MDS Essentials MDS Coding Essentials: Sections D, E, F, and Q 1 4 Faculty Disclosures I have no financial relationships to disclose I have no conflicts of interests to disclose I will not promote any commercial products or services All Planning Committee members, content reviewers, authors, and presenters have been evaluated for conflicts of interest and there are not any to disclose. Content User s Manual Chapter 3 Sections D, E, F, and Q Intent Basic coding instructions 5 Educational Activity Completion and CE Disclosure Requirements for Successful Completion 1.25 contact hours will be awarded for this continuing nursing education activity. Criteria for successful completion includes attendance for at least 80% of the entire event. Partial credit may not be awarded. Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services. American Association of Post Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. *AAPACN d/b/a American Association of Nurse Assessment Coordination (AANAC) Section D: Mood D 1 Intent: These items address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is very important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treated It is important to note that coding the presence of indicators in Section D does not automatically mean that the resident has a diagnosis of depression or other mood disorder. Assessors do not make or assign a diagnosis in Section D; they simply record the presence or absence of specific clinical mood indicators. Facility staff should recognize these indicators and consider them when developing the resident s individualized care plan. 6 1
D0100 D 1 D 2 D0200 D 3 Determine whether or not a resident or staff mood interview should be conducted Determine if resident is rarely/never understood If yes, code 0. No and skip to D0500 for PHQ 9 OV Determine if resident needs or wants an interpreter 7 14 day look back period Health related Quality of Life Depression can be associated with: Psychological and physical distress Less participation in therapy and activities Decreased functional status Poorer outcomes Mood disorders are common in NH and are often underdiagnosed and undertreated 10 MDS Scripted Interviews Appendix D Interview techniques Break the questions apart if necessary Unfolding: use of general question about the symptom followed by a sequence of more specific questions if the symptom is reported as present Example: Read the item (or part of the item) to the resident, then ask, Do you have this at all? If yes, then ask, Do you have it every day?, If no, then ask, Did you have it at least half the days in the past 2 weeks? D0200 D 1 D 8 Conduct interview preferably the day before or day of ARD Ask scripted questions as they appear May utilize Interview techniques Record the resident s responses as they are stated, regardless of whether the resident or the assessor attributes the symptoms to something other than mood 8 11 MDS Scripted Interviews Interview techniques Break the questions apart if necessary Appendix D Disentangling: Separating items with several parts into manageable pieces. The type of items that lend themselves to this approach are those that include a list and phases such as and or or. the resident is given a chance to respond to each piece separately. If a resident responds positively to more than one component, obtain frequency for each positive response. Score the item suing the component that occurred most often Example: Item asks about Poor appetite or overeating. Disentangle by asking, Poor appetite? ; pause for a response and then ask, Or overeating? If neither part is rated positively by the resident, mark no, If either are positively rated, then mark yes D0200 D 1 D 8 Say to the resident: Over the last 2 weeks, have you been bothered by any of the following problems? If yes, then ask, About how often have you been bothered by this? 9 12 2
D0200 For each question: Do not provide definitions Meaning must be based on resident s interpretation Each question must be asked in sequence to assess presence (column 1) and frequency (column 2) before proceeding to the next question Enter code 9 for responses that are: Unrelated, incomprehensible, incoherent, or nonsensical D 1 D 8 Do not conduct if resident interview was complete D0500 D 11 D 14 PHQ 9 OV Observation Version Resident interview is preferred When resident is unable or unwilling to complete the PHQ 9 interview, the PHQ 9 OV Staff assessment of mood is completed To identify any behaviors and signs or symptoms of mood distress 13 16 D0300 D 1 D 8 D0500 D 11 D 14 Add scores for frequency items (col. 2) Do not add score during interview, focus full attention on resident Code higher frequency if resident has difficulty selecting between 2 choices 1 4: minimal depression 5 9: mild depression 10 14: moderate depression 15 19: moderately severe depression 20 27: severe depression 14 Interview staff from all shifts who know the resident best Encourage staff to report symptom frequency, even if staff believes symptom to be unrelated to depression Use interview techniques as needed If resident has been in the facility less than 14 days, Talk to family or significant other Review medical records 17 D0350 Refers to D0200I: Thoughts that you would be better off dead, or of hurting yourself in someway Complete D0350 only if yes response to D0200I1 Documents if appropriate clinical staff and/or mental health providers were informed Untreated depression can cause significant distress and increased mortality in the geriatric population Recognition and treatment of depression can be lifesaving, reducing risk or mortality within the nursing home and also for those discharged to the community 15 D 10 D0500 Over the last 2 weeks, did the resident have any of the following problems or behaviors? Additional item not on PHQ 9 18 D 11 D 14 3
D0600, D0650 Add the numeric scores across all frequency items (Column 2) D 14 D 16 E0100 7 day look back E 1 E 4 Scoring for PHQ 9 OV is different from PHQ 9 interview 19 Refers to D0600I Distressing to residents and families Cause disability Interfere with delivery of medical, nursing, rehabilitative and personal care Lead to dangerous behavior or possible harm 22 Section E: Behavior E 1 Intent: The items identify behavioral symptoms in the last 7 days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff or the care environment. These behaviors may place resident at risk for injury, isolation, and inactivity and may indicate unrecognized needs, preferences or illness. Behaviors include those that are potentially harmful to the resident himself or herself. Emphasis is to identify behaviors, which do not necessarily imply a medical diagnosis. Identification of frequency and impact of behavioral symptoms on the resident and others is critical to distinguish behaviors that constitute problems from those that are not problematic. Once the frequency and impact of behavioral symptoms are accurately determined, followup evaluation and care plan interventions can be developed to improve the symptoms or reduce their impact. 20 E0100 E 1 E 4 Example: Resident carries a doll which she believes is her baby and the resident appears upset. When asked about this, she says she is distressed from hearing her baby crying and thinks she s hungry and wants to get her a bottle Code Hallucination and Delusion : The resident believes the doll is a baby, which is a delusion, and she hears the doll crying, which is an auditory hallucination 23 Section E: Behavior E 1 E0200 E 4 E 6 Intent (continued): Items focus on resident s actions, not the intent of his or her behavior. Because of their interactions with residents, staff may have become used to the behavior and may underreport or minimize the resident s behavior by presuming intent (e.g., Mr. A. doesn t really mean to hurt anyone. He s just frightened ). Resident intent should not be taken into account when coding for items in this section. 21 New onset of behavioral symptoms warrants prompt evaluation, assurance of resident safety, relief of distressing symptoms, and compassionate response to resident Reversible and treatable causes should be identified and addressed promptly 24 4
E0200 E 4 E 6 E0600 E 9 E 13 Review medical record for 7 day look back period Interview staff across all shifts, others who had close interactions, including family or friends who visit frequently Observe Tip: Code resident as present, in even a variety if staff of have situations become used to the behavior or view it as typical or tolerable Code based on all the behavior symptoms coded in E0200 Determine impact on others 25 28 E0300 E 6 E0800 E 13 E 17 To determine whether or not additional items E0500, Impact on resident, and E0600, Impact on others are required to be completed 26 29 E0500 E 7 E 9 E0800 E 13 E 17 Code based on all the behavior symptoms coded in E0200 Determine impact on resident 27 Intent is to identify potential behavioral problems Not situations in which care was rejected based on a choice that is consistent with the resident s preferences or goals for health and well being Do not include behaviors that have already been addressed and determined to be consistent with the resident s values, preferences or goals Residents who have made an informed choice about not wanting a particular treatment or procedure should not be identified as rejecting care 30 5
E0800 E 13 E 17 E1100 E 20 E 22 Example: Resident is given antibiotic for treatment of pneumonia and spits the pills out on floor. Resident s assessment does not show any swallowing problems. This happened the last 4 days. Resident s advanced directives indicate he wants antibiotics to treat a potentially life threatening infection. E0800 = 2, behavior occurred 4 6 days, but less than daily : Behavioral rejection of antibiotics prevents resident from achieving his stated goals for health care listed in his advanced directives. Therefore, the behavior is coded a care rejection 31 Change in behavior may be an important indicator of: Change in health status or change in environmental stimuli Positive response to treatment Adverse effects of treatment Coding Review response for items E0100 E1000 Compare responses with prior MDS assessment Make global assessment of change in behavior from the most recent to the current MDS Rate overall behavior as same, improved or worse 34 E0900 E 17 E 19 Review medical record and interview staff to determine if wandering occurred during the 7 day look back window Wandering = act of moving from place to place with or without a specified course or known direction Wandering may or may not be aimless Resident may be oblivious to his or her physical or safety needs May be searching to find something, but he or she persists without knowing the exact direction or location May or may not be driven by confused thoughts or delusional ideas Pacing (repetitive walking with a driven/pressured quality) within a constrained space is not included in wandering 32 Section F F 1 SECTION F: PREFERENCES FOR CUSTOMARY ROUTINE AND ACTIVITIES Intent: These items obtain information regarding resident s preferences for his or her daily routine and activities. Best accomplished with information obtained directly from the resident or through family or significant others, or staff interviews if the resident cannot report preferences. Information obtained during the interview is just a portion of the assessment. Nursing homes should use this as a guide to create an individualized plan based on the resident s preferences, and is not meant to be all inclusive. 35 E1000 E 20 E 22 F0300 F 1 Not all wandering is harmful Some resident who wander are at potentially higher risk for entering an unsafe situation Some resident who wander can cause significant disruption to other residents 33 If resident is rarely/never understood Interview may be completed by family/significant other Only code 0. No, if resident is rarely/never understand AND family/significant other is not available Identify if resident wants or needs an interpreter Utilize interview techniques and cue cards, if needed 36 6
F0400 F 2 F 8 F0700 F 13 F 14 Complete only if resident, family or significant other were unable to complete interview 37 40 F0500 The interview is considered incomplete if the resident gives nonsensical responses or fails to respond to 3 or more of the 16 items in F0400 and F0500. 38 F 8 F 12 F0800 Observe the resident when the care, routines and activities specified in these items are made available to the resident Across all shifts and departments If the resident appears happy or content during an activity listed then the item should be checked If the resident seems to resist or withdraw, then do not check that item 41 F 14 F 16 F0600 F 13 Establishes the source of the information regarding the resident s preferences Only MDS interview which allows family or significant only the respond if resident is unable 39 Section Q 42 Q 1 SECTION Q: PARTICIPATION IN ASSESSMENT AND GOAL SETTING Intent: The items in this section are intended to record the participation and expectations of the resident, family members, or significant other(s) in the assessment, and to understand the resident s overall goals. Discharge planning follow up is already a regulatory requirement (CFR 483.20 (i)(3)). Section Q of the MDS uses a person centered approach to ensure that all individuals have the opportunity to learn about home and communitybased services and to receive long term care in the least restrictive setting possible. Interviewing the resident or designated individuals places the resident or their family at the center of decision making. 7
Q0100 Q 1 Q0300 Q 4 Residents who actively participate in the assessment process and in developing their care plan through interview and conversation often experience improved quality of life and higher quality of care based on their needs, goals, and priorities 43 Steps for assessment Ask the resident about his or her overall expectations/goals If resident is unable to provide a clear response, information can be obtained from family or significant other If family or significant other not available, the information should be obtained from the guardian or legally authorized representative 46 Q0100 Q 1, Q 2 Q0400 Q 8 Understand definitions Coding instructions Code 0, No: if there is not active discharge planning already occurring for resident to return to community Code 1, Yes: if there is active discharge planning already occurring for the resident to return to the community Skip to Q0600 44 47 Q0100 Q 2 Q0490 Q 12, Q 13 Coding instructions Code resident, family and/or significant other and guardian or legally authorized representative participation in the assessment process Medical record review, interview with staff, resident, family and/or significant other or legally authorized representative 45 Complete only if A310A= 02: Quarterly 06: Significant Correction to prior Quarterly 99: None of the above Code 0, no, if there is no notation in resident s clinical record that he/she does not want to be asked Question Q500B (Return to Community) again Code 1, yes, if there is a notation in resident s record to not ask Question Q0500B, except on comprehensive assessments 48 8
Q0500 Q 16 Q0600 Q 20 Code 0, no, if resident states he or she does not want to talk to someone about the possibility of returning to the community Code 1, yes, if the resident states that he or she does want to talk to someone about possibility of returning to community Code 9, unknown or uncertain, if the resident cannot understand or respond and the family or significant other is not available to respond on the resident s behalf, and a guardian or legally authorized representative is not available or has not been appointed by the court 49 Coding instructions (continued) Code 0, no referral not needed if determination has been made by the resident and care planning team that the designated LCA does not need to be contacted Discharge plan has been completely developed by the nursing home staff, and there are no additional needs that the SNF/NF cannot arrange for, and there is no need for a LCA referral Code no, if resident responded no to Q0500B 52 Q0550 Q 18 Q0600 Q 21 Some residents (those with cognitive impairments, mental illness, or endstage life conditions) may be upset by asking if they want to return to the community Provides opportunity to opt out of being asked the question every quarter Provide better balance between giving resident a voice and a choice about the services they receive, while being sensitive to those individuals who may be unable to voice their preferences or be upset by being asked question Q0500B in the assessment process Guides future response to Q0490 50 Coding instructions Code 1, no referral is or may be needed if determination has been made by the resident that the designated local contact agency need to be contacted but the referral has not been initiated at this time If the resident has asked to talk to someone about available community services and supports and referral is not made at this time, care planning and progress notes should indicate the status of discharge planning and why a referral was not initiated 53 Q0600 Q 20 Q0600 Q 20 Q0600 is only completed if: Q0400A is coded YES = active discharge plan is occurring OR Q0490 is coded YES = resident is asked only on comprehensive assessments OR Q0500B is coded YES = resident wants to talk to someone possibility of leaving this facility and returning to live in the community 51 Coding instructions Code 2, yes referral made if the referral was made to the local contact agency. The facility care planning team was notified and initiated contact with the local contact agency Section Q Point of Contact list for Local Contact Agencies: http://medicaid.gov/medicaid chip program information/by topics/longterm services and supports/community living/downloads/state by state poclist.pdf 54 9
MDS Essentials Questions Please submit questions to: The New to MDS Community 55 58 Please continue with MDS Coding Essentials: Sections G and J 56 MDS Essentials RAC CT Education Advancement Education Advancement Professional Development Expert within your Organization Successfully Completed RAC CT Completed QCP CT Completion of Medicare University RAC MT, QCP MT 57 10