Skilled Nursing Facility Prospective Payment System (SNF PPS) MDS assessments rightfully get a lot of attention during the COVID-19 public health emergency as nurse assessment coordinators (NACs) continue to try to obtain accurate Medicare Part A payments for their facilities. However, OBRA assessments remain important too, impacting payment in Medicaid case-mix states, as well as care area assessment (CAA) development and resident-centered care planning for all residents. The following steps can help NACs navigate OBRA assessments as the pandemic continues to unfold:
Set ARDs timely
In theory, the Centers for Medicare & Medicaid Services (CMS) relaxed the MDS assessment and transmission requirements this past spring, issuing a COVID-19 emergency blanket declaration waiver that waived “42 CFR 483.20 to provide relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission.”
“The waiver is confusing because CMS never clarified exactly what that means, especially in terms of OBRA assessments,” says Jennifer LaBay, RN, RAC-MT, RAC-MTA, CRC, an MDS/policy consultant with Triad Health Care in Providence, RI.
“However, if you’re in a Medicaid case-mix state that uses OBRA assessments in case-mix calculations or you are doing a combined PPS/OBRA assessment, you can’t afford to use much leeway for relaxed timing because you need the assessments accepted into the QIES database for billing,” says LaBay. “The safest course would be to set the assessment reference date (ARD) timely no matter what on every OBRA and PPS assessment. Then if you have a time crunch during the public health emergency, you should prioritize the completion and transmission of any assessment that will affect the facility’s payment.”
Build wiggle room into the schedule
The OBRA scheduled assessment cycle is as follows:
- An initial comprehensive assessment with an ARD set within 14 days of admission;
- Quarterly assessments, each with an ARD within 92 days of the previous OBRA assessment of any type; and
- An annual comprehensive assessment with an ARD within 366 days of the previous comprehensive OBRA assessment and within 92 days of the previous OBRA quarterly.
Note: For information on completion and submission requirements, including CAA and care plan completion requirements for comprehensive assessments, see the RAI OBRA-Required Assessment Summary table on pages 2-16 – 2-18 in chapter 2 of the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual.
During the public health emergency, interdisciplinary team members and even NACs may have unplanned absences, notes Donna Adendorff, BA, LNHA, RAC-MT, vice president of skilled nursing center operations at Turenne and Associates Healthcare in Montgomery, AL, and a research and development consultant for the Compliance Store.
“To meet the scheduling requirements, it’s useful to build some padding around the 92-day and 366-day deadlines into the OBRA assessment schedule,” suggests Adendorff. “If you project out those dates and schedule OBRA assessments a little earlier than you normally might, then you have some extra time to move the ARD if you need to and still be compliant.”
Remember to code COVID-19 symptoms/services
“When residents become symptomatic for COVID-19, NACs need to be sure those symptoms and related services are captured on OBRA assessments, as well as SNF PPS assessments,” says Adendorff. NACs should be especially attentive to the following symptoms/services, she suggests:
- Fever in item J1550A;
- Pain in J0300 – J0600 or, if necessary, J0800;
- Oxygen therapy in O0100C;
- Isolation for active infectious disease in O0100M; and
- Physician examinations in O0600 (for states where this item is completed).
Check whether a COVID-19 diagnosis has resolved
When a resident receives a diagnosis of COVID-19 that is coded in section I (Active Diagnoses) on an OBRA or a PPS assessment, NACs should follow up on that diagnosis when completing a subsequent OBRA assessment, says Adendorff. “Sometimes, these residents have lingering effects from COVID-19 even though they may no longer test positive for the disease. You should review the physician documentation—and query the physician if necessary—to determine whether COVID-19 is still an active diagnosis.”
Note: If a COVID-19 diagnosis is resolved but the resident now has a specific condition that physician documentation shows is caused by COVID-19, NACs may need to code sequelae (late effects) of COVID-19 in section I. For details, see the AANAC LTC Leader article, “FY 2021 ICD-10 Coding Updates: How to Prepare.”
“The process to follow up on a COVID-19 diagnosis should feed right into your existing system,” adds Adendorff. “The coding instructions require that all diagnoses coded in section I be physician-documented in the last 60 days and active in the last seven days. You need to follow up on COVID-19 diagnoses the same way you would any other diagnosis coded in section I. It’s just an additional element to look for.”
Note: Page I-7 in chapter 2 of the RAI User’s Manual defines an active diagnosis as follows: “Active diagnoses are diagnoses that have a direct relationship to the resident’s current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Do not include conditions that have been resolved, do not affect the resident’s current status, or do not drive the resident’s plan of care during the 7-day look-back period, as these would be considered inactive diagnoses.”
Pay special attention to resident interviews
The MDS includes four key resident interviews:
- Brief Interview for Mental Status (BIMS) in MDS items C0200 – C0500;
- Resident Mood Interview in D0200 – D0300;
- Interview for Daily Preferences and Activity Preferences in F0400 – F0500; and
- Pain Assessment Interview in J0300 – J0600.
In some facilities, these resident interviews aren’t always completed even though the residents are capable of doing them, says LaBay. “Sometimes staff are overwhelmed with their resident care duties, sometimes the facility doesn’t have PPE available, and sometimes they just don’t want to go in the room of a resident with suspected or confirmed COVID-19.”
Not doing these resident interviews is a concern, stresses LaBay. “The pandemic has already taken away so much from residents, isolating them from family and friends, that you don’t want to lose hearing their voice as well. And by not doing the scripted interviews properly, you do that—you lose hearing their voice.”
NACs may be able to adjust the OBRA assessment schedule to free up time for team members to conduct resident interviews, says LaBay. “It may help just to give them the schedule far enough in advance that they can better plan how to carve out the time to do the interviews from their schedule.”
However, some NACs may need to adjust their scheduling style to assist with resident interviews, says LaBay. “For example, if you typically set ARDs for OBRA assessments on one day of the week (e.g., Fridays), that may be overwhelming for staff members who complete resident interviews during the pandemic. You may need to spread out those ARDs so they don’t all fall on one day.”
Some facilities may even need to change which staff members do resident interviews, says LaBay. “For example, while social services staff typically conduct the resident interviews in many facilities, nurses who are wearing PPE and going in the rooms anyway could temporarily take on the job.”
Making that change requires serious cross-training, stresses LaBay. “Staff who conduct interviews should use the interview techniques in Appendix D, ‘Interviewing to Increase Resident Voice in MDS Assessments,’ of the RAI User’s Manual, as well as each interview’s steps for assessment in chapter 3. For example, conducting the BIMS means that the interviewer needs to allow the resident up to five seconds for spontaneous recall of each word in C0400 (Total Recall), while allowing the resident up to 30 seconds for each answer (without providing clues) in C0300 (Temporal Orientation (Orientation to Year, Month, and Day)). If you haven’t provided staff with the training they need to know to do that, they may not be able to obtain an accurate picture of the resident’s voice.”
Available training tools include the following:
- Video on Interviewing Vulnerable Elders (VIVE) from CMS.
- AANAC: Conducting MDS Interviews.
- BIMS video tutorial from CMS. Note: The related Confusion Assessment Method (CAM) video tutorial may be helpful as well since CAM coding uses staff observations from conducting the BIMS.
- MDS 3.0 Section D, Mood from CMS. Note: While some MDS coding instructions may have changed since this video came out in 2010, a simulated resident mood interview begins at the 16:56 mark.
- MDS 3.0 Section F, Preferences for Customary Routine and Activities and Section H, Bladder and Bowel. Note: While some MDS coding instructions may have changed since this video came out in 2010, a simulated resident interview for preferences begins at the 14:13 mark.
- MDS 3.0 Section J, Health Conditions. Note: While some MDS coding instructions may have changed since this video came out in 2010, a simulated resident pain assessment interview begins at the 46:22 mark.
Break open the RAI User’s Manual
Anyone who codes the MDS must be trained to follow the coding instructions in the RAI User’s Manual, stresses LaBay. “MDS item O0100M (Isolation for Active Infectious Disease (Does not Include Standard Precautions)) has become the most common example of the inaccurate coding that can occur when the coding instructions aren’t followed. Meeting the isolation guidelines for COVID-19 from the Centers for Disease Control and Prevention (CDC) does not mean that you can code isolation in O0100M. You still have to meet the four conditions for coding ‘single room isolation’ that are detailed on page O-5 in chapter 3 of the RAI User’s Manual in order to code isolation.”
Another example involves item O0600 (Physician Examinations), says Adendorff. “In states where O0600 is completed, coders would know from reading the coding instructions in the RAI User’s Manual that billable telehealth visits by a physician or state-allowed practitioner can be coded in that item.”
Talk to management about priorities
“NACs spend an average of five hours and five minutes per resident completing a comprehensive assessment,” says AANAC in the 2017 AANAC Nurse Assessment Coordinator Time Work Study and Salary Report. “This includes averages of 80 minutes on the OBRA comprehensive assessment, 54 minutes on care planning, and 171 minutes on CAAs, with each comprehensive assessment resulting in an average of 8.9 triggered care areas per resident.”
It’s worth noting that this average time to complete an OBRA comprehensive assessment does not include the completion time for section GG (Functional Abilities and Goals), which a number of Medicaid case-mix states began requiring providers to collect on all OBRA assessments this Oct. 1 in order to generate Patient-Driven Payment Model (PDPM) billing codes. Adding section GG to PPS assessments effective Oct. 1, 2016, added 13.5 minutes to the completion time of the 5-day PPS MDS, says AANAC.
As staffing shortages continue to occur and even expand nationwide, many NACs are faced with handling multiple competing priorities, says LaBay. “They are expected to cover the floor and do other nursing duties while still completing their own work managing the MDS process. Consequently, the time they have left in the day to complete each OBRA assessment may not be enough time to do a high-quality assessment. In Medicaid case-mix states, this may mean the facility doesn’t receive accurate reimbursement because the MDS coding doesn’t provide an accurate representation of the residents. However, it also may mean that the CAAs are lacking and that the care plans that drive resident care aren’t up-to-date, individualized, and resident-centered.”
NACs who don’t have sufficient time to complete OBRA assessments should have a discussion with management, suggests LaBay. “It can be tricky, but you need to lay it out on the line and explain the average time to complete OBRA assessments vs. how much time you actually have to do them because you have this list of additional tasks during the public health emergency. Then shift the problem back to them and ask, ‘What do you want me to prioritize? What are your suggestions?’ So you want to tell leadership your responsibilities and your barriers, and ask for advice.”
NACs also should follow up on the conversation by e-mailing the management team a copy of those same points with the request for help, says LaBay. “Nursing home leaders are very busy, especially during the COVID-19 pandemic, and may not be able to give their direct focus during a conversation. Consequently, you want to make it very clear in writing, ‘Here is what I told you about my situation.’ Leadership may not have been aware of these problems you’re having. However, if your management team is unable to help you find the time you need for the MDS process, that e-mail can serve as proof that you made the effort to alert them to the problem.”
Be careful about working from home
Some NACs are working from home during the pandemic, points out LaBay. “Working from home can be beneficial on a temporary basis, helping to conserve personal protective equipment (PPE) and reduce transmission risks. However, it can also lead to inaccurate MDS coding if NACs don’t receive significant in-facility support because the job isn’t designed to be full-time work-from-home.”
NACs need to be able to assess the resident, interview staff members, and find information that isn’t necessarily in the electronic health record (EHR), explains LaBay. “It’s great to have the ability to work from home, but there still must be some way to obtain all of the information required for accurate assessments. For example, there may a paper-based wound log at the nursing station. Who ensures that it is scanned into the EHR so that you see it? Or the facility is in a Medicaid case-mix state that is requiring the completion of section GG on OBRA assessments, but direct-care staff don’t have a good understanding of those new OBRA items. How do you conduct staff interviews in order to code section GG accurately? There is definitely room for error if the process isn’t planned carefully.”
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