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PDPM: Clearing Up Nursing Component Confusion – Part 4 – Focus on Clinically Complex

Editor’s note: This is the fourth article in a series on the PDPM categories for the nursing component, covering various missteps to avoid in PDPM calculation, as well as essential coding tips. Part one focused on Extensive Services, part two focused on Special Care High, and part three, Special Care Low. The final article in the series will address the additional nursing categories of Behavior and Cognitive Performance and Reduced Physical Functioning.

The intricate journey into the qualifiers of the PDPM nursing component continues beyond the Extensive Services, Special Care High, and Special Care Low categories and into the Clinically Complex category. Unlike the three previous nursing categories, Clinically Complex does not apply a maximum nursing function score derived from section GG; it utilizes the full function score range of 0-16. The second article in this series, PDPM: Clearing Up Nursing Component Confusion – Part Two – Focus on Special Care High, emphasizes the importance of section GG and section I accuracy, which applies to Clinically Complex as well. Knowledge of what qualifies for the nursing categories is essential for effective case management and assessment reference date (ARD) selection. Additionally, understanding which clinical items qualify for each nursing clinical category is necessary to identify changes that may warrant the completion of an interim payment assessment (IPA).

Here are four additional tips to simplify the Clinically Complex nursing category.

1. Nurse assessment coordinators (NACs) and interdisciplinary team (IDT) members must understand what clinical items qualify into the Clinically Complex category.

In addition to residents who qualified into Extensive Services, Special Care High, or Special Care Low but have a nursing function score of 15 or 16, there are eight clinical conditions that could place a resident into the Clinically Complex category:

1. Pneumonia (I2000)
2. Hemiplegia/hemiparesis (I4900) with nursing function score ≤ 11
3. Open lesions (other than ulcers, rashes, and cuts) or surgical wounds (M1040D, E) with any selected skin treatment
M1200F Surgical wound care
M1200G Application of nonsurgical dressing (other than to feet)
M1200H Application of ointments/medications (other than to feet)
4. Burns (M1040F)
5. Chemotherapy while a resident (O0100A2)
6. Oxygen therapy while a resident (O0100C2)
7. IV medications while a resident (O0100H2)
8. Transfusions while a resident (O0100I2)

It is important to note that diagnoses that qualify for the Clinically Complex category come only from the checkbox items in I0100 – I7900. Any additional diagnosis coded at I8000 does not affect categorization.

2. NACs and IDT members must ensure all RAI User’s Manual instructions and definitions are supported in the medical record for M1200F, G, and H.

Skin and ulcer/injury treatments in M1200 have very specific instructions and definitions. The following items in M1200 potentially affect the Clinically Complex category: M1200F, Surgical wound care; M1200G, Application of dressings (other than to feet); and/or M1200H, Application of ointments (other than to feet).

Surgical wound care may be coded inadvertently when there is a surgical wound coded in M1040E. A surgical wound on a resident does not automatically translate to coding surgical wound care on the MDS. Consider this situation: a resident had a total hip replacement, and the physician has orders in place not to remove the dressing on the surgical wound until the resident is seen at the follow-up appointment. If the resident’s follow-up appointment is not until after the ARD of the 5-Day PPS assessment, and the dressing has not required any care, then no surgical wound care has been completed. In addition, leaving a wound open to air does not constitute surgical wound care. Similarly, surgical wound care does not include post-operative care following eye or oral surgery.

Often, MDS scrubbers may review the MDS and suggest that surgical wound care be coded when a surgical wound has been coded. These scrubbers are great reminders, but they do not consider physician orders or whether the documentation supports that surgical wound care was provided for the individual resident. Therefore, in the hip replacement scenario above, the best practice would be to document in the medical record the reason surgical wound care was not coded and ignore the MDS scrubber’s suggestion if it isn’t warranted.

The NAC also needs a clear understanding of what is included when coding M1200G, Application of dressings (other than to feet), and M1200H, Application of ointments (other than to feet). The RAI User’s Manual clarifies on page M-37 that even if there are no skin problems documented, M1200G and H could be coded on the MDS if the ointment or dressing is in place for the purpose of preventing a skin condition. These items cannot be coded, however, if the intervention is not related to a skin treatment, such as nitroglycerine or testosterone cream. Moreover, the NAC must recognize that any treatments applied to a pressure ulcer or injury cannot be captured at M1200G or H, but are only coded under M1200E, Pressure ulcer/injury treatment. When coding treatments to skin or ulcers, pages M-33 to M-40 of the RAI User’s Manual should be reviewed carefully for additional guidance.

3. NACs must consider services provided while a resident that may not be delivered in the facility.

Section O0100 has four items that impact the Clinically Complex category: Chemotherapy (O0100A2), Oxygen therapy (O0100C2), IV medications (O0100H2), and Transfusions (O0100I2). Only items coded in column 2, while a resident, are considered for qualification into the Clinically Complex category. However, the NAC must understand that “while a resident” does not require that the services be provided in the facility. Any of these four items could be delivered at a physician’s office, an emergency room visit, outpatient oncology appointment, or other providers. If documentation from these offsite visits demonstrates that any of these items were delivered, as long as the resident was not discharged from the facility at the time of the delivery of the service, it can be captured in section O0100, column 2.

The key is having supporting documentation. It is important that facility staff obtain documentation after these visits and include it in the medical record. NACs should be mindful of these visits so they know to seek out any documentation that may be in a physician’s folder for review or waiting to be filed into the medical record. The NAC must also recognize that any services that occur at dialysis or chemotherapy appointments such as IV medications, IV fluids, or transfusions, cannot be coded individually. Dialysis and chemotherapy centers are all-inclusive treatment locations, which means that additional services provided at such appointments are not captured separately on the MDS.

4. Determining the case-mix group (CMG)

If the resident meets any of the criteria to achieve the Clinically Complex nursing category, the final case-mix group is determined further by nursing function score and finally the end split of symptoms of depression. The additional nursing function score of 15 to 16 brings two additional case-mix groups to the Clinically Complex category—CA1 and CA2. A PHQ-9 score greater than or equal to 10, but not 99, qualifies for the depression end-split.

In addition to understanding the interview techniques outlined in the RAI User’s Manual, the NAC and IDT must understand that timeliness of the PHQ-9 interview plays a key role in the determination of the depression end-split. The resident interview must occur within the look-back period, preferably the day before or the day of the ARD. If the interview should have been attempted but was not, item D0100, “Should Resident Mood Interview Be Conducted?,” must be coded 1, Yes, and the standard “no information” code (a dash “-”) is entered in the resident interview items. The interviewer cannot proceed to the Staff Assessment of Resident Mood items (D0500) when the resident interview should have been conducted but was not done. However, if the interview was attempted within the look-back period, but the resident was unable or unwilling to complete the interview, then the interviewer may proceed to the staff assessment. The final CMG determinations can be made using different tools available to the NAC, such as the AAPACN PDPM At-a-Glance Tool or chapter 6 of the RAI User’s Manual.


Understanding the RAI User’s Manual instructions and accuracy of MDS coding cannot be overstated. MDS completion is not the place to cut corners, as missteps could be costly. Miscoding a Clinically Complex item may result in underpayment, or recoupment of money if the services are deemed to be inaccurately coded under medical review. Review the record to ensure that proper documentation is in place to support the diagnoses, skin conditions and treatments, and complex services delivered while a resident.

Coming Up:

If the resident does not qualify for the Extensive Services, Special Care High, Special Care Low, or Clinically Complex categories, the next step in the nursing component is to review if the resident qualifies for the Behavioral Symptoms and Cognitive Performance category, or, finally, the Reduced Physical Function category.

Look for the final installment of this article series focusing on these final two nursing components in a future edition of the Leader for the NAC newsletter.

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