feeding and Feeding Tube with minor spelling changes New example of calculation fluid when you have hospital and nursing home fluids during the same week

Section M 

M0610 Dimensions of the worst PU. In the instructions it has clarified to look at Stage III or IV pressure ulcer or pressure ulcer that is unstageable due to slough or eschar.

Section O 

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Ventilator or respirator: Residents receiving closed-system ventilation includes those residents receiving ventilation via an endotracheal tube (e.g. nasally or orally intubated) as well as those residents with a tracheostomy Some minor grammar changes and removal of web sites under Special Treatments

Section O 

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In the Influenza section now “pc” correct with saying influenza and not “flu” In the Planning of care it now spells out risk and benefits of getting immunization National goal is to 90% on LTC residents vaccinated Throughout this section typos etc. were noted and fixed

Section O 

Increase discussion on –

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Flu season and how flu can occur at any time Discussed the “high does” vaccine for people age 65 and older and asking the physician if it is appropriate for the resident

Section O 

In the therapy sections several typos were corrected

Section X 

Emphasis placed on when correcting a MDS this section must have the same information on it as the one in the data basis even if it is wrong so that it can find it. The computer must find the wrong one before it can change it.

Chapter 5 

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Changes from A0410 are repeated in this section in regards to submission requirements Multiple typos are fixed: – –

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Capitol vs small letters Missing ( Taking out 06 for the Medicare readmission return assessment

Chapter 5 

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May correct a MDS within 3 years of the target date if facility still open If facility has been terminated corrections must be submitted with 2 years of the termination date

Chapter 6 

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Changes in the section where it discusses the Second AI (Assessment Indicator) digit for billing. They have added a completely new bullet 7 which discusses EOT-R and resuming at previous level. In this discussion it talks about the ARD of the EOT-R and a grace days

Chapter 6 

NEW Example 7 – – – – –

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Admitted 10/01/14 5 day 10/07/14 RVB 14 day 10/14/14 RVB 30 day 10/28/14 RVA No therapy 10/29 – 10/31 EOT on 10/31/14 CE2 R on 11/2/14

NEW EXAMPLE BILLING     

Days 1-14 RVB10 Days 15-28 RVB20 Days 29-31 CE20A Days 32-41 RVA0A (RUG from 30 day) This represents the one and only occasion where the 3 characters RUG-IV therapy RUG may differ from that which was billed prior to the break in therapy and the difference is only in the ADL score that had not gone into play yet because of the missed therapy

Chapter 6 

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The previous Example 7 is now Example 8 The previous Example 8 is now 9 Example 9 is now 10

Chapter 6 

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Removed any reference to the readmission return assessment Reminds us when looking at the nursing RUG with the third level split for depression. Instructions for completing Patient Health Questionnaire are in Chapter 3 but also refer to Appendix E, and what to do if complete but not all questions were answered. The software does this behind the scenes.

Disclaimer 

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This is as accurate as possible with the first Change Sheets sent out on September 16, 2014. When the ERRATA sheets are sent out further additions/corrections may have to be made These updates will be made available ASAP Thank you CMS for making things so easy to understand