The MDS Mentor Sept. 2011 – DADS
Contents
1. Coding Instruc tions on page G 4 of the RAIM3 CMS notes that A resident s ADL self performance may vary from day to day shift to shift or within shifts There are many possible reasons for these varia tions including mood medical condi tion relationship issues e g willing to perform for a nursing assistant that he or She likes and medications The re sponsibility of the person completing the assessment therefore is to capture the total picture of the resident s ADL self performance over the 7 day period 24 hours a day i e not only how the evaluating clinician sees the resident but how the resident performs on other shifts as well The Steps for Assess ment on page G 3 of the RAIM3 instruct staff who are coding Section G to Talk with direct care staff from each shift and to review records interview staff and observe the resident When facility staff document in Section Z0400 that they completed Section G accurately they are documenting that they com plied with these instructions VOLUME 4 We want to give a big thank you to Deborah Estes RN and MDS Coordina tor at Homestead Nursing amp Rehab of Cisco for helping DADS test the state MDS server during the August 15 2011 maintenance ce E a m F ISSUE 2 PAGE 2 Defining Facility Staff From pages G 3 to G 4 of the RAIM3 For the purposes of completing Section G facility staff pertains to2. Mail Code 279 4 Mail Code E 345 Phone 210 619 8010 Phone 512 438 2396 Fax 210 619 8100 Fax 512 438 4286 Shared Fax Call First Shared Fax Call First Useful Web Links DADS MDS Web Site Texas MDS site for MDS policy procedures clinical and technical informa tion including The MDS Mentor http www dads state tx us providers MDS TOMHT W po m E E a aaa er a a Sign up for MDS Resource E mail updates Go to http www dads state tx us click on the E mail updates tab and follow the directions The DADS Texas Minimum Data Set MDS Re sources emails are the key line of communication for MDS updates and alerts to nursing home and swing bed facilities from the DADS MDS staff Centers for Medicare amp Medicaid Services CMS MDS Web Site for MDS 3 0 MDS 3 0 High lights RAI Manual Item Sets forms related MDS 3 0 materials and a link to MDS 2 0 http www cms gov NursingHomeQualityInits 25 NHOIMDS30 as QIES TECHNICAL SUPPORT OFFICE QTSO MDS 3 0 2 0 RAVEN RAVEN and AT amp T Client Software information Validation Report Messages Guides Training and DAVE DAVE 2 Tip sheets https www atso com CMS MDS Training Web Site MDS 2 0 computer based training CBT http www mdstraining org upfront ul as Quality Reporting System QRS DADS information site on Texas nursing homes http facilityquality dads state tx us Nursing Home Compare CMS site that compares nursing ho
3. Therapy with Resumption EOT R is completed In cases where therapy resumes after the EOT OMRA is performed and the resumption of therapy date is no more than 5 consecutive calendar days after the last day of therapy provided and the therapy services have resumed at the same RUG IV classification level that had been in effect prior to the EOT OMRA an End of Therapy OMRA with Resumption EOT R may be completed Continuing on page 2 49 of the RAIM3 CMS introduces the new Change of Therapy COT OMRA which is Required when the resident was receiving any amount of skilled therapy services and when the intensity of therapy as indicated by the total reimbursable therapy minutes RTM delivered and other therapy qualifiers such as number of therapy days and disciplines providing therapy changes to such a degree that it would no longer reflect the RUG IV classification and payment assigned for a given SNF resident based on the most re cent assessment used for Medicare payment The very next bullet informs staff The COT observation peri ods are successive 7 day windows with the first observation period beginning on the day following the ARD set for the most recent scheduled or unscheduled PPS assessment except for an EOT R assessment So for any PPS MDS except an EOT R the COT ARD if a COT is due would be seven 7 days after the ARD of the most recent PPS MDS However if the previous PPS MDS was an EOT R the COT ARD if a COT is due
4. in Item A2300 OR create a hard copy of Section A of the MDS Item Set entering the resident s name in A0500 and the ARD in Item A2300 ARDs that are only noted in meeting minutes PPS calculating tools therapy logs nurse s notes facility forms memos or by any other method not specifically mentioned on page 2 8 of the RAIM3 as quoted above may NOT use that notation as the ARD in Item A2300 The reason is because the ARD was noted but not set per CMS policy Once an assessment is transmitted the only way to change the ARD is to inactivate the assessment From page 5 10 to 5 11 of the RAIM3 An Inactivation of the existing record followed by submission of a new corrected record is required to correct Type of Provider Item A0200 Type of Assessment A0310 Entry Date Item A1600 on an Entry tracking record A0310F 1 Discharge Date Item A2000 on a Discharge Death in Facility record A0310F 10 11 12 or Assessment Reference Date Item A2300 on an OBRA or PPS assessment Facility staff must be informed that once the ARD has been transmitted the only reason to inactivate the MDS to change the ARD is if it was mistyped on the Item Set and is not the date set by the facility Prior to 10 1 11 staff were advised to keep a copy of whatever documentation that set the ARD as evidence the assessment was only changed to correct the ARD to the date that facility staff set in the first place Effective 10 1 11 the only acceptab
5. no nourishment by any route oral IV TPN enteral during the 7 day look back period or if the resident was not fed by facility staff during the 7 day look back period mm eel VOLUME 4 ISSUE 2 PAGE 3 CMS Sets New Rules for Setting the ARD An optimist isa Effective October 1 2011 CMS has new rules which Texas MDS staff have empha person who starts a new diet on Thanksgiving Day Irv Kupcine sized by underlining below for setting the ARD on OBRA and Medicare required PPS MDS From page 2 8 of the RAIM3 Assessment Reference Date ARD refers to the last day of the observation or look back period that the assessment covers for the resident Since a day begins at 12 00 a m and ends at 11 59 p m the ARD must also cover this time period The facility is If the only prayer required to set the ARD on the MDS form itself or in the facility software within the ap eeu ach ae dis propriate timeframe of the assessment type being completed This concept of setting thankyou that the ARD is used for all assessment types OBRA and Medicare required PPS and varies would suffice by assessment type and facility determination Meister Eckhart It is extremely important to ensure that the ARD is set according to CMS rules not only to avoid inaccurate assessments but also to avoid potential payment consequences Facility staff must open up an item set for a resident in the facility MDS software and set the ARD
6. INSIDE THIS ISSUE The MDS Mentor Cheryl Shiffer BSN RN RAC CT MDS Clinical Coordinator Section G Coding ADLs Defining Facility Staff Focus on G0110H Eating CMS Sets New Rules for Setting the ARD Andy Alegria Department of Aging and Disability Service Private Pay and Medicare Part C MDS MDS Automation Coordinator VOLUME 4 ISSUE 2 SEPTEMBER 2011 New Unscheduled Medicare Assessments The MDS Mentor is published in March June September and December each year ACRONYMS Activities of Daily Liv ing ADL Assessment Reference Date ARD Centers for Medicare and Medicaid Services CMS CMS Long Term Care Facility Resident Assessment Instrument User s Manual Version 3 0 RAIM3 Minimum Data Set MDS Omnibus Budget Reconciliation Act OBRA Prospective Payment System PPS Skilled Nursing Facility Nursing Facility SNF NF 1 2 2 3 4 MDS News in Review 4 5 6 Useful Web Links Section G Coding ADLs Although facility staff often focus on the four late loss ADLs Bed Mobility Transfer Eating and Toilet Use it is important that all ADL coding be accu rate Facility staff responsible for the MDS coding of residents ADL self performance and level of staff support must ensure they follow the instruc tions in the RAIM3 for coding G0110 Before coding for any section of the MDS begins it is important that facility management staff understand that it i
7. d entry tracking records discharge assessments and death in fa cility records are the only MDS records that are sent to CMS for private pay and Medicare Part C patients that are placed in a Medicare bed or swing bed All SNF and swing beds must code item A0410 3 for all OBRA required MDS that are sent to CMS ers should update jRaven to the newest version If the Medicare HMO policy requires the provider complete MDS that resemble PPS assessments for Medi care Part C payment then ensure that these HMO requested assessments are not submitted to the CMS MDS system It is the responsibility of the facility to determine how the assessments completed for Medicare Part C payment will be completed without being submitted We recommend that you find a way to preserve i e save and backup Medicare Part C MDS assessments in case the SNF or swing bed provider later finds out the resi dent was on Part A and needs to submit a Part A MDS assessment Section O Errata for October 2011 According to CMS the changes to the RAIM3 noted below are effective October 1 2011 However the RAIM3 will not be updated to include these changes until Spring 2012 Please make the following changes to your copy of the RAIM3 Chapter 3 Section O Page 0 39 Item 00600 Physician Examinations in the first bullet under Coding Tips and Special Populations the last sentence Cannot be an employee of the facility was added in error and should be ignored Chapte
8. direct employees and facility contracted employees e g re habilitation staff nursing agency staff Thus does not include individuals hired compensated or not by individuals outside of the facility s management and admini stration Therefore facility staff does not include for example hospice staff nurs ing CNA students etc Other examples of those not included in the definition of facility staff include ambulance staff family and visitors In addition private sitters and private personal care aides cannot be included as facility staff even when the facility pays for the pri vate staff if the resident family or guardian is ultimately charged for these services CMS explains why on page G 4 Not including these individuals as facility staff supports the idea that the facility retains the primary responsibility for the care of the resident outside of the arranged services another agency may provide to facility residents Focus on GO110H Eating After staff read page G 3 of the RAIM3 When reviewing records interviewing staff and observing the resident be spe cific in evaluating each component as listed in the ADL activity definition they often ask where CMS defines each compo nent of an ADL The answer is found in the RAIM3 page G 2 in the box titled Definitions under ADL Aspects which are defined as Components of an ADL ac tivity These are listed next to the activi
9. le evidence of the date that you set the ARD would be if you set the ARD on a hard copy of Section A of the MDS Item Set If you set the ARD only in the facility software and you set it incorrectly that is the date the ARD was originally set and itis considered intentional Therefore if facility staff elect to establish the ARD in the facility software be extremely careful and ensure that the date is correct Time Saving Survey Your time is very important and you do not have The DADS MDS staff will include selected tips and enough ofit The discharge assessments and new FY tools in the next MDS Mentor When submitting your 2012 PPS rules require more work so time is more tips to us let us know whether or not you want your valuable than ever Help the DADS MDS staff pass name another person s name and or your facility along your wisdom for how to make the most effi name to be identified as the source of your submitted cient use of your time Please e mail your MDS time tips Help other MDS coordinators save time com saving tips efficiency tools and words of wisdom to pleting MDS by sharing your wisdom with us andy alegria dads state tx us VOLUME 4 ISSUE 2 MDS News in Review Starting April 1 2011 the reason for assessment items assessment reference date ARD discharge date and entry date can no longer be changed with a modification record on MDS 3 0 records Instead these items must be corrected by inactivating the old rec
10. mes in a given area http www medicare gov NHCompare Include DataSection Questions SearchCriteria as 5 Star Technical Manual Explains data used to create the 5 Star Report http www cms gov CertificationandComplianc 13 FSQRS asp
11. ord and submitting a new record The April 1 2011 start date is based on the submission date not the ARD of the record On June 23 2011 CMS quietly posted DRAFT MDS 3 0 Quality Measure QM documents You may ac cess the DRAFT QM information on the CMS MDS 3 0 Technical Information page by scrolling down to the DRAFT MDS 3 0 QM User s Manual ZIP PAGE 4 prior to the implementation of the QMs CMS confirmed that April 2012 is the earliest date that the Quality Measures will be implemented in CASPER On August 2 2011 jRaven version 1 1 2 was posted on the QTSO website On September 20 2011 CMS updated Chapters 2 and 6 and Chapter 3 Section O of the October 2011 RAIM3 that was originally posted August 31 2011 on the CMS MDS 3 0 Training Materials web page On September 30 2011 jRaven version 1 1 3 was posted on the QTSO website All jRaven us 582KB link Please note that this is a DRAFT document and additional changes may be made Private Pay and Medicare Part C MDS When a patient stays in a Medicare certified swing bed or a Skilled Nursing Facility SNF but the payer source is private pay or Medicare Part C Medicare Advantage Medicare HMO then OBRA required MDS re cords item A0310A or Item A0310F does not equal 99 are required to be submitted to CMS however PPS assessments items A0310B 1 7 or A0310C 1 3 must NOT be submitted to CMS In other words federal OBRA assessments SNFs only not swing be
12. r 3 Section O Page 0 40 Item 00700 Physician Orders in the first bullet under Coding Tips and Special Populations the last sentence Cannot be an employee of the facility was added in error and should be ignored VOLUME 4 ISSUE 2 PAGE 5 Medicare Questions Who Has Answers When answers cannot be found in the relevant Medicare manuals Medicare eligibility and payment questions should be directed to TrailBlazer Health Enterprises the Medi care Administrative Contractor MAC for Texas Http www trailblazerhealth com is the TrailBlazer website where you can find answers and contact information MDS related Medicare eligibility and payment questions to ask the MAC include Does a resident qualify for Medicare Part A under these conditions Is this a diagnosis that I can use for Medicare Part A Can I change the diagnosis that was used for Medi care Part A during the Part A stay Is this procedure covered by Medicare Part A Why SE did I not get paid the expected rate for this MDS PPS assessment Visit https www cms gov MedicareContractingReform for additional MAC pro Ea gram information As always your state MDS staff are your contacts for OBRA and Medi care scheduling and MDS coding questions SS New Unscheduled Medicare Assessment Types For MDS assessments that have an ARD on and after October 1 2011 two new Medicare unscheduled PPS assessment types go into effect From page 2 49 of the RAIM3 the new End of
13. s their responsibility to determine which facility staff document gather and code residents ADLs as well as all other clinical information coded on the MDS From page 1 6 of the RAIM3 CMS in structs Nursing homes are left to deter mine 1 who should participate in the assessment process 2 how the assess ment process is completed and 3 how the assessment information is documented while remaining in compli ance with the requirements of the Fed eral regulations and the instructions contained within this manual In addi tion from page 1 7 As such nursing homes are responsible for ensuring that all participants in the assessment proc ess have the requisite knowledge to complete an accurate assessment There is no RAIM3 or DADS require ment that the staff assigned to docu ment gather or complete the coding for Section G be a licensed nurse Facility management staff can illus trate compliance with the requirement to ensure that staff had the requisite knowledge to complete an accurate assessment when there is evidence that facility staff were trained provided ac cess to a current RAIMS3 in its entirety or at least provided access to RAIM3 instructions for the sections they are assigned to complete and acting within the scope of practice parameters set by their licensing or certification entity While it is a CMS expectation that facility staff consistently document ADL performance under
14. ty in the item set For example the compo nents of GO110H Eating are eating drinking and intake of nourishment or hydration by other means including tube feeding total parenteral nutrition and IV fluids for hydration In addition CMS provides a copy of Section G0110 on page G 1 of the RAIM3 so components may be reviewed without having to leave Section G of the RAIM3 to access an MDS Item Set Under Coding Instructions for G0110 on page G 3 of the RAIM3 CMS clarifies that To assist in coding ADL self perform ance items please use the algorithm on page G 6 Consider each episode of the activity that occurred during the 7 day look back period On page G 7 of the RAIM3 under Coding Tips and Special Populations CMS provides an example for coding ADL Support Setup Help when the ac tivity involves the following Eating cutting meat and opening containers at meals giving one food item at a time Further along on the same page CMS provides the following instructions for G0110H Code Supervision for residents seated together or in close proximity of one another during a meal who receive individual supervision with eating Gen eral supervision of a dining room is not the same as individual supervision of a resident and is not captured in the cod ing for Eating Moving on to page G 8 of the RAIM3 CMS writes Eating would be coded 8 activity did not occur if the resident received
15. would be seven 7 days including the date in 00450B the date therapy resumed In addition CMS has posted new guidance regarding setting the ARD on unscheduled PPS MDS The ARD for a Start of Therapy SOT EOT or COT PPS MDS may be set for days in the ARD window of the assessment even after the window has closed preferably within the first few days after the window closes In no cases can an ARD within the window for a SOT EOT or COT be set 14 days after the chosen ARD because all PPS MDS must be completed no later than 14 days after the ARD This new policy of allowing the ARD to be set after the window for setting the ARD has closed applies only to the SOT EOT and COT PPS MDS For scheduled PPS MDS there has been no change and the ARD must be set while the resident is in the window for that type of Medicare assessment CMS has posted this clarification and others at http www cms gov OpenDoorForums Downloads Transcript090111SNTLTC pdf Unemployment is high work is in short supply so I m blessed to be MDS assessing But with Change of Therapy the new PPS policy I m not sure I can handle more blessing VOLUME 4 ISSUE 2 PAGE 6 f m E _ E E E O y T T E A Cheryl Shiffer BSN RN RAC CT JE Andy Alegria MDS Clinical Coordinator MDS Automation Coordinator 11307 Roszell Street Room 1310 P O Box 149030 San Antonio TX 78217 Austin TX 78714 9030
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