Category: MDS 3.0 and the RAI Process

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 …

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 …

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 …

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 …

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 …

Question: If a Discharge – return not anticipated was completed for a resident discharge against medical advice (AMA), and he returned less than 30 days later, is a new OBRA Admission assessment required? Answer from Jessie McGill RN, BSN, RAC-MTA, RAC-CTA: When the OBRA discharge is named “Return not anticipated” …