Q&A: A resident on a Medicare Part A stay was sent to the emergency department by ambulance at 6:45 p.m. on Feb. 2 and returned to the facility just after midnight without being admitted to the hospital. Would this situation qualify as an interrupted stay?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: A resident on a Medicare Part A stay was sent to the emergency department by ambulance at 6:45 p.m. on Feb. 2 and returned to the facility just after midnight without being admitted to the hospital. Would this situation qualify as an interrupted stay? Answer from Jeff Taylor:The interrupted …

Q&A: If the registered dietitian documents a resident is at risk for malnutrition within the MDS look-back period, can “risk for malnutrition” be coded on the MDS section I5600?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: If the registered dietitian documents a resident is at risk for malnutrition within the MDS look-back period, can “risk for malnutrition” be coded on the MDS section I5600? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: Since this is section I, the documentation can ONLY come from a …

Q&A: How do you code discharge status, A2105, when the resident discharged to a hotel?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: How do you code discharge status, A2105, when the resident discharged to a hotel? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: A discharge to a homeless shelter, jail, or hotel would be coded as 99, None of the above. This AAPACN resource is copyright protected. AAPACN individual members …

Q&A: If a resident has a diagnosis of “schizoaffective disorder, bipolar type,” how is this coded on the MDS?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: If a resident has a diagnosis of “schizoaffective disorder, bipolar type,” how is this coded on the MDS? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: Schizoaffective disorder would be coded at I6000, but ONLY if all of the DSM-5 requirements are met (physician comprehensive assessment present and …

Q&A: Can you please clarify “head injury”—the criteria for coding major injury at J1900C?

MDS 3.0 and the RAI Process / NAC / Q&A

Question:  Can you please clarify “head injury”—the criteria for coding major injury at J1900C? Answer from Jessie McGill RN, BSN, RAC-MTA, RAC-CTA: CMS did not provide a definition of major injury but instead provided a list of comparable injuries: “Includes, but is not limited to, traumatic bone fractures, joint dislocations/ …

Q&A: When coding height for a resident with bilateral lower leg amputations, do you code the height prior to amputation or after?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: When coding height for a resident with bilateral lower leg amputations, do you code the height prior to amputation or after? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: You code the height in the 7-day look-back. If the resident now has bilateral amputations, the height would be measured …

Q&A: If a long-stay resident has a Stage 2 pressure ulcer and it heals, would a Significant Change in Status Assessment (SCSA) be required?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: If a long-stay resident has a Stage 2 pressure ulcer and it heals, would a Significant Change in Status Assessment (SCSA) be required? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: On page 2-24 the RAI User’s Manual defines a Significant Change in Status as “a major decline …

Q&A: Am I able to code “yes” in item J1400, Prognosis, when the documentation supporting “life expectancy less than six months” is signed by nurse practitioners or physician assistants, or is a physician signature required?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: Am I able to code “yes” in item J1400, Prognosis, when the documentation supporting “life expectancy less than six months” is signed by nurse practitioners or physician assistants, or is a physician signature required? Answer from Jessie McGill, RN, BSN, RAC-MTA, RAC-CTA: Yes, if allowable by state laws, on …

Q&A: Can I set a 5-Day PPS assessment on a non-billable day such as a skip day? The resident was sent to the hospital, did not return prior to midnight, and was not admitted.

Billing and Reimbursement / NAC / Q&A

Question: Can I set a 5-Day PPS assessment on a non-billable day such as a skip day? The resident was sent to the hospital, did not return prior to midnight, and was not admitted. Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: No, the ARD for the 5-Day cannot …

Q&A: What specialized training is needed to capture respiratory therapy provided by nurses?  

MDS 3.0 and the RAI Process / NAC / Q&A

Question: What specialized training is needed to capture respiratory therapy provided by nurses?   Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC:The Glossary of the RAI User’s Manual (Appendix A-22) states this: Respiratory Therapy Services that are provided by a qualified professional (respiratory therapists, respiratory nurse). Respiratory therapy services …