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 …

Q&A: The SNF QRP Data Validation Audit notification letter requested Admission and Discharge assessments. What assessments should be submitted?

Billing and Reimbursement / NAC / Q&A

Question: The Skilled Nursing Facility Quality Reporting Program (SNF QRP) Data Validation Audit notification letter requested Admission and Discharge assessments. What assessments should be submitted? Answer from Jessie McGill RN, BSN, RAC-MTA, RAC-MT: On the notification letter, there are instructions for the “MDS Assessment Type is Admission” or a “Discharge.” …

Q&A: When a resident is discharged to the hospital and admitted with a diagnosis of UTI. Does the UTI get coded on the discharge return anticipated MDS? 

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

Question: When a resident is discharged to the hospital and admitted with a diagnosis of UTI. Does the UTI get coded on the discharge return anticipated MDS?  Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: If the diagnosis of UTI did not occur until the resident was at the …

Q&A: How do I code the “Will [care area] be addressed in the care plan” question when a resident discharges return not anticipated before the care plan is complete?  

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

Question: How do I code the “Will [care area] be addressed in the care plan” question when a resident discharges return not anticipated before the care plan is complete?   Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: Federally, if the care plan was not completed because the resident …

Q&A: Is a Significant Change in Status Assessment (SCSA) required for a new pressure ulcer?

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

Question: Is a Significant Change in Status Assessment (SCSA) required for a new pressure ulcer? Answer from Jennifer LaBay RN, RAC-MT, RAC-MTA, QCP, CRC: A Significant Change in Status Assessment is required if there are two or more areas of decline or improvement that will not resolve on its own …