Q&A: A resident has a catheter for urinary retention. Would this be coded as neurogenic bladder or obstructive uropathy?

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

Question: A resident has a catheter for urinary retention. Would this be coded as neurogenic bladder or obstructive uropathy? Answer from Jeff Taylor:Neither. Retention is a symptom used when the physician hasn’t determined the cause of the retention. The cause will usually be one of those two diagnoses. The physician …

Q&A: Can I code isolation in section O for Extended Spectrum Beta-Lactamase (ESBL) of urine with contact isolation?

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

Question: Can I code isolation in section O for Extended Spectrum Beta-Lactamase (ESBL) of urine with contact isolation? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC: The RAI User’s Manual prohibits coding isolation for any urinary tract infection (UTI). See section O: “Examples of when the isolation criterion …

Q&A: For OBRA assessments starting Oct. 1, 2023, will section O therapies data elements be collected or is this item being removed completely?

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

Question: For OBRA assessments starting Oct. 1, 2023, will section O therapies data elements be collected or is this item being removed completely? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: Therapy minutes/days are still captured on the 5-Day PPS assessment and the End of Medicare Stay (Part …

Q&A: Can the MDS 3.0 scripted interviews be coded directly on the MDS or is additional separate documentation required? 

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

Question: Can the MDS 3.0 scripted interviews be coded directly on the MDS or is additional separate documentation required?  Answer from Kim Steele RN, WCC, RAC-CT, RAC-CTA: You are not required to document the answers to interviews anywhere but on the MDS. You ARE required to sign the interviews off …

Q&A: A resident exhausted benefits in March 2023 with a new G-tube and 100% tube feeding. She was recently admitted to the hospital for three days and had the G-tube removed and was eating by mouth. Can this resident be skilled for Medicare Part A? 

Billing and Reimbursement / NAC / Q&A

Question: A resident exhausted benefits in March 2023 with a new G-tube and 100% tube feeding. She was recently admitted to the hospital for three days and had the G-tube removed and was eating by mouth. Can this resident be skilled for Medicare Part A?   Answer from Scott Heichel RN, …

Q&A: How do you code GG0130E, Shower/bathe self, when the resident did not have a bath scheduled during the three-day assessment period? 

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

Question: How do you code GG0130E, Shower/bathe self, when the resident did not have a bath scheduled during the three-day assessment period?  Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC: If there was no scheduled bath during the 3-day window, the item would be dashed.  Resource: Post-event question …

Q&A: If a resident admits to the facility with a second or third degree burn and it was documented as healed during the look-back period, would it be coded on the MDS at M1040F? 

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

Question: If a resident admits to the facility with a second or third degree burn and it was documented as healed during the look-back period, would it be coded on the MDS at M1040F?  Answer by Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC: There is an instruction to not …

Q&A: We have a resident on a Medicare Advantage (MA) plan, who went out for a one-day leave of absence. Since this is covered by the MA plan, do we need to complete a discharge assessment, reentry, and set a new 5-Day assessment? 

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

Question: We have a resident on a Medicare Advantage (MA) plan, who went out for a one-day leave of absence (LOA). I understand that the discharge assessment and reentry would not be required for Medicare Part A, but since this is covered by the MA plan, do we need to …

Q&A: When will the new changes affect the MDS assessment? Is this according to the assessment reference date (ARD) or the admission date?

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

Question: When will the new changes affect the MDS assessment? Is this according to the assessment reference date (ARD) or the admission date? For example, if the resident admitted on Sept. 28, 2023, and has an ARD of Oct. 1, 2023, would the new changes be included on this MDS? …

Q&A: Are there specific requirements for CNA documentation?

CNA / DNS / MDS 3.0 and the RAI Process / Q&A / Survey and Regulatory Compliance

Question: Are there specific requirements for CNA documentation? Answer from Alexis Roam, MSN, RN-BC, CPHQ, DNS-MT, QCP-MT: Although Appendix PP of the State Operations Manual (SOM) includes numerous references to documentation, it does not specify what role is responsible for that documentation. There may be requirements specific to your state, so …