3/12/2015. Session Objectives. RAI User s Manual. Polling Question
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1 Session Objectives MDS 3.0 Coding Challenges: Questions, Answers, and Explanations Jen Pettis, BS, RN, WCC Associate March 19, 2015 Upon completion of the program, the participate will: Describe the four late loss activities of daily living (ADLs) Discuss the Rule of 3 for coding G01101: ADL Self- Performance List the criteria for coding urinary tract infection on the MDS 3.0 Give an example of a worsening pressure ulcer Define a physical restraint Abt Associates pg 2 RAI User s Manual The information in this program refers to publicly available information as of the date of the presentation (March 19, 2015) For the most accurate and up-to-date information regarding the Resident Assessment Instrument (RAI), including the Minimum Data Set, Version 3.0 (MDS 3.0), please refer to the CMS RAI User s Manual Web page at the following link: Assessment- Instruments/NursingHomeQualityInits/MDS30RAIManual.html The Late Loss Activities of Daily Living (ADLs) Transfer - how resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet) Toilet use - how resident uses the toilet room, commode, bedpan, or urinal, transfers on/off toilet, cleanses self after elimination, changes pad, manages ostomy or catheter, and adjusts clothes. Does not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag Abt Associates pg 3 Abt Associates pg 4 The Late Loss Activities of Daily Living (ADLs) Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture Eating - how resident eats and drinks, regardless of skill. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g., tube feeding, total parenteral nutrition, IV fluids administered for nutrition or hydration) Polling Question Mr. Jones napped during the day and slept at night in bed with the head of the elevated on some days during the look back period. However, most of the time, he napped during the day and slept at night in his recliner in his room. When coding Bed Mobility, the assessor will consider how Mr. Jones moved and positioned his body: A. In bed only B. In the chair only C. In bed and the chair Abt Associates pg 5 Abt Associates pg 6 1
2 Coding G0110: Activities of Daily Living A two-part evaluation: Self-Performance: measures how much of the ADL activity the resident can do for himself or herself Support Provided: measures how much facility staff support is needed for the resident to complete the ADL Consider all episodes of each ADL over each 24- hour period during the 7-day look-back Only facility staff assistance is considered when coding G0110 Coding G01101: ADL Self-Performance Code 0 - Independent: if resident completed activity with no help or oversight every time during the seven day look back period and the activity occurred at least three times Code 1 - Supervision: if oversight, encouragement, or cueing was provided three or more times during the last seven days Code 2 - Limited assistance: if resident was highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weightbearing assistance on three or more times during the last seven days Abt Associates pg 7 Abt Associates pg 8 Coding G01101: ADL Self-Performance Code 3 - Extensive assistance: if resident performed part of the activity over the last seven days and help of the following type(s) was provided three or more times: Weight-bearing support provided three or more times Full staff performance of activity three or more times during part but not all of the last seven days Code 4 - Total dependence: if there was full staff performance of an activity with no participation by resident for any aspect of the ADL activity and the activity occurred three or more times. The resident must be unwilling or unable to perform any part of the activity over the entire seven day look back period Coding G01101: ADL Self-Performance Code 7 - Activity occurred only once or twice: if the activity occurred at least once but fewer than three times Code 8 - Activity did not occur: if the activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire seven day look back period Abt Associates pg 9 Abt Associates pg 10 The Rule of 3 for Coding G01101: ADL Self-Performance A method that was developed to help determine the appropriate code for ADL Self-Performance Accuracy depends on a solid understanding of each ADL (including each component), the coding definitions, and the Rule of 3 Exceptions to the Rule of 3: Code 0 - Independent Code 4 - Total dependence Code 7 - Activity occurred only once or twice Code 8 - Activity did not occur The Rule of 3 for Coding G01101: ADL Self-Performance Remember the exceptions and the ADL coding definitions 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 Abt Associates pg 11 Abt Associates pg 12 2
3 The Rule of 3 for Coding G01101: ADL Self-Performance 3. When an activity occurs at various levels, but not three times at any given level, apply the following: Convert episodes of full staff performance to weight-bearing assistance when applying the third Rule of 3 (as long as the full staff performance episodes did not occur every time) When there is a combination of full staff performance and extensive assistance, code extensive assistance (3) When there is a combination of full staff performance, weight bearing assistance and/or non-weight bearing assistance code limited assistance (2) If none of the above are met, code supervision Mrs. Callie required the following help for transfer during the look back period: supervision nine times, limited assistance three times, extensive assistance twice, and total assistance twice. What is the correct code for Column 1, ADL Self-Performance for Transfer (G0110B1)? A. 1, Supervision B. 2, Limited C. 3, Extensive D. 4, Total Abt Associates pg 13 Abt Associates pg 14 Mrs. Coates was only in the facility for a short time. While there, she required the following help for toileting: supervision twice, limited assistance twice, and extensive assistance twice. What is the correct code for Column 1, ADL Self-Performance for Toilet Use (G0110I1)? A. 1, Supervision B. 2, Limited C. 3, Extensive D. 4, Total Coding G01102: ADL Support Code for the most support provided over all shifts No rule of 3 to consider when coding Column 2 Code regardless of how Column 1 ADL Self- Performance is coded Abt Associates pg 15 Abt Associates pg 16 Coding G01102: ADL Support 0 - No setup or physical help from staff 1 - Setup help only 2 - One person physical assist 3 - Two+ person physical assist 8 - ADL activity itself did not occur during the entire period (or family and/or non-facility staff provided care 100% of the time for that activity for the 7 days) Mrs. Boone was very ill and unable to get in and out of bed during the look back period with the exception of one time when she transferred in and out of bed via mechanical lift with two staff assist to attend a religious service with her family. The correct coding for transfer (G0110B) for Mrs. Boone in Column 1 and Column 2 is: A. 4 (total dependence) / 3 (two assist) B. 4 (total dependence) / 8 (activity did not occur) C. 7 (activity occurred only once or twice) / 3 (two assist) D. 7 (activity occurred only once or twice) / 8 (activity did not occur) Abt Associates pg 17 Abt Associates pg 18 3
4 Section I Active Disease Diagnosis Intended to capture diseases that have a direct relationship to the resident s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death Two look back periods: Diagnosis identification (Step 1): 60 days Diagnosis status (Step 2): Seven days (except urinary tract infection [UTI]) Definitions of diagnoses are not provided Section I Active Disease Diagnosis Diagnoses are listed by major disease category Examples provided for certain disease categories are not meant to limit what is coded to those examples Check off all active diagnoses that apply If a disease or condition is not specifically listed, enter the diagnosis and ICD code in item I8000, Additional active diagnosis Abt Associates pg 19 Abt Associates pg 20 Section I Active Disease Diagnosis Item I2300: Urinary Tract Infection Code only if all the following are met: Physician, nurse practitioner, physician assistant, or clinical nurse specialist or other authorized licensed staff as permitted by state law diagnosis of a UTI in last 30 days Sign or symptom attributed to UTI, including but not limited to fever, urinary symptoms, pain or tenderness in flank, confusion or change in mental status, change in character of urine Significant laboratory findings Current medication or treatment for a UTI in the last 30 days According to the transfer summary, Mrs. Flannigan was hospitalized with pneumonia prior to being admitted to the nursing home last week. She has finished her antibiotics but continues with dyspnea and a cough. Her exercise tolerance is improving with therapy. She continues to wear her oxygen. Would I2000, Pneumonia be coded? A. Yes, check I2000, Pneumonia as the diagnosis is active B. No, the antibiotic ended therefore the diagnosis is no longer active Abt Associates pg 21 Abt Associates pg 22 M0210: Unhealed Pressure Ulcer(s) A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction Code based on the presence of any pressure ulcer (regardless of stage) in the past 7 days Code 0, no: if the resident did not have a pressure ulcer in the 7-day look-back period. Then skip Items M0300 M0800 Code 1, yes: if the resident had any pressure ulcer (Stage 1, 2, 3, 4, or unstageable) in the 7-day look-back period. Proceed to Current Number of Unhealed Pressure Ulcers at Each Stage item (M0300) Coding Tips for Pressure Ulcer(s) Coding Tips (excerpts): If primarily caused by pressure, then the ulcer should be included as a pressure ulcer The primary etiology should be considered when coding whether the diabetic has an ulcer that is caused by pressure or other factors If a pressure ulcer healed during the look-back period, and was not present on prior assessment, code 0 Mucosal ulcers are not staged using the skin pressure ulcer staging system. Cartilage serves the same anatomical function as bone Abt Associates pg 23 Abt Associates pg 24 4
5 Step 1: Determine Deepest Anatomical Stage For each pressure ulcer, determine the deepest anatomical stage Do not reverse or back stage Observe and palpate the base of any identified pressure ulcers Review the history of each pressure ulcer in the medical record Note: the assessor also documents the date of origin of the oldest Stage 2 pressure ulcer Pressure Ulcer Stages (adapted from the National Pressure Ulcer Advisory Panel s [NPUAP s] staging system) Stages 1-4 Unstageable - Non-removable dressing Unstageable - Slough and/or eschar Unstageable Deep tissue (suspected deep tissue injury in evolution) Abt Associates pg 25 Abt Associates pg 26 Step 2: Identify Unstageable Pressure Ulcers If anatomical depth can t be determined due to slough or eschar, the pressure ulcer should be coded as unstageable Intact skin that is a suspected deep tissue injury (sdti) should be coded as unstageable Known ulcers covered by a non-removable dressing or device should be coded as unstageable Step 3: Determine Present on Admission... present on admission/entry or reentry and subsequently increases in stage during the stay... not present on admission... unstageable on admission/entry or reentry, but becomes stageable considered present on admission at that stage if it subsequently increases in stage, not present on admission Abt Associates pg 27 Abt Associates pg 28 Step 3: Determine Present on Admission (continued) If a resident who has a pressure ulcer is hospitalized and returns with that pressure ulcer at the same stage not present on admission If a current pressure ulcer increases in stage during a hospitalization present on admission What is considered on admission? As close to the actual time of admission as possible Abt Associates pg 29 Abt Associates pg 30 5
6 Mr. Ester has a full thickness pressure ulcer on his right ischial tuberosity. It measures 3.1 cm long, 1.2 cm wide, and 0.5 cm deep. The wound bed is free of necrotic tissue. Currently there are no underlying structures visible; however, at its deepest point, there was visible bone at the base of the wound. What stage is Mr. Ester s ulcer? A. Stage 2 B. Stage 3 C. Stage 4 D. sdti Mrs. Lally developed a Stage 2 pressure ulcer while at the nursing facility. She was hospitalized for six days and returned with a Stage 3 pressure ulcer in the same location. Would her pressure ulcer be considered present on admission? A. Yes, Mrs. Lally s pressure ulcer should be considered present on admission. B. No, Mrs. Lally s pressure ulcer should not be considered present on admission. Abt Associates pg 31 Abt Associates pg 32 M0800: Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or scheduled PPS) or Last Admission/Entry or Reentry Worsening Pressure Ulcer: A pressure ulcer that has progressed to a deeper level of tissue damage and is therefore staged at a higher number using a numerical scale as compared to the previous assessment M0800: Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or scheduled PPS) or Last Admission/Entry or Reentry Look back period for this item is back to the ARD of the prior assessment For each current stage, count the number of current pressure ulcers that are new or have increased in numerical stage since the last MDS assessment was completed If a numerically staged pressure ulcer increases in numerical staging it is considered worsened Abt Associates pg 33 Abt Associates pg 34 M0800: Worsening in Pressure Ulcer Status Since Prior Assessment (OBRA or scheduled PPS) or Last Admission/Entry or Reentry Unstageable on admission becomes stageable is not considered worsened unless it subsequently increases in stage Stageable ulcer and becomes unstageable due to slough or eschar is not considered worsened Two merged ulcers are not considered worsened unless numeric stage increases Present on admission = not new/worsened Mr. Brown was admitted with an unstageable pressure ulcer on the right hip, which was debrided and reclassified as a Stage 4 pressure ulcer three weeks later. The initial MDS assessment listed the pressure ulcer as unstageable. On the current assessment, would the pressure ulcer be considered to have worsened? A. Yes, the pressure ulcer is considered to have worsened B. No, the pressure ulcer is not considered to have worsened Abt Associates pg 35 Abt Associates pg 36 6
7 Miss Kirby has obtained a Stage 3 pressure ulcer while at the nursing home. The wound bed was subsequently covered with slough and was coded on the next assessment as unstageable due to slough. After debridement, the wound bed is clean and the pressure ulcer is reassessed and determined to still be a Stage 3 pressure ulcer. On the current assessment, would the pressure ulcer be considered to have worsened? A. Yes, the pressure ulcer is considered to have worsened B. No, the pressure ulcer is not considered to have worsened Section P Restraints Any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident s body that the individual cannot remove easily, which restricts freedom of movement or normal access to one s body Abt Associates pg 37 Abt Associates pg 38 Section P Restraints Remove easily: The device, material, or equipment can be removed intentionally by the resident in the same manner as it was applied by the staff considering the resident s physical condition and ability to accomplish his or her objective Freedom of movement: Any change in place or position for the body or any part of the body that the person is physically able to control or access Consider the device s effect on the resident, not the intent of its use Exclude items that are typically used in the provision of medical care that are serving in their usual capacity to meet medical needs. Section P Restraints Coding Instructions: Identify all physical restraints that were used at any time (day or night) during the 7-day look-back period. Code 0, not used Code 1, used less than daily Code 2, used daily Abt Associates pg 39 Abt Associates pg 40 Let s Chat! A resident uses a geriatric chair that is reclined when out of bed. What are some issues that the interdisciplinary team should consider when determining if the chair is a restraint? Please use the Chat box on your screen to type in some things that you would consider. MDS 3.0 RAI User s Manual (v1.12r) Errata (v1) Abt Associates pg 41 7
8 MDS 3.0 RAI User s Manual (v1.12r) Errata (v1) Effective February 5, 2015 MDS 3.0 RAI User s Manual (v1.12r) Errata (v1) Effective February 5, 2015 Admission refers to the date a person enters the facility and is admitted as a resident. A day begins at 12:00 a.m. and ends at 11:59 p.m. Regardless of whether admission occurs at 12:00 a.m. or 11:59 p.m., this date is considered the 1st day of admission. Completion of an OBRA Admission assessment must occur in any of the following admission situations: When the resident has never been admitted to this facility before; OR When the resident has been in this facility previously and was discharged prior to completion of the OBRA Admission assessment; OR When the resident has been in this facility previously and was discharged return not anticipated; OR When the resident has been in this facility previously and was discharged return anticipated and did not return within 30 days of discharge (see Discharge assessment below). Abt Associates pg 43 Reentry refers to the situation when all three of the following occurred prior to this entry: The resident was previously in this facility Was discharged return anticipated and Returned within 30 days of discharge Abt Associates pg 44 MDS 3.0 RAI User s Manual (v1.12r) Errata (v1) Effective February 5, 2015 If the Type of Entry for this assessment is an Admission (A1700 = 1), the Admission Date (A1900) and the Entry Date (A1600) must be the same If the Type of Entry for this assessment is a Reentry (A1700 = 2), the Admission Date (A1900) will remain the same, and the Entry Date (A1600) must be later than the date in A1900 Any questions? Thank you! Abt Associates pg 45 8
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