MDS 3.0 Resident Assessment Manual Chapter 3 Section A
Contents
1. aJaAes J A r BJBABS Je J pOo A Z PININ L SAep sej y JOAO Uled 1SJOM JNOA 3 2e1 SL jd je s J1ol diu9S dq jeqis SAep G sej y JOAO uled 1SJOM INOA 9 2e1 SE d gjeos Bbuney oWewNny Handout Page 5 Pain Frequency Cue Card MDS 3 0 J0400 How much of the time have you experienced pain or hurting over the last 5 days 1 2 Almost constantly Frequently Occasionally Rarely RRS Healthcare Consuslting Services 2010 CMS s RAI Version 3 0 Manual CH 3 MDS Items G G0110 Activities of Daily Living ADL Assistance cont ADL Self Performance Algorithm START HERE Remember to review the instructions for the Rule of 3 and the ADL Self Performance Coding Level Definitions before using the algorithm STOP at the first code that applies when moving down the algorithm Did the activity occur at least 1 time i Did the activity occur 3 or more times 9 N Yes Yes Did the resident fully perform the ADL activity Code 0 Independent without ANY help or oversight from staff every time No Yes Code 4 Total Dependence Did the resident require full staff performance every time No Yes Did the resident require full staff performance at least 3 times but not every time OR weight bearing assistance 3 or more times Code 3 Extensive Assistance Did the resident require a combination of full staff performance2. Worsening in Pressure Ulcer Status Since Prior Assessment OBRA or scheduled PPS or Last Admission Entry or Reentry cont 4 A resident develops a Stage 3 pressure ulcer while at the nursing home The wound bed is subsequently covered with slough and is 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 Coding Code MO800A as 0 M0800B as 0 and M0800C as 0 Rationale MO800B would be coded 0 because the numerical stage of the pressure ulcer is the same numerical stage as it was prior to the period it became unstageable M0900 Healed Pressure Ulcers M0900 Healed Pressure Ulcers Complete only if A0310E 0 EnterCode A Were pressure ulcers present on the prior assessment OBRA or scheduled PPS 0 No Skip to M1030 Number of Venous and Arterial Ulcers 1 Yes Continue to MO900B Stage 2 Indicate the number of pressure ulcers that were noted on the prior assessment OBRA or scheduled PPS that have completely closed resurfaced with epithelium If no healed pressure ulcer at a given stage since the prior assessment OBRA or scheduled PPS enter 0 Enter Number Enter Number Enter Number Item Rationale Health related Quality of Life Pressure ulcers do not heal in a reverse sequence that is the body does not replace the types and layers of tissue e g muscle fat
3. and dermis that were lost during pressure ulcer development before they re epithelialize Stage 3 and 4 pressure ulcers fill with granulation tissue This replacement tissue is never as strong as the tissue that was lost and hence is more prone to future breakdown Handout Page 13 M0900 Healed Pressure Ulcers cont Planning for Care Pressure ulcers that heal require continued prevention interventions as the site is always at risk for future damage Most Stage 2 pressure ulcers should heal within a reasonable timeframe e g 60 days Full thickness Stage 3 and 4 pressure ulcers may require longer healing times Clinical standards do not support reverse staging or backstaging as a way to document healing as it does not accurately characterize what is physiologically occurring as the ulcer heals For example over time even though a Stage 4 pressure ulcer has been healing and contracting such that it is less deep wide and long the tissues that were lost muscle fat dermis will never be replaced with the same type of tissue Previous standards using reverse or backstaging would have permitted identification of this pressure ulcer as a Stage 3 then a Stage 2 and so on when it reached a depth consistent with these stages Clinical standards now would require that this ulcer continue to be documented as a Stage 4 pressure ulcer until it has completely healed Nursing homes can document the healing of pressure ulcers using descripti
4. home care or community based services If a resident returns from a hospital stay an initial evaluation must be performed upon readmission to the facility and only those therapies that occurred since readmission to the facility may be counted The therapist s time spent on documentation or on initial evaluation are not included The therapist s time spent on subsequent reevaluations conducted as part of the treatment process should be counted The resident s treatment time starts when he or she begins the first treatment activity or task and ends when he or she finishes with the last apparatus or intervention task and the treatment is ended as long as the services were not interrupted for example by a bathroom break or a nontherapeutic rest The time required to adjust equipment or otherwise prepare for the individualized therapy of a particular resident is the set up time and may be included in the count of minutes of therapy delivered to the resident Include only skilled therapy services Skilled therapy services must meet the following conditions for Part A services must be ordered by a physician For Part B the plan of care must be certified by a physician following the therapy evaluation the services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by a qualified therapist prior to the start of therapy services in the facility t
5. ulcer prevention and skin health interventions that are a part of providing quality care and consistent with good clinical practice for those with skin health problems These general treatments should guide more individualized and specific interventions in the care plan If skin changes are not improving or are worsening this information may be helpful in determining more appropriate care Steps for Assessment 1 Review the medical record including treatment records and health care provider orders for documented skin treatments during the past 7 days Some skin treatments may be part of routine standard care for residents so check the nursing facility s policies and procedures and indicate here if administered during the look back period 2 Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review 3 Some skin treatments can be determined by observation For example observation of the resident s wheelchair and bed will reveal if the resident is using pressure reducing devices for the bed or wheelchair Coding Instructions Check all that apply in the last 7 days Check Z None of the above were provided if none applied in the past 7 days M1200A Pressure reducing device for chair M1200B Pressure reducing device for bed M1200C Turning repositioning program M1200D Nutrition or hydration intervention to manage skin problems M1200E Pressure ulcer care M1200F Surgic
6. agents Ointments medications may include topical creams powders and liquid sealants used to treat or prevent skin conditions This category does not include ointments used to treat non skin conditions e g nitropaste for chest pain testosterone cream M1200 Application of Dressings to the Feet with or without Topical Medications Includes interventions to treat any foot wound or ulcer other than a pressure ulcer Do not code application of dressings to pressure ulcers on the foot use M1200E Pressure Ulcer Care Do not code application of dressings to the ankle The ankle is not considered part of the foot Examples 1 A resident is admitted with a Stage 3 pressure ulcer on the sacrum Care during the last 7 days has included one debridement by the wound care consultant application of daily dressings with enzymatic ointment for continued debridement nutritional supplementation and use of a pressure reducing redistribution pad on the wheelchair The medical record documents delivery of care and notes that the resident is on a 2 hour turning repositioning Handout Page 25 Minutes of therapy for 00400 Includes only therapies that were provided once the individual is actually living being cared for at the long term care facility Do NOT include therapies that occurred while the person was an inpatient at a hospital or recuperative rehabilitation center or other long term care facility or a recipient of
7. and lack of success That s true for the MDS 3 0 interviews as well as any other interviews we do with our residents So let s take a look at some of the interview techniques that can help residents to complete the interviews and with responses that are meaningful Ensure the environment is conducive to interview Private location Comfortable seating Relaxed atmosphere Minimal distractions Optimal resident ability to hear To begin with ensuring that the interview environment is conducive to interviewing is critical to conducting the interview First of all be sure the location is private And this is something that the facility needs to address from a system perspective since most residents live in a semi private room which doesn t offer much privacy as far as conversation is concerned Also important are comfortable seating and a relaxed atmosphere for the resident minimal stress and minimal noise and activity that might distract the resident Another very critical factor is the resident s hearing Obviously when a resident doesn t hear everything you re saying the interview results are not meaningful Using a simple hearing device such as the kind with the head set attached to a cigarette pack sized amplifier can make a significant difference Nurses who know their residents really well often are very surprised at how much more responsive and appropriate some of their residents are when they use such
8. have dry cracked skin on his other foot Do not include pressure ulcers that occur on residents with diabetes mellitus here For example an ulcer caused by pressure on the heel of a diabetic resident is a pressure ulcer and not a diabetic foot ulcer M1040D Open Lesion Other than Ulcers Rashes Cuts Do not code rashes skin tears cuts lacerations here Although not recorded on the MDS assessment these skin conditions should be considered in the plan of care M1040E Surgical Wounds This category does not include healed surgical sites and healed stomas or lacerations that require suturing or butterfly closure as surgical wounds PICC sites central line sites and peripheral IV sites are not coded as surgical wounds Surgical debridement of a pressure ulcer does not create a surgical wound Surgical debridement is used to remove necrotic or infected tissue from the pressure ulcer in order to facilitate healing A pressure ulcer that has been surgically debrided should continue to be coded as a pressure ulcer Handout Page 19 M1040 Other Ulcers Wounds and Skin Problems cont Code pressure ulcers that require surgical intervention for closure with graft and or flap procedures in this item e g excision of pressure ulcer with myocutaneous flap Once a pressure ulcer is excised and a graft and or flap is applied it is no longer considered a pressure ulcer but a surgical wound M1040F Burns Second or Third Degree Do not inclu
9. increased in numerical stage to a Stage 3 pressure ulcer Coding Code MO800A as 0 M0800B as 1 and MO800C as 0 Rationale The pressure ulcer was at a lesser numerical stage on the prior assessment A resident is admitted with an unstageable pressure ulcer on the sacrum which is debrided and reclassified as a Stage 4 pressure ulcer 3 weeks later The initial MDS assessment listed the pressure ulcer as unstageable Coding Code MO800A as 0 MO8OOB as 0 and M0800C as 0 Rationale The unstageable pressure ulcer was present on the initial MDS assessment After debridement it numerically staged as a Stage 4 pressure ulcer This is the first numerical staging since debridement and therefore should not be considered or coded as worsening on the MDS assessment A resident has previous medical record and MDS documentation of a Stage 2 pressure ulcer on the sacrum and a Stage 3 pressure ulcer on the right heel Current skin care flow sheets indicate a Stage 3 pressure ulcer on the sacrum a Stage 4 pressure ulcer on the right heel as well as a new Stage 2 pressure ulcer on the left trochanter Coding Code MO800A as 1 MO800B as 1 and M0800C as 1 Rationale M0800A would be coded 1 because the new Stage 2 pressure ulcer on the left trochanter was not present on the prior assessment MO800B would be coded 1 and MO800C would be coded 1 for the increased numerical staging of both the sacrum and right heel pressure ulcers Handout Page 12 M0800
10. source of information e g mood preferences pain Self report is the single most reliable indicator of these topics Staff should actively seek information from the resident regarding these specific topic areas however resident interview inquiry should become part of a supportive care environment that helps residents fulfill their choices over aspects of their lives In addition a simple performance based assessment of cognitive function can quickly clarify a resident s cognitive status The majority of residents even those with moderate to severe cognitive impairment are able to answer some simple questions about these topics Even simple scripted interviews like those in MDS 3 0 involve a dynamic collaborative process There are some basic approaches that can make interviews simpler and more effective Introduce yourself to the resident Be sure the resident can hear what you are saying Do not mumble or rush Articulate words clearly Ask the resident if he or she uses or owns a hearing aid or other communication device Help him or her get the aid or device in place before starting the interview The assessor may need to offer an assistive device headphones If the resident is using a hearing aid or other communication device make sure that it is operational Ask whether the resident would like an interpreter language or signing if the resident does not appear to be fluent in English or continue
11. you try to reword questions too much their meanings may change or they may become too open ended and lose their effectiveness Use visual aids cue cards along with providing verbal instructions It is very helpful to residents to use a cue card or a paper that has the answer options written in large print that they can refer to each time you review them With long answers summarize echo the answer You re saying that and then ask which response option represents what he said and review the response options This technique can be very helpful in refocusing the resident It s called echoing This is useful when you get a sort of long winding answer from the resident that s really not on point In that case you would summarize or echo what he said You might say for example You re saying that and then summarize briefly and then ask which response option represents what he said and then review the response options with him again Echoing also should be used whenever a resident provides a response to validate that you heard what was said and to help the resident maintain focus Handout Page 33 Help to narrow the response when necessary unfolding Unfolding is a technique that can help to narrow the response when the resident is trying to figure out how often something has occurred Here is an example from the PHQ 9 of how the conversation might go Q Over the last two weeks have you b
12. Handout Page 1 Medicare Stay End Date Algorithm A2400C Is the resident s Medicare stay Yes Enter dashes ongoing Did the resident s Enter the date of the SNF benefit Yes last covered day i e the 100th day exhaust Enter the effective date on the Generic Notice for last covered day Was a generic notice issued to the Yes U resident Did the resident s Enter the date of the Yes _ fast paid day of Medicare A payer source change from Part A to another payer Enter the date resident was discharged from facility if resident leaves facility prior to last covered day as recorded on the generic notice enter date resident left facility Aep Asano IHE N S eG yl ZL SAep y JO B1OW 10 Ji H sAeg LIL Z x x s ep Ie J A 9S s eqd 9 Z Aep 10 I A N Aep 10 JOA0N Eee aAndusseq JUN wajgoid ay q palayjog u q nok aney u yo Moy noge sy A z Se y 1940 Handout Page 3 Preferences for Customary Routine and Activities Symptom Frequency Cue Card MDS 3 0 F0400 and F0500 While you are in this facility how Important is it to you to 1 Very important 2 Somewhat important 3 Not very important 4 Not important at all 5 Important but can t do or no choice RRS Healthcare Consulting Services 2010 Handout Page 4 OLOZ s 3lAJ S Buninsuog eseouyeaH SHY qiou
13. Moisture Associated Skin Damage MASD i e incontinence IAD perspiration drainage Z None of the above were present Handout Page 17 M1040 Other Ulcers Wounds and Skin Problems cont Item Rationale Health related Quality of Life Skin wounds and lesions affect quality of life for residents because they may limit activity may be painful and may require time consuming treatments and dressing changes Many of these ulcers wounds and skin problems can worsen or increase risk for local and systemic infections Planning for Care This list represents only a subset of skin conditions or changes that nursing homes will assess and evaluate in residents The presence of wounds and skin changes should be accounted for in the interdisciplinary care plan This information identifies residents at risk for further complications or skin injury Steps for Assessment 1 Review the medical record including skin care flow sheets or other skin tracking forms 2 Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review 3 Examine the resident and determine whether any ulcers wounds or skin problems are present Key areas for diabetic foot ulcers include the plantar bottom surface of the foot especially the metatarsal heads the ball of the foot Coding Instructions Check all that apply in the last 7 days If there is no evidence of such problems
14. a device Explain in simple terms what the process is for the interview Handout Page 32 Here is an example using PHQ 9 I m going to be asking you if you have been bothered in the last two weeks by a number of different problems These are things that we ask everybody because it helps us a lot to be able to meet your needs Any time you say yes to a problem will then ask you to tell me how often you were bothered by it in the last two weeks Then review the answer options with the resident Meaning of words and phrases is based on resident s definitions The meaning of words and phrases used in the interview questions is based on the resident s definitions If the resident asks for a definition let him her know it means whatever he or she thinks it means For example when you say to the resident Over the last 2 weeks have you been bothered by any of the following problems he might ask you Well what does bothered by mean Your answer would be something like It means whatever you think it means If you feel that something has bothered you in the last 2 weeks then it has Stick to the script It is very important to stick to the script These questions have been tested with nursing home residents and found to be very effective in collecting the kind of information they are intended to collect If you go too far off script you run the risk of going down an unintended path Also if
15. ails may also be present The wound may start with some kind of minor trauma such as hitting the leg on a wheelchair The wound does not typically occur over a bony prominence however can occur on the tops of the toes Pressure forces play virtually no role in the development of the ulcer however for some residents pressure may play a part Ischemia is the major etiology of these ulcers Lower extremity and foot pulses may be diminished or absent Venous Ulcers The wound may start with some kind of minor trauma such as hitting the leg on a wheelchair The wound does not typically occur over a bony prominence and pressure forces play virtually no role in the development of the ulcer Example 1 A resident has three toes on her right foot that have black tips She does not have diabetes but has been diagnosed with peripheral vascular disease Coding Code M1030 as 3 Rationale Ischemic changes point to the ulcer being vascular M1040 Other Ulcers Wounds and Skin Problems M1040 Other Ulcers Wounds and Skin Problems J Check all that apply Foot Problems A Infection of the foot e g cellulitis purulent drainage B Diabetic foot ulcer s C Other open lesion s on the foot Other Problems Open lesion s other than ulcers rashes cuts e g cancer lesion Surgical wound s Skin tear s D E F Burn s second or third degree G H
16. aining interview sections It is particularly important to complete the performance based cognitive items in one sitting Do not try to talk a resident out of an answer If the resident expresses strong emotions be nonjudgmental and listen Record the resident s response not what you believe he or she should have said Ifthe resident becomes deeply sorrowful or agitated sympathetically respond to his or her feelings Allowing emotional expression even when it is uncomfortable for you as the interviewer recognizes its validity and provides cathartic support to residents April 2012 Appendix D 3 Handout Page 30 CMS s RAI Version 3 0 Manual Appendix D Interviewing to Increase Resident Voice If the resident remains agitated or overly emotional and does not want to continue respond to his or her needs This is more important than finishing the interview at that moment You can complete this and other sections at a later point in time Resident preferences may be influenced by many factors in a resident s physical psychological and environmental state and can be challenging to truly discern Residents should be encouraged to articulate their desires and not be strictly limited by their physical limitations and perceived environmental restrictions When a resident is unable to communicate information about his or her preferences a family member close friend or other representative must be us
17. al wound care Handout Page 22 M1200 Skin and Ulcer Treatments cont M1200G Application of non surgical dressings with or without topical medications other than to feet Non surgical dressings do not include Band Aids M1200H Application of ointments medications other than to feet M1200I Application of dressings to feet with or without topical medications M1200Z None of the above were provided Coding Tips M1200A M1200B Pressure Reducing Devices Pressure reducing devices redistribute pressure so that there is some relief on or near the area of the ulcer The appropriate reducing redistribution device should be selected based on the individualized needs of the resident Do not include egg crate cushions of any type in this category Do not include doughnut or ring devices in chairs M1200C Turning Repositioning Program The turning repositioning program is specific as to the approaches for changing the resident s position and realigning the body The program should specify the intervention e g reposition on side pillows between knees and frequency e g every 2 hours Progress notes assessments and other documentation as dictated by facility policy should support that the turning repositioning program is monitored and reassessed to determine the effectiveness of the intervention M1200D Nutrition or Hydration Intervention to Manage Skin Problems The determination as to whether or not one sh
18. and weight bearing assistance that total 3 or more times No Code 2 Did the resident require non weight bearing Limited assistance 3 or more times Assistance No Did the resident require a combination of full staff performance weight bearing assistance and or non weight bearing assistance that total 3 or more times N Code 1 Did the resident require oversight Supervision encouragement or cueing 3 or more times o No Yes If none of the above are met Code 1 Supervision October 2013 R 2 Code 8 The ADL Activity or any part of the ADL was not performed by the resident or staff at all Code 7 Activity occurred fewer than 3 times Instructions for the Rule of 3 Exceptions to the Rule of 3 e Code 0 Code 4 and Code 8 as the definition for each of these coding levels is very specific and cannot be entered on the MDS unless it is the level that occurred every time the ADL occurred Code 7 as this code only applies if the activity occurred fewer than 3 times Rule of 3 1 When an activity occurs 3 or more times at any one level code that level When an activity occurs 3 or more times at multiple levels code the most dependent level that occurred 3 or more times When an activity occurs 3 or more times and at multiple levels but not 3 times at any one level apply the following a Convert episodes of full staff performance to weight bearing a
19. assessment To track increasing skin damage this item documents the number of new pressure ulcers and whether any pressure ulcers have worsened or increased in numerical stage since the last assessment Such tracking of pressure ulcers is consistent with good clinical care Planning for Care The interdisciplinary care plan should be reevaluated to ensure that appropriate preventative measures and pressure ulcer management principles are being adhered to when new pressure ulcers develop or when pressure ulcers worsen Steps for Assessment Look back period for this item is back to the ARD of the prior assessment If there was no prior assessment i e if this is the first OBRA or scheduled PPS assessment do not complete this item Skip to M1030 Number of Venous and Arterial Ulcers 1 Review the history of each current pressure ulcer Specifically compare the current stage to past stages to determine whether any pressure ulcer on the current assessment is new or at an increased numerical stage when compared to the last MDS assessment This allows a more accurate assessment than simply comparing total counts on the current and prior MDS assessment Handout Page 10 M0800 Worsening in Pressure Ulcer Status Since Prior Assessment OBRA or scheduled PPS or Last Admission Entry or Reentry cont 2 For each current stage count the number of current pressure ulcers that are new or have increased in numerical stage since t
20. cer with flap and or graft coverage can be coded in this item as once a pressure ulcer is excised and flap and or graft applied it is no longer considered a pressure ulcer but a surgical wound Handout Page 24 M1200 Skin and Ulcer Treatments cont M1200G Application of Non surgical Dressings with or without Topical Medications Other than to Feet Do not code application of non surgical dressings for pressure ulcer s other than to feet in this item use M1200E Pressure Ulcer Care Dressings do not have to be applied daily in order to be coded on the MDS assessment If any dressing meeting the MDS definitions was applied even once during the 7 day look back period the assessor should check that MDS item This category may include but is not limited to dry gauze dressings dressings moistened with saline or other solutions transparent dressings hydrogel dressings and dressings with hydrocolloid or hydroactive particles used to treat a skin condition compression bandages etc Non surgical dressings do not include adhesive bandages e g BAND AID bandages M1200H Application of Ointments Medications Other than to Feet Do not code application of ointments medications e g chemical or enzymatic debridement for pressure ulcers here use M1200E Pressure Ulcer Care This category may include ointments or medications used to treat a skin condition e g cortisone antifungal preparations chemotherapeutic
21. d scope of treatment the services must be directly and specifically related to an active written treatment plan that is based on an initial evaluation performed by a therapeutic recreation specialist the services are required and provided by a state licensed or nationally certified therapeutic recreation specialist or therapeutic recreation assistant who is under the direction of a therapeutic recreation specialist and the services must be reasonable and necessary for the resident s condition Include services provided by a qualified occupational physical therapy assistant who is employed by or under contract with the long term care facility only if he or she is under the direction of a qualified occupational physical therapist Medicare does not recognize speech language pathology assistants therefore services provided by these individuals are not to be coded on the MDS Record only the actual minutes of therapy The conversion of units to minutes or minutes to units is not appropriate Do not round to the nearest 5th minute Please note that therapy logs are not an MDS requirement but reflect a standard clinical practice expected of all therapy professionals These therapy logs may be used to verify the provision of therapy services in accordance with the plan of care and to validate information reported on the MDS assessment Non Skilled Services e Services provided at the request of the resident or family that ar
22. de 2 Granulation tissue is selected because this is the most severe tissue present in the wound A resident has a Stage 2 pressure ulcer on the right heel and no other pressure ulcers Coding Code M0700 as 1 Epithelial tissue Rationale Coding for M0700 is Code 1 Epithelial tissue because epithelial tissue is consistent with identification of this pressure ulcer as a Stage 2 pressure ulcer A resident has a pressure ulcer on the left trochanter that has 25 black eschar tissue present 75 granulation tissue present and some epithelialization at the edges of the wound Coding Code M0700 as 4 Necrotic tissue eschar Rationale Coding is for the most severe tissue type present which is not always the majority of type of tissue Therefore Coding for M0700 is Code 4 Necrotic tissue eschar Handout Page 9 M0800 Worsening in Pressure Ulcer Status Since Prior Assessment OBRA or scheduled PPS or Last Admission Entry or Reentry M0800 Worsening in Pressure Ulcer Status Since Prior Assessment OBRA or Scheduled PPS or Last Admission Entry or Reentry Complete only if A0310E 0 Indicate the number of current pressure ulcers that were not present or were at a lesser stage on prior assessment OBRA or scheduled PPS or last entry If no current pressure ulcer at a given stage enter 0 Item Rationale Health related Quality of Life This item documents whether skin status overall has worsened since the last
23. de first degree burns changes in skin color only M1040G Skin Tear s Skin tears are a result of shearing friction or trauma to the skin that causes a separation of the skin layers They can be partial or full thickness Code all skin tears in this item even if already coded in Item J1900B M1040H Moisture Associated Skin Damage MASD Moisture associated skin damage MASD is a result of skin damage caused by moisture rather than pressure It is caused by sustained exposure to moisture which can be caused for example by incontinence wound exudate and perspiration It is characterized by inflammation of the skin and occurs with or without skin erosion and or infection MASD is also referred to as incontinence associated dermatitis and can cause other conditions such as intertriginous dermatitis periwound moisture associated dermatitis and peristomal moisture associated dematitis Provision of optimal skin care and early identification and treatment of minor cases of MASD can help avoid progression and skin breakdown Examples 1 A resident with diabetes mellitus presents with an ulcer on the heel that is due to pressure Coding This ulcer is not checked at M1040B This ulcer should be coded where appropriate under the Pressure Ulcers items M0210 M0900 Rationale Persons with diabetes can still develop pressure ulcers A resident is readmitted from the hospital after myocutaneous flap surgery to excise and close his sacral pre
24. e not medically necessary sometimes referred to as family funded services shall not be counted in Item 00400 Therapies even when performed by a therapist or an assistant e Nursing homes may elect to have licensed professionals perform repetitive exercises and other maintenance treatments or to supervise aides performing these maintenance services In these situations the services shall not be coded as therapy in Item 00400 Minutes since the specific interventions would be considered restorative nursing services when performed by nurses or aides Once the licensed therapist has designed a maintenance program and discharged the resident from rehabilitation i e skilled therapy program the services performed by the therapist and the assistant are not to be reported in Item O0400A B or C Therapies The services may be reported on the MDS assessment in Item 00500 Restorative Nursing Program provided the requirements for restorative nursing program are met e Services provided by aides are not skilled services Handout Page 27 CMS s RAI Version 3 0 Manual Appendix D Interviewing to Increase Resident Voice APPENDIX D INTERVIEWING TO INCREASE RESIDENT VOICE IN MDS ASSESSMENTS All residents capable of any communication should be asked to provide information regarding what they consider to be the most important facets of their lives There are several MDS 3 0 sections that require direct interview of the resident as the primary
25. ed to complete preference questions In this case it is important to emphasize that this person should try to answer based on what the resident would prefer The resident s preferences while in the nursing home and the resident s current responses when the particular item is offered or provided should form the basis for these responses April 2012 Appendix D 4 Handout Page 31 Skills for Effective Interviews The information in this document is compiled from techniques and scripts provided in the Long Term Care Facility Resident Assessment Instrument User s Manual as well as suggestions and examples by the author of this AANAC Education Program manual It is intended to assist interviewers to become comfortable with the process and not to imply that these are regulatory requirements See Appendix D of the Long Term Care Facility Resident Assessment Instrument User s Manual which also can be found in the Source Documents section of this AANAC Education Program Manual for CMS official information on this topic Bringing the resident s voice squarely into the midst of the assessment process is critical to being able to provide care that is truly resident centered and resident directed The resident after all is the one who knows best what is most important to him or her his or her preferences priorities values routines and concerns When it comes to interviewing interviewing skills may be the defining factor between success
26. een bothered by trouble falling or staying asleep or sleeping too much A I ve always had a lot of trouble falling asleep Q You ve always had trouble falling asleep In the last two weeks did it happen nearly every day or was it more like just one day in the last two weeks A Oh closer to one day Q Closer to one day Was it less than half the days A Yes think so Q So it was less than half the days Do you think it was just one day or several days A Oh it was more than one day so several days Here is another example Q How important is it to you to have books newspapers and magazines to read while you re in this facility Review answer options with resident A Well I ve always enjoyed reading a lot but I m not sure what can do here Since that response really doesn t answer the question the interviewer might respond as follows Q You ve always enjoyed reading is it important to you to have books and newspapers and magazines to read while you re here A Well yes think so The interviewer would then help him to narrow the answer in terms of importance via unfolding by reviewing the answer options with the aid of the visual aid again Break lists into component parts disentangling and obtain a rating for each when necessary Another technique called disentangling can really help the resident when the question contains multiple symptoms to addre
27. ent in general conversation to help establish rapport Ifthe resident asks a particular question or makes a request try to address the request or question before proceeding with the interview Explain the purpose of the questions to the resident Start by introducing the topic and explain that you are going to ask a series of questions You can tell the resident that these questions are designed to be asked of everyone to make sure that nothing is missed Highlight what you will ask End by explaining that his or her answers will help the care team develop a care plan that is appropriate for the resident Suggested explanations and introductions are included in specific item instructions Say and show the item responses lt is helpful to many older adults to both hear and read the response options As you verbally review the response options show the resident the items written in large clear print on a piece of paper or card Residents may respond to questions verbally by pointing to their answers on the visual aid or by writing out their answers Ask the questions as they appear in the questionnaire Use a nonjudgmental approach to questioning Don t be afraid of what the resident might say you are there to hear it Actively listen these questions can provide insights beyond the direct answer Break the question apart if necessary If the resident has difficult
28. erical stage before and after it was unstageable If the pressure ulcer s current numerical stage has increased consider this pressure ulcer as worsened If two pressure ulcers merge do not code as worsened Although two merged pressure ulcers might increase the overall surface area of the ulcer there would need to be an increase in numerical stage in order for it to be considered as worsened If a pressure ulcer is acquired during a hospital admission its stage should be coded on admission and is considered as present on admission entry or reentry It is not included or coded in this item Handout Page 11 M0800 Worsening in Pressure Ulcer Status Since Prior Assessment OBRA or scheduled PPS or Last Admission Entry or Reentry cont Ifa pressure ulcer increases in numerical stage during a hospital admission its stage should be coded on admission and is considered as present on admission entry or reentry It is not included or coded in this item While not included in this item it is important to recognize clinically on reentry that the resident s overall skin status deteriorated while in the hospital In either case if the pressure ulcer deteriorates further and increases in numerical stage on a subsequent MDS assessment it would be considered as worsened and would be coded in this item Examples 1 A resident has a pressure ulcer on the right ischial tuberosity that was Stage 2 on the previous MDS assessment and has now
29. hat is approved by the physician after any needed consultation with the qualified therapist the services must be of a level of complexity and sophistication or the condition of the resident must be of a nature that requires the judgment knowledge and skills of a therapist the services must be provided with the expectation based on the assessment made by the physician of the resident s restoration potential that the condition of the patient will improve materially in a reasonable and generally predictable period of time or the services must be necessary for the establishment of a safe and effective maintenance program the services must be considered under accepted standards of medical practice to be specific and effective treatment for the resident s condition and the services must be reasonable and necessary for the treatment of the resident s condition this includes the requirement that the amount frequency and duration of the services must be reasonable Handout Page 26 e Recreational therapy is not a skilled service according to the Social Security Act However for purposes of the MDS providers should record services for recreational therapy Item O0400F when the following criteria are met the physician orders recreational therapy that provides therapeutic stimulation beyond the general activity program in the nursing home the physician s order includes a statement of frequency duration an
30. he last MDS assessment was completed Coding Instructions for M0800 Enter the number of pressure ulcers that were not present OR were at a lesser numerical stage on prior assessment Code 0 if no pressure ulcers have increased in numerical stage OR there are no new pressure ulcers Coding Tips Coding this item will be easier for nursing homes that document and follow pressure ulcer status on a routine basis If a numerically staged pressure ulcer increases in numerical staging it is considered worsened Coding worsening of unstageable pressure ulcers Ifa pressure ulcer was unstageable on admission entry or reentry do not consider it to be worsened on the first assessment that it is able to be numerically staged However if the pressure ulcer subsequently increases in numerical stage after that assessment it should be considered worsened If a pressure ulcer was numerically staged and becomes unstageable due to slough or eschar do not consider this pressure ulcer as worsened The only way to determine if this pressure ulcer has worsened is to remove enough slough or eschar so that the wound bed becomes visible Once enough of the wound bed can be visualized and or palpated such that the tissues can be identified and the wound restaged the determination of worsening can be made If a pressure ulcer was numerically staged and becomes unstageable and is subsequently debrided sufficiently to be numerically staged compare its num
31. in the last 7 days check none of the above Pressure ulcers coded in M0200 through M0900 should not be coded here M1040A Infection of the foot e g cellulitis purulent drainage M1040B Diabetic foot ulcer s M1040C Other open lesion s on the foot e g cuts fissures Handout Page 18 M1040 Other Ulcers Wounds and Skin Problems cont M1040D Open lesion s other than ulcers rashes cuts e g cancer lesion M1040E Surgical wound s M1040F Burn s second or third degree M1040G Skin tear s M1040H Moisture Associated Skin Damage MASD i e incontinence IAD perspiration drainage M1040Z None of the above were present Coding Tips M1040B Diabetic Foot Ulcers Diabetic neuropathy affects the lower extremities of individuals with diabetes Individuals with diabetic neuropathy can have decreased awareness of pain in their feet This means they are at high risk for foot injury such as burns from hot water or heating pads cuts or scrapes from stepping on foreign objects and blisters from inappropriate or tight fitting shoes Because of decreased circulation and sensation the resident may not be aware of the wound Neuropathy can also cause changes in the structure of the bones and tissue in the foot This means the individual with diabetes experiences pressure on the foot in areas not meant to bear pressure Neuropathy can also cause changes in normal sweating which means the individual with diabetes can
32. lations Stage 2 pressure ulcers by definition have partial thickness loss of the dermis Granulation tissue slough or eschar are not present in Stage 2 pressure ulcers Therefore Stage 2 pressure ulcers should not be coded as having granulation slough or eschar tissue and should be coded as 1 for this item Code for the most severe type of tissue present in the pressure ulcer wound bed If the wound bed is covered with a mix of different types of tissue code for the most severe type For example if a mixture of necrotic tissue eschar and slough is present code for eschar Code this item with Code 9 None of the above in the following situations Stage l pressure ulcer Stage 2 pressure ulcer with intact blister Unstageable pressure ulcer related to non removable dressing device Unstageable pressure ulcer related to suspected deep tissue injury Code 9 is being used in these instances because the wound bed cannot be visualized and therefore cannot be assessed Examples 1 A resident has a Stage 2 pressure ulcer on the right ischial tuberosity that is healing and a Stage 3 pressure ulcer on the sacrum that is also healing with red granulation tissue that has filled 75 of the ulcer and epithelial tissue that has resurfaced 25 of the ulcer Coding Code M0700 as 2 Granulation tissue Rationale Coding for M0700 is based on the sacral ulcer because it is the pressure ulcer with the most severe tissue type Co
33. low sheet or other skin tracking form Speak with direct care staff and the treatment nurse to confirm conclusions from the medical record review Examine the resident and determine whether any venous or arterial ulcers are present Key areas for venous ulcer development include the area proximal to the lateral and medial malleolus e g above the inner and outer ankle area Key areas for arterial ulcer development include the distal part of the foot dorsum or tops of the foot or tips and tops of the toes Venous ulcers may or may not be painful and are typically shallow with irregular wound edges a red granular e g bumpy wound bed minimal to moderate amounts of yellow fibrinous material and moderate to large amounts of exudate The surrounding tissues may be erythematous or reddened or appear brown tinged due to hemosiderin staining Leg edema may also be present Arterial ulcers are often painful and have a pale pink wound bed necrotic tissue minimal exudate and minimal bleeding Coding Instructions Check all that apply in the last 7 days Pressure ulcers coded in M0210 through M0900 should not be coded here Enter the number of venous and arterial ulcers present Enter 0 if there were no venous or arterial ulcers present Handout Page 16 M1030 Number of Venous and Arterial Ulcers cont Coding Tips Arterial Ulcers Trophic skin changes e g dry skin loss of hair growth muscle atrophy brittle n
34. ould receive nutritional or hydration interventions for skin problems should be based on an individualized nutritional assessment The interdisciplinary team should review the resident s diet and determine if the resident is taking in sufficient amounts of nutrients and fluids or are already taking supplements that are fortified with the US Recommended Daily Intake US RDI of nutrients Handout Page 23 M1200 Skin and Ulcer Treatments cont Additional supplementation above the US RDI has not been proven to provide any further benefits for management of skin problems including pressure ulcers Vitamin and mineral supplementation should only be employed as an intervention for managing skin problems including pressure ulcers when nutritional deficiencies are confirmed or suspected through a thorough nutritional assessment AMDA PU Guideline page 6 If it is determined that nutritional supplementation i e adding additional protein calories or nutrients is warranted the facility should document the nutrition or hydration factors that are influencing skin problems and or wound healing and tailor nutritional supplementation to the individual s intake degree of under nutrition and relative impact of nutrition as a factor overall and obtain dietary consultation as needed AMDA PU Therapy Companion page 4 It is important to remember that additional supplementation is not automatically required for pressure ulcer management Any in
35. r part is rated positively by the resident mark no If either or both are rated positively then mark yes Clarify using echoing If the resident appears to understand but is having difficulty selecting an answer try clarifying his or her response by first echoing what he or she told you and then repeating the related response options Echoing means simply restating part of the resident s response This is often extremely helpful during clinical interviews If the resident provides a related response but does not use the provided response scale or fails to directly answer the question then help clarify the best response by repeating the resident s own comment and then asking the related response options again This interview approach frequently helps the resident clarify which response option he or she prefers Repeat the response options as needed Some residents might need to have response choices repeated for each item on a given list Move on to another question if the resident is unable to answer Even if the interview item cannot be completed the time spent is not wasted The observation of resident behaviors and attention during the interview attempt provide important insights into delirium cognition mood etc Break up the interview if the resident becomes tired or needs to leave for rehabilitation etc Try to complete the current item set and then offer to come back at another time to complete the rem
36. s to have difficulty understanding Interpreters are people who translate oral or written language from one language to another If an interpreter is used during resident interviews he or she should not attempt to determine the intent behind what is being translated the outcome of the interview or the meaning or significance of the interviewee s responses The resident should determine meaning based solely on his or her interpretation of what is being translated Find a quiet private area where you are not likely to be interrupted or overheard This is important for several reasons Background noise should be minimized Some items are personal and the resident will be more comfortable answering in private The interviewer is in a better position to respond to issues that arise Decrease available distractions July 2010 Appendix D 1 Handout Page 28 CMS s RAI Version 3 0 Manual Appendix D Interviewing to Increase Resident Voice Sit where the resident can see you clearly and you can see his or her expressions Have your face well lighted Minimize glare Ask the resident where you should sit so that he or she can see you best Some residents have decreased central vision or limited ability to turn their heads Establish rapport and respect The steps you have already taken to ensure comfort go a long way toward establishing rapport and demonstrating respect You can also engage the resid
37. schar black brown or tan tissue that adheres firmly to the wound bed or ulcer edges may be softer or harder than surrounding skin None of the Above ltem Rationale Health related Quality of Life The presence of a pressure ulcer may affect quality of life for residents because it may limit activity may be painful and may require time consuming treatments and dressing changes Identify tissue type Planning for Care Tissue characteristics of pressure ulcers should be considered when determining treatment options and choices Changes in tissue characteristics over time are indicative of wound healing or degeneration Steps for Assessment 1 Examine the wound bed or base of each pressure ulcer Adequate lighting is important to detect skin changes 2 Determine the type s of tissue in the wound bed e g epithelial granulation slough eschar Coding Instructions for M0700 Code 1 Epithelial tissue if the wound is superficial and is re epithelializing Code 2 Granulation tissue if the wound is clean e g free of slough and eschar tissue and contains granulation tissue Code 3 Slough if there is any amount of slough tissue present and eschar tissue is absent Code 4 Necrotic tissue eschar if there is any eschar tissue present Code 9 None of the above if none of the above apply Handout Page 8 M0700 Most Severe Tissue Type for Any Pressure Ulcer cont Coding Tips and Special Popu
38. ss Here is an example of how this conversation might go again using a question from the PHQ 9 interview Q Over the last two weeks have you been bothered by trouble falling or staying asleep or sleeping too much A Falling asleep or what did you say Q Let s try this a bit differently Over the last two weeks have you been bothered by trouble falling asleep A Yes have Q You ve been bothered by trouble falling asleep How often did that happen in the last two weeks Review answer options for frequency A Oh at least half the time Handout Page 34 Q Okay thank you Over the last two weeks have you been bothered by trouble staying asleep A Yes have Q You ve had trouble staying asleep How often did that happen in the last two weeks Review answer options for frequency A Oh just a couple of days 2 to 6 Q Okay And over the last two weeks have you been bothered by sleeping too much A No no haven t Now that you have the responses for all three symptoms on the MDS you would code the one with the highest frequency In this case that would make the frequency 7 11 5 G days half or more of the days In the process of conducting the interview it is important to avoid drawing conclusions about what the resident s answer is based on a more general response For example consider this exchange Q Over the last two weeks have yo
39. ssistance When there is a combination of full staff performance and weight bearing assistance that total 3 or more times code extensive assistance 3 Do not proceed to c below if b applies When there is a combination of full staff performance weight bearing assistance and or non weight bearing assistance that total 3 or more times code limited assistance 2 If none of the above are met code Supervision 1 This box in the algorithm corresponds to a b and c under the third Rule of 3 above The instruction in this box only applies when the third Rule of 3 applies i e an activity occurs 3 or more times and at multiple levels but not 3 times at any one level e g 2 times non weight bearing 2 times weight bearing If the coding scenario does not meet the third Rule of 3 do not apply a b or c of the third Rule of 3 answer No and then continue down the algorithm Page G 7 Handout Page 7 M0700 Most Severe Tissue Type for Any Pressure Ulcer Select the best description of the most severe type of tissue present in any pressure ulcer bed Enter Code Epithelial tissue new skin growing in superficial ulcer It can be light pink and shiny even in persons with darkly pigmented skin Granulation tissue pink or red tissue with shiny moist granular appearance Slough yellow or white tissue that adheres to the ulcer bed in strings or thick clumps or is mucinous Necrotic tissue E
40. ssure ulcer Coding Check M1040E Surgical Wound Rationale A surgical flap procedure was used to close the resident s pressure ulcer The pressure ulcer is now considered a surgical wound Mrs J was reaching over to get a magazine off of her bedside table and sustained a skin tear on her wrist from the edge of the table when she pulled the magazine back towards her Coding Check M1040G Skin Tear s Rationale The resident sustained a skin tear while reaching for a magazine Handout Page 20 M1040 Other Ulcers Wounds and Skin Problems cont 4 Mr S who is incontinent is noted to have a large red and excoriated area on his buttocks and interior thighs with serous exudate which is starting to cause skin glistening Coding Check M1040H Moisture Associated Skin Damage MASD Rationale Mr S skin assessment reveals characteristics of incontinence associated dermatitis 5 Mrs F complained of discomfort of her right great toe and when her stocking and shoe was removed it was noted that her toe was red inflamed and had pus draining from the edge of her nail bed The podiatrist determined that Mrs F has an infected ingrown toenail Coding Check M1040A Infection of the foot Rationale Mrs F has an infected right great toe due to an ingrown toenail 6 Mr G has bullous pemphigoid and requires the application of sterile dressings to the open and weeping blistered areas Coding Check M1040D Open lesion other
41. t Coding Instructions for MO900B C and D Enter the number of pressure ulcers that have healed since the last assessment for each Stage 2 through 4 Enter O if there were no pressure ulcers at the given stage or no pressure ulcers that have healed Coding Tips Coding this item will be easier for nursing homes that systematically document and follow pressure ulcer status Ifthe prior assessment documents that a pressure ulcer healed between MDS assessments but another pressure ulcer occurred at the same anatomical location do not consider this pressure ulcer as healed The re opened pressure ulcer should be staged at its highest numerical stage until fully healed M1030 Number of Venous and Arterial Ulcers M1030 Number of Venous and Arterial Ulcers Enter Number Enter the total number of venous and arterial ulcers present Item Rationale Health related Quality of Life Skin wounds and lesions affect quality of life for residents because they may limit activity may be painful and may require time consuming treatments and dressing changes Handout Page 15 M1030 Number of Venous and Arterial Ulcers cont Planning for Care The presence of venous and arterial ulcers should be accounted for in the interdisciplinary care plan This information identifies residents at risk for further complications or skin injury Steps for Assessment 1 Review the medical record including skin care f
42. terventions should be specifically tailored to the resident s needs condition and prognosis AMDA PU Therapy Companion page 11 M1200E Pressure Ulcer Care Pressure ulcer care includes any intervention for treating pressure ulcers coded in Current Number of Unhealed Pressure Ulcers at Each Stage M0300A G Examples may include the use of topical dressings enzymatic mechanical or surgical debridement wound irrigations negative pressure wound therapy NPWT and or hydrotherapy M1200F Surgical Wound Care Does not include post operative care following eye or oral surgery Surgical debridement of a pressure ulcer does not create a surgical wound Surgical debridement is used to remove necrotic or infected tissue from the pressure ulcer in order to facilitate healing and thus any wound care associated with pressure ulcer debridement would be coded in M1200E Pressure Ulcer Care The only time a surgical wound would be created is if the pressure ulcer itself was excised and a flap and or graft used to close the pressure ulcer Surgical wound care may include any intervention for treating or protecting any type of surgical wound Examples may include topical cleansing wound irrigation application of antimicrobial ointments application of dressings of any type suture staple removal and warm soaks or heat application Surgical wound care for pressure ulcers that require surgical intervention for closure e g excision of pressure ul
43. than ulcers rashes cuts Rationale Mr G has open bullous pemphigoid blisters 7 Mrs A was just admitted to the nursing home from the hospital burn unit after sustaining second and third degree burns in a house fire She is here for continued treatment of her burns and for rehabilitative therapy Coding Check M1040F Burns second or third degree Rationale Mrs A has second and third degree burns therefore burns second or third degree should be checked M1200 Skin and Ulcer Treatments M1200 Skin and Ulcer Treatments Check all that apply A Pressure reducing device for chair Pressure reducing device for bed Turning repositioning program Nutrition or hydration intervention to manage skin problems Pressure ulcer care Surgical wound care Application of nonsurgical dressings with or without topical medications other than to feet Applications of ointments medications other than to feet Application of dressings to feet with or without topical medications NI il I rial mm p i None of the above were provided Handout Page 21 M1200 Skin and Ulcer Treatments cont Item Rationale Health related Quality of Life Appropriate prevention and treatment of skin changes and ulcers reduce complications and promote healing Planning for Care These general skin treatments include basic pressure
44. u been bothered by trouble falling or staying asleep or sleeping too much A I ve always had a lot of trouble falling asleep It might be tempting to code Symptom Presence as Yes and Symptom Frequency as 12 14 days nearly every day However this answer actually is non responsive the question is very specific to the last two weeks and the resident hasn t addressed that time period Successful interviewing often requires patience Interviewers should schedule sufficient time for the interview ensuring that if the need arises for the techniques that will help the resident to answer the questions honestly and accurately a sense of rushing which can adversely affect the process will not be injected into the interview
45. ve characteristics of the wound i e depth width presence or absence of granulation tissue etc or by using a validated pressure ulcer healing tool Once a pressure ulcer has healed it is documented as a healed pressure ulcer at its highest numerical stage in this example a healed Stage 4 pressure ulcer For care planning purposes this healed Stage 4 pressure ulcer would remain at increased risk for future breakdown or injury and would require continued monitoring and preventative care Steps for Assessment Complete on all residents including those without a current pressure ulcer Look back period for this item is the ARD of the prior assessment If no prior assessment i e if this is the first OBRA or scheduled PPS assessment do not complete this item Skip to M1030 1 Review medical records to identify whether any pressure ulcers that were noted on the prior MDS assessment have healed by the ARD A2300 of the current assessment Identify the deepest anatomical stage see definition on page M 5 of each healed pressure ulcer Count the number of healed pressure ulcers for each stage Handout Page 14 M0900 Healed Pressure Ulcers cont Coding Instructions for MO900A Complete on all residents even if M0210 0 Enter O if there were no pressure ulcers on the prior assessment and skip to Number of Venous and Arterial Ulcers item M1030 Enter 1 if there were pressure ulcers noted on the prior assessmen
46. y understanding requests clarification or seems hesitant you can employ unfolding or disentangling techniques Do not however use these techniques for the memory test 1 Unfolding refers to the use of a general question about the symptom followed by a sequence of more specific questions if the symptom is reported as present This approach walks the resident through the steps needed to think through the question April 2012 Appendix D 2 Handout Page 29 CMS s RAI Version 3 0 Manual Appendix D Interviewing to Increase Resident Voice 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 2 Disentangling refers to 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 phrases 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 of a complex item obtain a frequency rating for each positive response and score that item using the frequency of the component that occurred most often Example An item asks about Poor appetite or overeating Disentangle this item by asking Poor appetite pause for a response and then ask Or overeating If neithe
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