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N0410H: The Key to Coding Opioids—And Why Accuracy Counts

Effective Oct. 1, providers must report the number of days that residents received opioid medications in the new MDS item N0410H (Opioid Medications Received) in Section N (Medications). The coding instructions for N0410H in the RAI Manual (page N-7) are straightforward. The Centers for Medicare & Medicaid Services (CMS) tells MDS assessors to: “Record the number of days an opioid medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or re-entry if less than 7 days).”

However, nurse assessment coordinators (NACs) still need to be alert to potential miscoding, says Carol Maher, RN-BC, RAC-MT, CPC, director of education for Hansen, Hunter & Co. PC in Vancouver, WA. “Some MDS assessors may be tripped up by the underlying question: Is this medication an opioid or not?” she explains.

“It’s important to investigate the pharmacological classification of medications the resident receives, and to code the ones that are opioids, according to the resources that are provided in the RAI Manual, says Maher. An excerpt from page N-11 details those resources:


The following resources and tools provide information on medications including classifications, warnings, appropriate dosing, drug interactions, and medication safety information.


GlobalRPh Drug Reference, http://globalrph.com/drug-A.htm

USP Pharmacological Classification of Drugs, http://www.usp.org/usp-healthcare-professionals/usp-medicare-model-guidelines/medicare-model-guidelines-v50-v40#Guidelines6. Directions: Scroll to the bottom of this webpage and click on the pdf download for “USP Medicare Model Guidelines (With Example Part D Drugs)”

Medline Plus, https://www.nlm.nih.gov/medlineplus/druginformation.html

The DrugLib.com Index of Drugs by Category, http://www.druglib.com/drugindex/category/


This list is not all-inclusive. CMS is not responsible for the content or accessibility of the pages found at these sites. URL addresses were current as of the date of this publication.


When MDS assessors still have questions about a drug’s pharmacological classification, “either the dispensing pharmacist or the facility’s consultant pharmacist should easily be able to provide that information,” suggests Joan Baird, PharmD, BCGP, FASCP, director of pharmacy practice and government affairs for the American Society of Consultant Pharmacists in Alexandria, VA.


Why you need to code accurately

“N0410H isn’t a qualifier in the RUG-IV payment classification in the skilled nursing facility prospective payment system; it isn’t a care area trigger that leads to a care area assessment for care planning; and it doesn’t currently impact any quality measures,” notes Susan Battaglia, RN-BC, RAC-CT, director of case-mix management and clinical services for Tara Cares in Orchard Park, NY.

“However, while this new MDS item doesn’t link directly to payment, care, or quality issues, the data is being collected for a reason,” says Battaglia. “It seems likely that this question was added to help gather data for surveyors. Instead of a surveyor having to gather the data on a facility’s opioid use, the MDS will do it for them.”

Here’s a small window into how this may work: In the new survey process that goes into effect Nov. 28, the survey team’s software system will select five residents for an Unnecessary Medication review based on MDS data, as well as from information entered by surveyors during the initial round of interviews, observations, record reviews they conduct to finalize their survey sample. (These five residents may or may not also be included in that sample.)

Opioids are one of the medications that drive selection for the Unnecessary Medication review. “The selection process considers all psychotropic medications, insulin, anticoagulants, opioids, diuretics and antibiotics, as well as some adverse consequences, including falls, weight loss, and sedation,” says CMS in the New Long-term Care Survey Process Slide Deck. “There are exclusions; for example, a resident would be excluded if they had a diagnosis of Huntington’s or Schizophrenia and was receiving an antipsychotic.”

In addition to gathering resident-level opioid data for survey use, “the expectation is that CMS will try to determine how widespread opioid use is in nursing homes,” points out Maher. “We all hear all the news stories about the opioid epidemic, especially in the elderly. So this will give CMS—and us—a chance to see how many of our residents really are using opioid medications.”

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