Q&A: I have a resident taking a medication that is classified as an antineoplastic. Can I code chemotherapy at MDS item O0100A?

Question: I have a resident taking a medication that is classified as an antineoplastic. Can I code chemotherapy at MDS item O0100A? Answer from Forrest Deimel, RN: If the antineoplasm medication is used to treat active cancer, yes, code it. For example, I had a patient receiving an antineoplastic for …

Q&A: I was recently instructed to dash item K0100 if a resident has a PEG tube. Is this correct?

Question: I was recently instructed to dash item K0100 if a resident has a PEG tube. Is this correct? Answer from Janine Cortesa RN, BSN: The RAI User’s Manual does not state to dash if a PEG tube is used. It does state to evaluate for each of the issues listed. I …

Q&A: Can IV fluids administered in the emergency room (ER) or during surgery be included in Section K, items K0510 or K0710?

Question: Can IV fluids administered in the emergency room (ER) or during surgery be included in Section K, items K0510 or K0710? Answer from Carol Maher, RN-BC, CPC, RAC-MT: IV fluids given in the ER can be coded if given for nutrition or hydration, since the resident is still considered …

FY 2022 ICD-10-CM Code Files and Official Coding Guidelines Updated (9/21)

2022 ICD-10-CM From https://www.cms.gov/medicare/icd-10/2022-icd-10-cm The 2022 ICD-10-CM files below contain information on the ICD-10-CM updates for FY 2022. These 2022 ICD-10-CM codes are to be used for discharges occurring from October 1, 2021 through September 30, 2022 and for patient encounters occurring from October 1, 2021 through September 30, 2022. …

MDS Validation Utility Tool (VUT) V3.6.0 – Effective 10/01/2021

Release Notes The Validation Utility Tool (VUT) is a software utility that can be used to validate MDS 3.0 submission files in XML format. The tool enforces the edits that are mapped to the MDS 3.0 items as published in the MDS 3.0 Data Specifications. The v3.6.0 VUT continues to …

FY 2022 PDPM ICD-10 Code Lookup File for MDS Item I0020B (9/21)

The lookup files containing the allowable ICD codes for item I0020B have been updated for FY2022, and is posted as a separate ZIP file. PDPM_ICD_Codes_for_I0020B_FY2022 (ZIP) From https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation

Q&A: What are the requirements for restorative program notes?

Question: I was recently told that our restorative nursing programs needed monthly progress notes/assessments, but I have only been completing these quarterly. What are the requirements for restorative notes?  Answer from Melissa Brown, OTR/L, RAC-CT, CDP, CSRS: There actually isn’t any prescribed frequency for supervisory nursing summary notes. The RAI …

Q&A: Is it acceptable to answer the PHQ-9 Mood questions directly in MDS section D if the signatures are prior to the ARD date?

Question: Is it acceptable to answer the PHQ-9 Mood questions directly in MDS section D if the signatures are prior to the ARD date (they usually complete the interview before, but code the MDS and sign after the ARD date)? Do we need to have separate documentation of the PHQ-9 …

Recognizing Rejection of Care: MDS Coding Accuracy for E0800

Rejection of care can occur in many ways—Mr. Jones refuses to have his nails trimmed; Mrs. Abrahams clenches her mouth, refusing to take medications in the evening; or Mr. Martin discharges against medical advice. However, not all of these instances may be coded as rejection of care on the MDS. …

Use MDS Section B to Improve Holistic Discharge Planning

MDS section B (Hearing, Speech, and Vision) is a lot more important than many nurse assessment coordinators (NACs) and other interdisciplinary team members give it credit for, says Jillian Martin, RN, BS, DNS-CT, RAC-MT, RAC-CTA, senior healthcare consultant at CliftonLarsonAllen in Quincy, MA. “This section of the MDS is a …