RAI Panel Q&As August-September 2008 Assessment Questions Question I understand that if a facility misses an assessment and discovers it shortly thereafter, they should do an assessment with a current ARD now. For example, if a facility missed an April quarterly assessment and discovered it in May, they would do a quarterly in May and transmit. They would be out of compliance with the assessment schedule for the period from April until the assessment was done in May. Correct? Answer YES, that is correct. Additionally, the facility would have gotten a warning error message saying that the quarterly assessment was late. AHFSA RAI Panel 08/07/2008 Question - What if a facility does not discover that they missed an assessment for many months? Let s say they do a quarterly in May and an annual in August on a resident. Then, they discover that the quarterly that was due in February was never done. What do they do? Answer There is nothing to do at this point just get back on schedule; the next quarterly would be due in November. If an assessment has been missed and it is now time to do another assessment, the facility needs to complete the one that is due now and forget the old one. AHFSA RAI Panel 08/07/2008 Question The facility found they didn't do an admission assessment when they got ready to do their quarterly. I know they can't backdate nor create an assessment that wasn't done. Do they now do a comprehensive assessment for their quarterly and get a warning that it is out of sequence or will there be other consequences? Answer - We are glad you sought clarification. The facility needs to complete a full assessment (admission)as soon as possible. They cannot go back and recreate the assessment from the missing time period. The AB1-Date of Entry, would be the actual admission date but the ARD would have to be current. They will be considered out of compliance with the requirements for the time period that a valid assessment was not present, so the sooner they can establish a new assessment reference date (ARD) and complete the assessment the better. They should also document in the resident's record, to explain why it was being done that way. There may also be state specific requirements that apply to these types of situations that will need to be considered in addition to the federal requirements.
AHSFA RAI Panel 08/07/2008 G1b(B) ADL Support Provided Question When using a sit to stand lift, if 1 person is operating the lift for a transfer, would G1b(B) be coded 3 (ADL Support Provided - two person transfer)? Would the lift itself be count as a person, as well as the person running the lift? Answer No, a standing lift is an assistive device, not a person. AHFSA RAI Panel 08/27/2008 Section I I1z Quadriplegia Question In the September 2007 ICD-9-CM Coordination and Maintenance Committee Meeting, Functional Quadriplegia was defined as the inability to move due to another condition (severe contractures, arthritis, etc.) and functionally the patient is the same as a paralyzed person." Would this include a resident with dementia who is bedridden, or frail, or in the end stage of life? Answer New ICD-9 diagnostic codes in the Symptom chapter have been proposed but currently there is no such diagnosis as functional quadriplegia. It is the responsibility of the physician, not the billing or medical records department, to provide the correct diagnoses. Regardless of the cause, if the physician is willing to provide the diagnosis of quadriplegia, and it meets the rest of the criteria, it can be coded under I1z. AHFSA RAI Panel 09/10//2008 Section M Question - If a hematoma was surgically removed, does it then become a surgical wound? Answer On page 3-166 (M4g) says a surgical wound includes healing and nonhealing, open or closed surgical incision, skin graft or drainage site on any part of the body. If surgery was performed, then we would assume it would be reasonable to code it as surgical wound. AHFSA 08/22/2008
Question - A resident was run over with her car; How would you code this type of wound? Answer - We don't have enough information to respond to this. Were there bruises, abrasions, skin tears, broken bones? Was surgery involved? The resident should be assessed for the wounds that were received during this accident and then all wounds should be coded accordingly. For example if she sustained a hip fracture then it would be coded in section J If the injuries don t fit elsewhere, then code the injury at I3. AHFSA 08/22/2008 Section P P1ac or O3 for Intrathecal Injection Question - Should an intrathecal injection (no IV tubing is used and there is no artificial "port" to use) be coded at P1ac? Answer - The RAI Manual states that epidural, intrathecal and baclofen pumps can be counted at P1ac. If this had been an intrathecal pump, the rationale in the manual suggests that it be coded under P1ac(IV Medication) because the continuous administration of a substance would require frequent monitoring. Given the circumstances in the example, the intrathecal injection directly into the site, without a port or a pump, would not count per the manual. This was just one injection and would be coded under O3(Injections). AHFSA 08/25/2008 P1a(d) Chest Tube Excretions Question - When a resident has a chest tube, is the volume of fluid collected from the chest tube included in the output? Answer - If there is clinical documentation showing monitoring and measurement of the chest tube excretions for at least 3 consecutive shifts, then it can be coded at P1a(d). AHFSA RAI Panel 08/11/2008 Compound Fracture Question - Resident fell & fractured femur. No surgery at the time of fracture. The bone then worked through the skin for a compound fracture. The resident is not a surgical candidate & refused surgery. The resident is now in traction & the fracture has been reduced. Sections I and J4 should be coded. Should this scenario be coded elsewhere?
Answer - The facility will want to consider P1a(e) Monitoring Acute Medical Condition. This resident is a poor candidate for surgery and/or is refusing surgery and, where there had been some sort of mobility, this person is now on full bed rest. Certainly there is a greater risk for a number of issues including pressure ulcers, so it would seem reasonable that this resident will require much closer monitoring and preventative measures put in place. AHFSA RAI Panel 08/08/2008 P1b(e) Psych Therapy Question Can a MSW employed by the facility, code the physician ordered psychological therapy minutes she provides that is over and above her role as the facility social worker? The facility MDS coordinator thinks this would not be acceptable since she works for the facility and doesn't have a Medicare provider I.D. and these minutes would increase their RUG scores. Answer The keyword here is "licensed mental health professional. In Chapter 3 at P1b(e), the RAI Manual lists a psychiatric social worker as an example of a licensed mental health professional. The manual also specifies that if the state doesn't license a category of professionals, then the services provided by that individual cannot be coded for this item. The panel does not believe a Medicare provider I.D is relevant to the issue and Psychological therapy is not a RUG item. AHFSA RAI Panel 09/08/2008 P3j Rehabilitation/Restorative Care Question - Can a restorative program(p3j)be coded when the deficit is a language barrier(only speaking a foreign language)? The RAI manual mentions functional communication skills, but does this include a language barrier? Answer On page 3-54, the manual differentiates between speaking a different language versus having a functional problem. At P3j, the MDS is meant to capture Nursing restorative/rehab programs - often initiated after formalized physical, occupational, or speech rehabilitation therapy. Speech therapists are not involved in teaching foreign languages. If this person has no "functional" speech impediment & the only problem is "communication," then communication issues are captured in Section C. AHFSA RAI Panel 08/27/2008 Extra RAPs Question - "May I complete a RAP even if it is not triggered?" Answer - See pages 1-13 to 1-14 of the RAI Manual, and a reference to the determining factor for the RAP process can be found on page 4-5, item #4, where it states: "Based on the review of assessment information, the interdisciplinary team
decides whether or not the triggered condition affects the resident's functional status or well-being and warrants a care plan intervention." Also, the manual states the RAP process may be applied to triggered and non-triggered items and even to items that are not listed - see item #2 same page. ~~The key words here are "warrants a care plan intervention." The facility must make the clinical judgment in this area. AHFSA 08/22/2008 I Care Plans Question - I have briefly mentioned the I care plans in training. My attendees want to know if CMS will be looking for them to be used in the near future. Answer - On page 4-26 of the RAI Manual, it says, It is not the intent of this chapter to specify a care plan structure or format. Beginning on page 4-29, the manual also directs the reader to the care planning requirements at the specified F Tags. In accordance with F279, a care plan must be oriented toward preventing avoidable decline and have measurable objectives. The Panel agrees that done correctly, the I care plans do have an individualized approach. However to this point, CMS has chosen not to dictate the format of the plan of care and we do not believe that stance will change. AHFSA RAI Panel 09/02/2008
New Facility & MDS Data Collection RAI Version 2.0 Q&As October-November 2008 Question: We are in the process of getting the rest of the beds in our facility certified for Medicare and Medicaid. So, currently, we have residents in beds that are not certified and their MDS assessments have been done per OBRA guidelines but not submitted to the database. My question is the following: When we do get the confirmation that all the beds in the facility are certified beds for Medicare and Medicaid will we need to submit an Admission MDS for each of these residents who do not have an Admission MDS in the database (and then follow a new OBRA schedule for their MDS assessments) or do we just change their sub req to "3" and start submitting MDS assessments where ever their current OBRA schedule falls? Answer: For the OBRA schedule there should be a new comprehensive assessment close to the date of certification (Admission) to get started and those assessments have to be done at the time of the certified date or close to it - that will start the MDS clock for the OBRA assessments. Please read 1-16 regarding newly certified nursing homes under 1.11 - Facility Responsibilities for Completing Assessments. You can't take old assessments and just change the Sub Req # to get them submitted. The facility will have to wait until they get their Medicare Provider number before they can start accepting PPS residents and then can follow the guidelines: 1. Necessary 3- day qualifying hospital stay and 2. Medically necessary skilled services are needed on a daily basis with physician's documentation. They can't collect data prior to the Medicare certification date, because they can't put a resident in a bed that is not certified unless they are ready to submit. AHFSA RAI Panel 10/30/08 G6 Siderails for Mobility Question: We have installed a Halo Safety Ring which is attached to the mattress frame and fits snug against the mattress. These do not prevent any freedom of movement for the residents; it enables them to have more independence in their bed mobility and transfers. <>The issue is how to appropriately code the Halo Safety Ring on the MDS. Section G6b states 'bedrails used for bed mobility or transfer'. Would you consider the Halo Safety Ring in the same category as a 'bedrail' which would allow a score on G6b? Answer: Based on the intent and definition, the RAI Panel members believe the Halo Safety Ring can be coded at G6, provided the resident uses the ring for bed mobility or transfer. As with all devices, it must be evaluated on an individual basis for risks and benefits.
AHFSA RAI Panel 11/24/2008 Questions on Section K K5c - Mechanically Altered Diet Question: Currently the definition for Therapeutic Diet in the RAI Manual version 2.0, does not include mechanically altered diets. However, in the newly revised F325 tag, (eff: 9-1-08), the definition of mechanically altered diets is now included in the definition of the therapeutic diet. I have been telling the providers that until the new MDS version is out, to continue completing the MDS as it is written, following the 2.0 instructions. HOWEVER, I have heard that some providers had contacted CMS directly, and were told to start coding the MDS now, with the new definition. Answer: The RAI User s Manual, currently the 2.0 version, has always been the source for coding the MDS, and this has not changed. You are correct in telling the providers that they need to continue to code item K5c according to the current RAI manual. This concept is also true with the revised F314 (eff: 11-12-04) which clearly expects facilities to provide care and services that are based in the current standards of practice but the MDS requires coding based on old standards that are reflected in the manual. AHFSA RAI Panel 10/31/2008 Section M M1 Deep Tissue Injury Question: One of our state LTC Nurse Consultants attended a Pressure Ulcer Consortium in Kansas (9/2008). She stated that a representative of CMS advised attendees at a break out session to code a deep tissue injury with no open areas as a stage IV, Have there been any written clarifications from CMS regarding staging a DTI? How do you code suspected deep tissue injuries? Answer: Suspected deep tissue injuries were discussed during the August Open Door Forum because CMS had been made aware of facilities coding them at Stage 1 or Stage 4. Currently there is no way to document a suspected deep tissue injury (SDTI) on the MDS 2.0 at item M1. The facilities should be directed to refer to the RAI Manual definitions for each stage and code what is known not what is suspected. Code based on the observed appearance of the area and whether or not it matches any of the definitions of the various stages described in the manual. The facility should also document in the resident's clinical record if they suspect the resident has a deep tissue injury. SDTIs can be coded on MDS 2.0 at I3, and on the billing UB. Effective October 1, 2008, the ICD9CM codes were updated. As part of this update, there are new codes for different ulcer stages, including suspected deep tissue injury and unstageable. The update can be found at: http://www.cdc.gov/nchs/datawh/ftpse...htm#guidelines
In addition, deep tissue injuries are a projected part of the MDS 3.0 coding. AHFSA 11/13/2008 Questions on Section P MDS 2.0 Section P4d - Restraints Question: I have another question to bring to the panel from one of our state's nurse consultants. Regarding a manual hold...has CMS given any clarifications regarding a hold to prevent movement of an arm during a blood draw? I assume this would be coded under P4d, but thought I would check with you, just in case there has been a CMS update, that I am not aware of. Answer: The AHFSA RAI Panel has reviewed your question and do not believe that this scenario would be considered a restraint. However, if the facility wanted to code this scenario if it occurred within the look-back period they could do so, but there should be a good restraint assessment according to the regulations and documentation as is required with any restraint. There has been no CMS guidance regarding this situation. P8 Physician orders Question: When the facility activates a standing order or a facility protocol, does that day count that as a day for physician order changes? The facilities activates the standing orders / facility protocols & then has the physician sign the order. I know PRN orders are not counted. Standing orders are defined as: Physician orders pre-established and approved for use by nurses and other professionals under specific conditions in the absence of a physician. Answer: As with PRN orders, the list of standing orders has already been written and the potential need for the service had already been identified. As you indicated, the standing orders had been approved for use. There is no change to the order simply because it has been implemented, so notifying the Dr. that the order was activated does not constitute a new or changed order and may not be counted for this MDS item. AHSFA RAI Panel 11/20/2008