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1. and in late 2012 as well and are now being enforced by state surveyors these changes still have not made their way into the official SOM The official version of Appendix PP for example has not been revised since January 2011 So you have to either keep track of all the S amp C memo updates and incorporate them into your manual or find a manual publisher who has a system for doing that for you Caralyn Davis Staff Writer cdavis48 bellsouth net My resident was out at Midnight do I start the MDS schedule over A resident returned from a hospital stay on November 6 as Medicare Part A On November 7 this resident was sent out to the ER at 9 00 p m She was not admitted to the hospital and returned November 8 at 2 20 a m meaning she was not in her bed for census count at midnight Billing is saying that because she wasn t in her bed at midnight on November 7 Medicare cannot be billed and therefore her calendar starts over beginning November 8 Is this correct and do I doa 5 day for November 6 to November 7h and then areadmit return assessment when it is due counting from November 8 Your biller is half correct You won t bill for November 7 But you should not start the schedule over November 7 becomes a skip day LOA Your Medicare schedule shifts by one day November 6 is day one and November 8 is day two November 7 is skipped You must adjust your schedule to reflect this as you are still required to us
2. So code according to that Note The Social Security gender is stated on the resident s Medicare card Dashing date items For most MDS items that allow dashes you single dash justified in the left most box according to the instructions in the RAI Manual says Otis Higgins continued on page 6 AANAC LTC LEADER 11 21 2013 2013 AANAC No part of this publication may be reproduced without written permission from AANAC The information presented is informative and does not constitute direct legal or regulatory advice TALKIN THE TALK ICD 10 AANACICD 10 Task Force When hearing of the impending implementation of ICD 10 the first thing that comes to mind is Really another change Then the realization hits This will happen you must learn and change The International Classification of Diseases 9th Edition Clinical Modification ICD 9 CM no longer reflects the care and services being provided in our current health care system The International Classification of Diseases ICD was developed to collect uniform data for research and education showing patterns of disease and causes of death ICD was revised in 1980 and this became the gth edition of the classification Who knew then that just like our MDS which was originally planned solely for quality the ICD would be expanded to define DRGs RUGs coverages and create auditing and Medical Necessity probes As the AANAC Task Force for ICD 10 meets to
3. don t understand how they will benefit from having a bit more diligence in gathering MDS data The primary reason why excessive dashes are a problem is that they indicate you did not do the required assessment says Brandt Therefore the resident is at risk for losing out on potential new or updated care plan interventions that will help him or her obtain the best outcomes A secondary issue is that it is a condition of participation that you follow the MDS schedule Too many dashes also can indicate an integrity issue says Brandt Sometimes facilities dash to cover up problems For example a facility puts a dash instead of coding a fall with a major injury which is a QM issue What to watch for Common questions that come up about the use of dashes address the following topics e Section I active diagnoses Inadvertent dashes can sometimes cause problems in 18000 additional active diagnoses says Otis Higgins This item has to be either coded with ICD 9 codes or left blank A dash isn t allowed Dashes indicate you did not do the required assessment says Brandt Therefore the resident is at risk for losing out on potential new or updated care plan interventions that will help him or her obtain the best outcomes Excessive dashing also can have a significant impact on a facility s quality measures QMs and via a dotted line the Five Star ratings says Otis
4. help our members the primary thought we all share is this What does all of this mean in understanding where we were where we are now and where we are going We decided we must first share the terminology with you and hopefully you can share this information with your team The date October 1 2014 is very important as this is the go live date This is when the oth edition ends and the roth edition begins Understand it will not be delayed as there are many government initiatives in motion that require the ro to occur such as the 5010 billing process and the Transformed Medicaid Statistical Information System T MSIS an actionable business intelligence software program k AANAC org 800 768 1880 The MDS 3 0 manual provides explanations of coding requirements and the official ICD 10 CM Coding Guidelines clarify why how and when you would code a disease or service The guidelines are reviewed and approved by four organizations that make up the cooperating parties for the ICD 10 CM the American Hospital Association AHA the American Health Information Management Association AHIMA the Center for Medicare amp Medicaid Services CMS and the National Center for Health Statistics NCHS These guidelines are included in the official government version of the ICD 9 CM and also appear in Coding Clinic for ICD 9 CM published by the AHA Who is in charge The WHO not the rock band but the Wo
5. the MDS database and seen more dashes than they would have expected adds Brandt So they have cautioned us not to use dashes unless we absolutely have to Providers should always go the extra mile to complete assessments stresses Brandt In the MDS 2 0 CMS said that dashes should be used if after exhaustively searching the data continued on page 2 WWW AANAC ORG LTC professionals least likely to comply with immunization recommendations Betty Frandsen RN NHA MHA C NE MT The Centers for Disease Control and Prevention CDC recently disclosed that long term care providers are in last place among health care professionals when it comes to getting the influenza vaccine Data shows that in the 2011 2012 influenza season vaccination rates for health care workers in hospitals was 76 9 for those in physicians offices 67 7 and for those working in nursing facilities the rate was 52 4 Overall rates of immunization across all three areas of health care practice were 85 6 for physicians 81 5 for nurse practitioners and physician assistants 77 9 for nurses 64 8 for other clinical personnel and 59 3 for nonclinical staff Because residents of nursing homes and other long term care facilities are at higher risk for medical complications they and the staff who care for them are recommended to receive the annual influenza vaccination Vaccination before December is best so that antibodies are in place b
6. they continue going to school or work and share the virus with others Because the influenza virus can circulate in water droplets in air for a period of time after a cough or sneeze even after the person has left the room the virus may remain causing exposure for others Influenza causes death each year for approximately 36 000 people in the United States More than 90 of those who die are over the age of 65 Nursing facility outbreaks are reported each year they vary from one in eight nursing facilities to as high as one facility in three Skilled nursing facilities reported data shows that when outbreaks occur one third of the residents are affected and one quarter of staff develop influenza like illness One in twenty of the infected residents dies Gregory Gahm wo of the Colorado Department of Public Health and Environment reports that the financial impact of an influenza outbreak can be enormous He offers the following scenario to demonstrate the reality of the impact Ina 100 bed facility 34 residents will be diagnosed with influenza and ultimately 2 will die One quarter of the staff will become sick and for three to seven days will be unable to work so replacements will be needed The 34 ill residents and the sick staff will receive antiviral medications which cost approximately 100 per person The other 66 residents and unvaccinated staff will also be placed on prophylaxis at 10 per person per day Proph
7. two days after symptoms develop The CDC each other and at least one of them has aconfirmed case of influenza chemoprophylaxis should begin in order to prevent transmission This is intended for residents who are not ill or exhibiting signs or symptoms of influenza and should continue for a minimum of two weeks at least seven to ten days after the last case is identified Antiviral prophylaxis should be considered for all employees regardless of their vaccination status To obtain additional information about the above CDC recommended actions visit the following link http www cdc gov flu professionals infectioncontrol Itc facility guidance htm The CDC provides extensive information and educational materials for influenza prevention and management Improved knowledge may result in better immunization rates among long term health care professionals so share the CDC facts with your team The influenza immunization campaign is about doing all we can to protect our residents AANAC LTC LEADER 11 21 2013 2013 AANAC No part of this publication may be reproduced without written permission from AANAC The information presented is informative and does not constitute direct legal or regulatory advice Q A When a hospice resident clinically declines isa Significant Change of Status Assessment required When someone is enrolled in Hospice the Hospice significant change MDS has already been done and that per
8. AMERICAN ASSOCIATION OF NURSE ASSESSMENT COORDINATION LTC LEADER a SSS Z A dash primer Why matters Caralyn Davis BA Staff Writer The use of the dash on the MDS requires a balancing act Dashes absolutely shouldn t be routine says Judy Wilhide Brandt rn Ba Rac mt president of Judy Wilhide MDS Consulting in Virginia Beach VA ICMS has cautioned us not to use dashes unless we absolutely have to says Judy Wilhide Brandt RN BA RAC MT However that doesn t mean that dashing should be an incredibly rare event points out Andrea Otis Higgins rn mea CDONA RAC MT MLNHA CEO administrator of St Andre HealthCare Facility in Biddeford ME According to the RAI User s Manual for the MDS 3 0 there are times when dashes can be used legitimately Dashes are indicated when you are unable to assess an item or the information was unavailable to you In that regard there is an allocation for the dash The key is to avoid excessive dashing says Otis Higgins CMS addressed coding with dashes in its first web based MDS 3 0 Provider Updates training video Discharge Assessments and the Use of Dashes The video came on the heels of several Skilled Nursing Facility Long term Care Open Door Forums where CMS officials cautioned providers against the too frequent use of dashes particularly for unplanned discharge assessments says Otis Higgins Apparently they have done some querying of
9. Higgins For example the use of dashes has the potential to reduce the size of a facility s QM resident sample Missing data also can distort the QMs inaccurately representing a facility s actual resident population and undermining its ability to show quality improvement Last but definitely not least is the potential impact on payment says Brandt If you have a dash in an item used for RUG payment you re not going to get the money Providers whose MDS assessments indicate excessive dashing should look for system issues suggests Brandt For example if a social worker consistently cannot complete interviews timely for standard quarterlies and is always dashing them then that social worker needs education guidance and assistance from her bosses on time management e Section A identification information Item A2400C end date of most recent Medicare stay should be dashed if the Part A stay is ongoing because there is no end date yet However many items in Section A don t allow dashes points out Otis Higgins In the May 2013 RA Manual update CMS clarified that the dash isn t an acceptable response in item A0800 gender a choice of 1 male or 2 female must be made says Otis Higgins If you are uncertain or if a patient declares as transgender you look to how their gender is identified in the Social Security system The gender documented in A0800 should match the Social Security gender
10. art B therapy services rise to a skilled level of care when they are provided 5 days per week 5 days per week of Part B therapy interrupts the 60 day wellness count toward obtaining a new benefit period Mark McDavid otr Rac ct mmcdavid rehabmanagement com Where can I find the most recent State Operations Manual SOM for nursing home regulations What is the most recent version of the State Operations Manual SOM I have one that was revised in 2011 the one on CMS website under the IOM is from 2004 Just need to make sure I have the most up to date version The official version of the SOM is kept here http www cms gov Regulations and Guidance Guidance Manuals Internet Only Manuals IOMs Items CMS1201984 html Each chapter appendix has its own revision date which you will find on the first page under the Table of Contents heading These revision dates vary wildly Typically the most important sections for both skilled nursing facilities SNFs and nursing facilities NFs are Appendix P and Appendix PP In addition be aware that providers are responsible for implementing the draft updates to these appendices that CMS has released over the past year via survey and certification letters at http www cms gov Medicare Provider Enrollment and Certification Survey CertificationGenInfo Policy and Memos to States and Regions html Note that even though multiple updates have been released over the past year
11. dashed then all active items from E0100A hallucinations through E0300 overall presence of behavioral symptoms must be dashed as well Note Logic requirements for each item also are listed on the Detailed Data Specifications Reports Talkin the Talk continued from page 3 in documentation for clinicians This webinar further explains that if organizations are expecting CMS to provide the items necessary to make the transition they are mistaken There are many useful tools available from CMS and others but the responsibility for implementation lies with the provider Although this webinar targets small physician practices it presents principles that can assist anyone in the conversion to ICD 10 CM including a slide presentation that appropriate nursing facility staff can use as a guide To participate in the webinar visit the following CMS webpage http www cms gov Medicare Coding ICD10 index html Included on the webpage are two free Medscape education modules that offer guidance in making the transition to ICD 10 They are ICD 10 A Roadmap for Small Clinical Practices and ICD 10 Small Practice Guide to a Smooth Transition Continuing medical education CME and continuing education CE credits are available to physicians and nurses who complete the learning modules If you are not a current Medscape user you can create a free account in order to log in Additionally at AANAC the ICD 10 CM Task Force will provide guidanc
12. e allowable days for your ARDs for the entire roo day cycle Some software systems will account for this if your census reflects the LOA day correctly and some folks have to track this shift manually Rosie Hedrick rosie hedrick tlcmgmt com AANAC LTC LEADER 11 21 2013 2013 AANAC No part of this publication may be reproduced without written permission from AANAC The information presented is informative and does not constitute direct legal or regulatory advice AANAC Board of Directors Ruth Minnema RN MA C NE RAC CT Chair Peter Arbuthnot AA BA RAC CT Vice Chair Carol Maher RN BC RAC CT Secretary Susan Duong RN BSN NHA RAC CT C NE Treasurer Gail Harris RN BSN RAC CT C NE Jo Anna Hurd RN MSN RAC CT Stephanie Kessler RAc cT Linda Krueger RN AAS BA RAC CT Benjamin Ruggles BSN RN RAC CT C NE CPRA Carol Smith RN BSN RAC CT AANAC Expert Panel AANAC is pleased to introduce you to our panel of volunteer reviewers who represent the best and the brightest in our field Robin L Hillier cpa STNA LNHA RAC MT President RLH Consulting Becky LaBarge RN RAC MT Vice President Clinical Reimbursement The Tutera Group Deb Myhre RN C NE RAC MT Nurse Consultant Continuum Health Care Services Andrea Otis Higgins RN MLNHA CDONA CLNC RAC MT CEO Administrator St Andre Healthcare Biddeford ME Judy Wilhide Brandt RN RAC MT C NE Regional MDS Medicare Consu
13. e and support during this challenging time by providing resource guides planning and implementation tips and a method of communication for your input Over the next few months we will present a series of articles designed to increase understanding which can also be shared with facility team members Watch future issues of LTC Leader and check our website for this valuable ICD 10 CM information But the Medscape guidance is already there for you so don t wait to get started AANAC ICD 10 TASK FORCE MEMBERS Casey Bastemeyer RHIT CCA RAC CT Betty Frandsen RN MHA NHA C NE Amy Franklin CDON RAC MT RAC CT Leah Killian Smith LNHA RHIA Judi Kulus NHA RN MAT RAC MT C NE Jennifer LaBay RN RAC MT RAC CT Sharon Vandagriff MBA RHIA AANAC LTC LEADER 11 21 2013 2013 AANAC No part of this publication may be reproduced without written permission from AANAC The information presented is informative and does not constitute direct legal or regulatory advice
14. efore flu activity is at its highest The CDC has declared the week of December 8 14 2013 as National Influenza Vaccination Week They recommend that everyone get vaccinated to protect against influenza stating that vaccination before December is best so that antibodies are in place before flu activity is at its highest Antibody protection typically develops within two weeks after vaccination In the United States influenza outbreaks typically occur through the fall and winter months Although infection rates are highest among children influenza related complications hospitalizations and deaths have the highest rate of occurrence among adults aged 65 and older as well as 50 to 64 year olds with underlying medical conditions Children and continued on page 4 A dash primer continued from page 1 remains unattainable she notes That is a really good standard to meet now as well However sometimes answering a particular question is just not feasible the information remains unknowable In that case you are allowed to use the dash But a dash should never be used to shirk your responsibility to assess the resident It s not an excuse not to do your job What can be dashed Most but not all MDS items can be dashed Items that don t allow dashes generally are found in Section A identification information Section I active diagnoses Section V care area assessment summary and Section X correcti
15. ght versus left laterality episodes of care 7th digit character extensions level of care and both alpha and numeric components compare this to the 9th edition which did not specify the side of the body or level of care and used only two alpha letters V and E Areas that will have the greatest impact on skilled nursing facilities will be e Coding of fractures and using the 7th digit character extensions to indicate subsequent level of care e Elimination of 18 Aftercare Fracture codes e Elimination of Late Effects e Coding of medication underdosing e Time changes for myocardial infarctions e Use of a placeholder X e Elimination of Hypertension table e Introduction of Z codes Under ICD 10 CM as is the case under version 9 inconsistent missing and conflicting documentation must be resolved by the attending physician As the MD presenter states in a free Medscape webinar link provided on page 6 If you are practicing good care then there will be little change continued on page 6 AANAC LTC LEADER 11 21 2013 2013 AANAC No part of this publication may be reproduced without written permission from AANAC The information presented is informative and does not constitute direct legal or regulatory advice LTC professionals least likely to comply with immunization recommendations continued from page 1 working adults who acquire the illness often aren t incapacitated by it or even very ill so
16. ltant President Judy Wilhide MDS Consulting Inc Mark E McDavid OTR RAC CT Vice President of Professional Services Rehab Management Inc Lisa Hohlbein RN RAC MT Director of Clinical Reimbursement LeaderStat Jennifer LaBay RN RAC MT Director of Clinical Reimbursement Health Concepts Ltd All the articles in this LTC Leader can also be found on the AANAC org website AANAC org 800 768 1880 A dash primer continued from page 2 However dating items that allow dashes are somewhat an exception in the directions on dashing Typically when the date has not yet occurred or is unknown you need to dash all eight of the spaces that have been allocated for that date For example if a resident continues to receive ongoing physical therapy occupational therapy or speech language pathology services the therapy end date in 00400A6 00400B6 and or 00400C6 is filled with eight dashes The same is true with M0300B3 date of oldest Stage 2 pressure ulcer and A2400C end date of most recent Medicare stay Eight dashes would be used Inconsistent dashing Often providers think about the MDS 3 0 asa collection of siloed items However in many ways it is a highly integrated document says Otis Higgins The inconsistent use of dashes dashing one item but not another interconnected item will create a logic error often resulting in fatal errors on MDS submissions For example if B0100 comatose is
17. luenza A viruses Antiviral Chemoprophylaxis The CDC states that in a nursing facility with even one confirmed case of influenza all residents not just those on the same unit should receive chemoprophylaxis When two or more residents are ill within 72 hours of In a 100 bed facility 34 residents will be diagnosed with influenza and ultimately 2 will die Surveillance Active surveillance for influenza illness should be conducted daily for new and current residents staff and visitors continuing until the end of flu season Non resident individuals who are ill should be excluded from the facility until their illness has resolved Testing Even if it is not influenza season influenza testing should be conducted when any resident exhibits signs or symptoms of flu like illness as influenza can occur outside of the normal influenza season Two or more confirmed cases constitutes an outbreak Infection Control For any residents suspected of or confirmed by laboratory testing as having influenza implement standard and droplet precautions and continue for seven days after the onset of illness or 24 hours after resolution of fever and respiratory symptoms whichever is longer Antiviral Treatment All residents with suspected or confirmed influenza should receive antiviral treatment immediately It is not recommended to wait until laboratory confirmation as the medication is most effective if given within the first
18. on request However the MDS 3 0 data submission specifications on the MDS 3 0 Technical Information webpage are the definitive source of information on whether a specific MDS item allows a dash The data specs include Detailed Data Specifications Reports for every MDS section The reports have an Item Values section that lists all allowable values i e coding answers for each MDS item For example according to the MDS 3 0 Submission Specs V1 13 2 for the October 1 2013 Release item Aooso type of record can only be coded with the values 1 add new record 2 modify existing record or 3 inactivate existing record If any other value such as a dash is submitted for this item the result will bea fatal error on the Final Validation Report in the CASPER reporting application meaning the MDS record will not be accepted into the QIES ASAP system until the error is corrected Note Section 7 Nursing Home Final Validation Report of the CASPER Reporting User s Guide for MDS Providers explains how to access and read Final Validation Reports Section 5 Error Messages of the MDS 3 0 Provider User s Guide interprets warning and fatal error message numbers on the reports offering tips and actions to resolve the potential problems that have been identified AANAC org 800 768 1880 Why excessive dashes hurt Often providers don t realize the impact of using dashes says Otis Higgins They
19. rld Health Organization published the ICD 10 and has appointed the Centers for Disease Control and Prevention s CDC National Center for Health Statistics NCHS responsible for the implementation of ICD 10 CM and Procedure Classification System PCS This appointment fulfills the international obligations for comparable classifications and the national health data needs of the United States What does that mean Well when you look on the CDC website you can find out where the HINT swine flu is where there is a yellow fever outbreak information on the bird flu epidemic and the seasonal increase in asthma due to molds and leaf burning This reporting is based on the information in ICD codes Whom does this impact The transition to ICD r0 CM and PCS is required for everyone covered by the Health Insurance Portability Accountability Act HIPAA All of health care is changing to ICD 10 CM with the exception of Current Procedural Terminology CPT coding for outpatient procedures and physician services but they too must learn ICD 10 CM Think about it laboratory X ray pharmacy hospice long term care acute care clinics etc changing from an estimated 9 000 to over 90 000 total codes in the transition from the gth edition to the roth edition Don t let that volume scare you this is what they mean when they talk about more specificity in coding ICD 10 CM With ICD 10 CM we have additional codes for ri
20. son declines as would be expected is another SCSA MDS required when the definition of SCSA is met or is the change expected just by virtue of being on Hospice and therefore a SCSA does not have to be done each time there is a decline Thank you in advance for your response Iam unable to find any direction on this in either the regulations or the RAI manual If the declines are expected due to the terminal diagnosis no SCSA is required because the hospice SCSA was already completed Carol Maher rn 8c RAC MT cmahero121 earthlink net Does Medicare Part B Therapy go against the 60 day wellness period for Skilled Care I have a question on Medicare Part B starting after a resident has used all covered days with Medicare A The resident used days in August and continued with all three disciplines ending with speech discontinuing in October Is the last day of Part B coverage when you would start the recount for 60 days to get another 100 days of Medicare A benefit Also is there a certain amount of days on Part B that you would not count if they were on them after Medicare A days are used The first day after the last day that the patient was receiving 5 days per week of therapy would be day 1 for your 60 day count The fact that the patient is receiving Part B therapy does not AANAC org 800 768 1880 preclude the 60 day count from starting What matters is whether the patient is receiving a skilled level of care P
21. ylaxis must continue for one full week after the last case is diagnosed which extends from two weeks to one month or longer and will result in a cost for antivirals of an additional 15 000 to 30 000 As the residents become sicker from the influenza they will need more treatment for congestive heart failure pneumonia and other comorbidities Dr Gahm states that if every resident staff member vendor visitor and volunteer were vaccinated an outbreak could likely be prevented AANAC org 800 768 1880 The CDC provides long term care facilities with information designed to guide their preparation for flu season and outbreak management Their article Interim Guidance for Influenza Outbreak Management in Long Term Care Facilities recommends the following multifaceted approach e Vaccination The CDC data attributes influenza outbreaks in long term care facilities to low influenza vaccination coverage among health care personnel in those settings Higher influenza vaccination rates among health care personnel in nursing home settings can reduce influenza related illness and even prevent resident deaths further states that administration of antiviral medication does benefit those who are very sick even if given after 48 hours Oseltamivir pills or suspension and zanamivir disk inhaler are the recommended antivirals Amantadine and rimantadine are not recommended due to high levels of resistance among circulating inf
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