Category: Q&A

Question: Please clarify when resident interviews need to be completed for the MDS? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: All resident interviews, including the Customary Routine/Activities, BIMS, PHQ-2 to 9, and Pain, must be completed in the 7-day look-back window of the MDS. Any non-interview …

Question: Do I need to complete discharge assessments for an emergency evacuation? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: You may not be required to complete the discharge MDS in this situation. Here is a link to the all-cause waiver information: https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Provider-Survey-and-Certification-Frequently-Asked-Questions.pdf. Review the SNF information and watch …

Question: What are the correct dates for flu season and pneumonia vaccines for MDS purposes to count if present during that time? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: The influenza vaccine question O0250 is asking if the vaccine was delivered in your facility during the current flu …

Question: I need clarification regarding the CAA notes: I was understanding that anything that triggers we would address in the care plan. Do we have to address every single CAA note even if it does not trigger? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, CRC: Not every item that triggers …

Question: During our annual survey, I was questioned about coding methenamine as an antibiotic on the MDS. I had coded it based on information received from AAPACN and references discussed in this forum. The surveyor appreciated the reference but disagreed, stating that the medication is an anti-infective rather than an …

Question: Is a signed diagnosis list enough to support coding diagnoses in section I, or does the physician need to document the diagnosis as active in their notes? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, CRC: Just having a diagnosis list signed by a physician is not quite enough. There …

Question: If a resident was discharged return anticipated and comes back on day 30, would this be considered a readmission or a new admission? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: If the resident comes back on day 30, she would be a readmission not a new admission. …

Question: When resuming Medicare Part A within the 30-day transfer rule, which GG observation period should be used on a Significant Change in Status (SCSA) combined with a 5-Day? Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC: The GG observation period is the first three days of the Medicare …

Question: Does “at risk for malnutrition” qualify for coding if it is only documented by a dietitian and not by a physician? Answer from Jeff Taylor: The steps for assessment and coding instructions for I5600 require provider documentation during the 60-day observation period. You need a provider (physician, nurse practitioner …