Appendix B RAI User’s Manual/State RAI Coordinators Contact List Updated (6/22)

The June update of Appendix B to the RAI 3.0 User’s Manual contains changes to the list of State RAI Coordinators, MDS Automation Coordinators, RAI Panel members, and CMS locations and contacts. To ensure accurate formatting, use a current version of Adobe Acrobat Reader to view this PDF. Web-based or mobile browser plug-ins …

Baseline Care Plan: Connecting the Dots to the Comprehensive

Unlike the baseline care plan, the comprehensive care plan is largely MDS-based and analysis-driven, points out Mary Madison, RN, RAC-CT, CDP, a long-term care and senior living clinical consultant for Briggs Healthcare in Clive, IA. “It goes beyond the minimal requirements for the baseline. As a result of these differences, some …

Q&A: When a resident who elected hospice switches to a different hospice company, is a Significant Change in Status Assessment required?

Question: When a resident who elected hospice switches to a different hospice company, is a Significant Change in Status Assessment required? Answer from Janine Cortesa, RN: RAI User’s Manual, page 2-23:  An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or …

Q&A: Can someone clarify the guidelines or protocol to use sepsis as the principal diagnosis in MDS?

Question: Can someone clarify the guidelines or protocol to use sepsis as the principal diagnosis in MDS? Answer from Jeff Taylor: This is what I follow from the blog post, “Conquer Coding for Sepsis and SIRS” from AAPC: Coding tips: Per ICD-10-CM guideline I.C.1.d.4, if a patient is admitted with localized …

FY 2023 ICD-10-CM Codes and Official Coding Guidelines Effective Oct. 1, 2022 (6/22)

2023 release of ICD-10-CM The FY2023 ICD-10-CM codes are to be used from October 1, 2022 through September 30, 2023.    Note: This replaces the FY 2022 – April 1, release. These files listed below represent the ICD-10-CM FY2023 October 1, release. The October 1, FY2023 ICD-10-CM is available in both …

Q&A: When should a urinary tract infection (UTI) be coded at MDS item I2300?

Question: I have a resident with an increase in confusion and a UA with C&S showing >=100,000 CFU/mL of Klebsiella. He has no other noted symptoms and advanced dementia, so he is unable to describe any if he has symptoms. He does not have a catheter. The physician has diagnosed …

TIP: IV Fluids Given for Nutrition or Hydration in the Hospital Affect Special Care High

When considering assessment reference date selection, do not forget that IV fluids given in the hospital within the 7-day look-back period “while not a resident” may impact the Special Care High nursing category. Unlike the NTA component, which only captures IV fluids “while a resident” and requires more specific caloric …

Which Do I Follow? Federal vs. State Regulations for the MDS

In this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, curriculum development specialist for AAPACN, discuss some of the differences between federal and state-specific regulations for MDS completion.

Coding Diagnoses in MDS Section I: The Art of the Physician Query

The coding instructions for MDS section I (Active Diagnoses) in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual require that every diagnosis coded in this section be documented by a physician or a physician extender (i.e., a nurse practitioner, physician assistant, or clinical nurse specialist when allowed under …

Q&A: Do 48-hour care plan meetings need to be completed for readmissions?

Question: Do 48-hour care plan meetings need to be completed for readmissions? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC [email protected]: Assuming the resident already had the Admission MDS completed on their original stay, no new baseline care plan or meeting is required upon readmission because the comprehensive …