MDS 3.0 and the RAI Process
The MDS 3.0 and the RAI (Resident Assessment Instrument) is a comprehensive nurse assessment and care planning process used by the long-term and post-acute care field as a requirement for reimbursement under Medicare and Medicaid. AAPACN nurse experts help you stay up to date on changes to the MDS with breaking news, articles, and practical tools.
- CASPER Reporting User’s Guide for MDS Providers UPDATED (5/22)The CASPER Reporting User’s Guide for MDS Providers provides information and instructions pertaining to the CASPER Reporting application. This system enables users to connect electronically to the National Reporting Database. This guide is intended for …
- Coding Malnutrition and Morbid Obesity on the MDS: Two Core Rules Must Be FollowedThe most common mistake that nurse assessment coordinators (NACs) and other MDS assessors make when coding malnutrition, at risk for malnutrition, or morbid obesity on the MDS is being unaware that a dietitian cannot diagnose …
- Changing ARDs and Assessment Windows: When to Consider This StepNurse assessment coordinators (NACs) often set assessment reference dates (ARDs), which determine the look-back periods for MDS assessments, using a fairly regimented schedule to establish consistency in the Resident Assessment Instrument (RAI) process. However, an …
- Q&A: We have a resident with indwelling catheter due to urinary retention. The resident also has a history of traumatic intracranial hemorrhage. Am I able to code I1550 (Neurogenic Bladder)?Question: We have a resident with indwelling catheter due to urinary retention. The resident also has a history of traumatic intracranial hemorrhage. Am I able to code I1550 (Neurogenic Bladder)? Answer from Jeff Taylor: No, …
- Q&A: A resident admitted to our facility with a diagnosis of MRSA infection of a wound, receiving oral antibiotics, and in a single room—can I code Isolation in section O?Question: We have a resident who admitted to our facility with a diagnosis of MRSA to a wound and is receiving oral antibiotics. The resident is in a single room by himself. Can I code …
- Care Compare April Refresh of SNF QRP Data – Now Available (4/22)The April 2022 refresh of the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) data is now available on Care Compare and Provider Data Catalog (PDC). The data are based on quality assessment data submitted …
- Appendix B/RAI Manual State RAI Coordinator Contact List Updated (4/22)The April 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 …
- Highlights from CMS’s 2022 Updates AAPACN Conference SessionLast week, the AAPACN 2022 Conference was held in Las Vegas, bringing together nursing professionals for exceptional learning opportunities. One outstanding session occurred on Thursday, April 14, when representatives from the Centers for Medicare & …
- Section GG: What It Takes to Get the Coding RightHow can nurse assessment coordinators (NACs) lead the interdisciplinary team (IDT) to develop a workable plan to ensure that MDS section GG (Functional Abilities and Goals) is coded accurately per the coding guidelines in the …
- Q&A: My electronic software pulls in ADL documentation, but when I do a final refresh, the ADLs that pull in are inaccurate. Now I must manually verify every ADL. Is there a way to fix this?Question: My electronic software pulls in ADL documentation, but when I do a final refresh, the ADLs that pull in are inaccurate. Now I must manually verify every ADL. Is there a way to fix …
- Q&A: The nursing note states a resident has intermittent shortness of breath with coughing. How would this be coded on the MDS?Question: The nursing note states a resident has intermittent shortness of breath with coughing. How would this be coded on the MDS? Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: I would …
- Q&A: A resident had a fall with fracture and discharged to the hospital on the eighth day following admission. When should the Admission Assessment be scheduled and completed?Question: I have a new resident who fell and broke her hip on the eighth day after admission. The Admission MDS was not completed. She has been discharged to the hospital for surgical repair and …
- FY 2023 SNF PPS Proposed Rule Is Posted: Link, Press Release, and Fact Sheet (4/22)Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Quality Reporting Program and Value-Based Purchasing Program; Long-Term Care Facilities to Establish Mandatory Minimum Staffing Levels https://www.federalregister.gov/public-inspection/2022-07906/medicare-program-prospective-payment-system-and-consolidated-billing-for-skilled-nursing-facilities Press release:HHS Takes Actions to Promote …
- Hospice Requirements: Significant Changes and Care PlanningWhen it comes to the MDS and hospice, there are several rules the nurse assessment coordinator (NAC) must be aware of, especially with the requirements of the Significant Change in Status Assessment (SCSA). While many …
- Q&A: If a resident is receiving a full liquid diet due to a recent surgical procedure, is it considered a mechanically altered diet?Question: If a resident is receiving a full liquid diet due to a recent surgical procedure, is it considered a mechanically altered diet? Answer from Debbie Kohn : According to the RAI User’s Manual (p. K-11), …
- Definition and Uses of Health Insurance Prospective Payment System (HIPPS) Codes (4/22)CMS has updated the following document: Definition and Uses of HIPPS Codes (Updated 04/01/2022) (PDF) From https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes
- Correction: CMS Seems to Plot Transition from MDS 3.0 v1.17.2 to v1.18.1 (3/22)MDS 3.0 v.1.17.2 has been in place since Oct. 1, 2020, and CMS wants it to run to Oct. 1, 2023, which presumably means for all of FY 2024. That could put the implementation of …
- Q&A: When a resident was sent to the emergency department (ED) and then later admitted to the hospital, can we code any new diagnoses the resident received in the ED on the discharge assessment? Question: When a resident was sent to the emergency department (ED) and then later admitted to the hospital, can we code any new diagnoses the resident received in the ED on the discharge assessment? For …
- Q&A: Can the three words used in the BIMS interview (sock, blue, and bed) be changed? Can other words be used like shirt, red, and chair?Question: Can the three words used in the BIMS interview (sock, blue, and bed) be changed? Can other words be used like shirt, red, and chair? Half of our team say it must be those …
- Q&A: We just found that we missed some discharge assessments from two years ago. Can these assessments still be completed and submitted?Question: We just found that we missed some discharge assessments from two years ago. Can these assessments still be completed and submitted? Answer from Carol Maher, RN-BC, CPC, RAC-MT: Any missed discharge assessments should be …
- Utilizing Social Determinants of Health in Discharge PlanningSocial determinants of health (SDOH) are items most long-term care professionals are familiar with, but they may not immediately recognize how the determinants affect their job. According to the Office of Disease Prevention and Health …
- TIP: ACIP Released Updated Adult Immunization ScheduleThe Advisory Committee on Immunization Practices (ACIP) released an updated immunization schedule for adults aged 19 years or older. Nurse assessment coordinators (NACs) need to utilize this updated schedule when coding O0300 Pneumococcal Vaccine data. …
- Q&A: What are the criteria to code Malnutrition?Question: What are the criteria to code Malnutrition? Answer from Jeff Taylor: For I5600, I would answer yes if a physician/NP/PA wrote “malnutrition,” “at risk for malnutrition,” or some other diagnostic statement (i.e., marasmus or …
- Q&A: If a resident is discharged before their planned Medicare discharge date, do I open an OBRA Discharge or a Part A PPS Discharge for a new end of Medicare stay?Question: If a resident is discharged before their planned Medicare discharge date, do I open an OBRA Discharge return not anticipated (DCRNA) or do I open a Part A PPS Discharge for a new end …
- Q&A: My software does not allow us to code two digits in the venous/arterial ulcer section on the MDS. How do we code if a resident has more than nine ulcers?Question: My software does not allow us to code two digits in the venous/arterial ulcer section on the MDS. How do we code if a resident has more than nine ulcers? Answer from Carol Maher, …
- SNF PPS Web Pricer for FY 2020 – FY 2022 Available (3/22)The Skilled Nursing Facility (SNF) PPS Web Pricer is now available for Fiscal Years (FYs) 2020 through 2022. The new SNF Web Pricer can be accessed via the following link: https://webpricer.cms.gov/#/pricer/snf. For the best user experience, …
- Q&A: Some members of my PDPM team feel that the diagnosis R27.8 “Other lack of coordination” should be used as the primary diagnosis. What kind of documentation would you need to be able to use this code?Question: Some members of my PDPM team feel that the diagnosis R27.8 “Other lack of coordination” should be used as the primary diagnosis. What kind of documentation would you need to be able to use …
- Q&A: Can I code triple antibiotic ointment and/or Bacitracin in section N under antibiotics?Question: Can I code triple antibiotic ointment and/or Bacitracin in section N under antibiotics? Answer from Janine Cortesa RN, BSN: Yes. The RAI states on page N-7 “Include any of these medications given to the resident …
- Q&A: Am I allowed to complete a Significant Change in Status Assessment on a resident who continues to receive hospice services but experienced other unexpected changes?Question: A resident was admitted with hospice services. She improved significantly in her physical functioning, but also worsened significantly in her behaviors. She remains under hospice at this time but is due for review in …
- jRAVEN Free MDS Software Updated to v1.8.1 (2/22)The Resident Assessment Validation and Entry System (jRAVEN) was developed by the Centers for Medicare & Medicaid Services (CMS). jRAVEN is a free Java based software application which provides an option for facilities to collect …
- Crisis Mode: RAI Process Survival Checklist toolSevere staffing shortages have led to nurse assessment coordinators (NACs) working the floor and not having the time to dedicate to the MDS and RAI process. When the facility is in a staffing crisis mode, …
- The Substantial Impact of the PHQ-9Nearly two years into the COVID-19 public health emergency (PHE), nursing home staff continue to see its impact on all residents, not just those who have recovered from COVID-19. According to the CMS memorandum QSO-20-39-NH, CMS’s …
- NACs Working the Floor: Tips to Keep the RAI Process AfloatThe COVID-19 public health emergency (PHE) has upended many systems in nursing homes, including the Resident Assessment Instrument (RAI) process. Nurse assessment coordinators (NACs) working the floor should be a last resort—even in a PHE—because …
- Q&A: A resident discharged return anticipated to the hospital, but then admitted to another SNF before returning to our SNF within 30 days. What assessments are required?Question: We had a resident discharge to the hospital and an OBRA Discharge return anticipated (DCRA) assessment was completed. Resident admitted to different SNF from the hospital but returned to our SNF within 30 days …
- Q&A: I completed a Medicare PPS assessment one day after the completion due date. What is the penalty for late MDS assessment completion?Question: I completed a Medicare PPS assessment one day after the completion due date. What is the penalty for late MDS assessment completion? Answer: There is no financial penalty for late completion. You may possibly …
- Q&A: I was recently told that if a resident is cognitively intact, then behaviors would not be coded, is this correct?Question: I was recently told that if a resident is cognitively intact, then behaviors would not be coded, is this correct? Answer: Behavior coding is not affected by the resident’s cognitive level. The RAI User’s …
- Dementia Care: Use MDS and Other Tools to Interpret Behavior, Boost ComfortComfort—palliation—should be a critical component of all nursing home care, suggests Ann Wyatt, a palliative and residential care consultant for CaringKind in New York City. “It is not about giving up. It’s about deciding, Why …
- PDPM: Clearing Up Nursing Component Confusion: Part Two – Focus on Special Care HighEditor’s note: This is the second article in a series on the PDPM categories for the nursing component, covering various missteps to avoid in PDPM calculation, as well as essential coding tips. Part one focused …
- Section GG Process Flow Chart ToolThe functional assessment coded in section GG often brings with it many questions— Should therapy complete this section? What type of documentation is needed? Can I use nurse aide documentation? How do we determine usual …
- How to Utilize Your Staff to Mentor and Fill Gaps in the MDS DepartmentIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN is joined by AAPACN Master Teacher and Board Member, Maureen McCarthy, RN, BS RAC-MT, QCP-MT, …
- Q&A: What are some best practices for collecting and documenting section GG?Question: What are some best practices for collecting and documenting section GG? Answer: We trained our floor nurses to complete GG documentation daily on days 1-3, and our therapists also complete a GG assessment during …
- Q&A: If a mechanically altered diet is being trialed during a speech therapy visit to facilitate oral intake, could K0510C, mechanically altered diet, be coded on the MDS?Question: We are seeking clarification on MDS item K0510C, mechanically altered diet. If a resident is being trialed on a mechanically altered diet or given thickened liquids provided during a speech therapy visit to facilitate …
- Q&A: A resident developed a new pressure ulcer while on leave of absence with family for Christmas. Is this considered “present on admission” or “in-house acquired”?Question: A resident developed a new pressure ulcer while on leave of absence with family for Christmas. Is this considered “present on admission” or “in-house acquired”? Answer: Since we do not complete an OBRA Discharge …
- MDS Section Q: Unlock the Full Potential of This Foundational SectionSection Q (Participation in Assessment and Goal Planning) is not a high-powered section of the MDS that drives payment or any of the quality measures (QMs). As a result, nurse assessment coordinators (NACs) sometimes may …
- Admission Sample Questionnaire ToolThis conversation starter will help your team learn more about a new residents’ interests, routines, and goals and engage the resident in their care planning right from admission. AAPACN’s Admission Sample Questionnaire tool (print) can …
- TIP: CY 2022 OBRA Scheduling Tools Now AvailableAAPACN offers two great tools to assist nurse assessment coordinators (NACs) schedule OBRA assessments. Be prepared for 2022 with these two tools that are free to members: The Static OBRA Scheduling Tool is a 4-page tool that …
- Q&A: Has anyone encountered surveyors requesting consents for assist bars/enabler bars used for functional mobility not posing as a restraint per the interdisciplinary team assessment?Question: Has anyone encountered surveyors requesting consents for assist bars/enabler bars used for functional mobility not posing as a restraint per the interdisciplinary team assessment? Answer by Carol Maher, RN-BC, CPC, RAC-MT : A restraint …
- Avoid Costly SNF QRP Coding MistakesMisunderstandings about the Skilled Nursing Facility Quality Reporting Program (SNF QRP) can involve everything from the risk adjustments to the quality measure (QM) calculations to how to use certain reports. These issues can cause headaches …
- PDPM: Extensive Services Nursing Category SimplifiedEditor’s note: This is the first article in a series on the PDPM categories for the nursing component, covering missteps to avoid in PDPM calculation, as well as essential coding tips. Future articles will address …
- OBRA Scheduling Tools for Calendar Year 2022AAPACN offers two great tools to assist nurse assessment coordinators (NACs) schedule OBRA assessments. Be prepared for 2022 with these two tools that are free to members: The Static OBRA Scheduling Tool is a 4-page tool that …
- Survey and Section I: Diagnosis-Related DeficienciesLong-term care leadership often observes that the nurse assessment coordinator (NAC) role calls for detail-orientation and strong time-management and assessment skills, because these nurses must coordinate the resident assessment that drives the care plan, quality …
- PHQ-9 Monitoring Can Help Counter Mood/Depression Issues in ResidentsDepression and other mood disorders historically have been a significant risk for nursing home residents. “In 2011 and 2012, the percentage of users of long-term care services with a diagnosis of depression was highest in …
- TIP: Which RAC-CT Certification Format is Right for Me?There are basically four format options for pursing the RAC-CT certification. Here’s a quick breakdown: Online + PDF – this is essentially a self-paced format where you would read through course content online and also …
- Q&A: Is a Significant Change in Status Assessment required for a new stage 3 pressure ulcer?Question: Is a Significant Change in Status Assessment required for a new stage 3 pressure ulcer? Answer from Janine Cortesa RN, BSN: A stage 3 pressure ulcer may signify the need for a Significant Change …
- PDPM: Making the Speech Language Pathology (SLP) Component Easier to SwallowEditor’s note: this article was reviewed and revised December 2, 2021. Without a full understanding of how the SLP component of the Patient-Driven Payment Model (PDPM) is calculated, it can seem complicated. The SLP methodology …
- Coding UTI on the MDS: I2300 Requirements Are Not One-Size-Fits-AllSince the implementation of the Patient-Driven Payment Model (PDPM) in the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), urinary tract infections (UTIs) can be coded on the MDS in up to …
- TIP: CMS Releases Job Aids for Section GG Self-Care ItemsThe Centers for Medicare & Medicaid Services (CMS) is offering companion job aids to assist providers in the assessment and coding of Job Aids – GG0130A. Eating, GG0130B. Oral Hygiene, GG0130C. Toileting Hygiene, GG0130E. Shower/Bathe …
- Q&A: Can Incentive Spirometer still be counted on the MDS as long as a respiratory nurse or therapist counts the minutes they assess, monitor, and evaluate?Question: Can Incentive Spirometer still be counted on the MDS as long as a respiratory nurse or therapist counts the minutes they assess, monitor, and evaluate? Answer form Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, QCP, …
- Q&A: How do you code a resident who is fed by staff for all meals but can chew and swallow independently?Question: We have been discussing how to code a resident who is fed for all meals but can chew and swallow independently. The argument is the RAI User’s Manual indicates that if someone cannot participate …
- MDS Section GG, Section J Fall Items, and Pressure Ulcer Assessment and Coding Pocket Guides (11/21)Quick Assessment Reference Pocket Guides / Badge Buddies for Coding The Centers for Medicare & Medicaid Services (CMS) is offering Pocket Guides to assist providers in assessing and coding self-care and mobility, falls, and pressure ulcers/injuries. The pocket guides provide a quick reference for important terms and definitions that promote coding …
- SNF QRP MDS Item GG0130 Assessment and Coding Job Aids (11/21)Job Aids – GG0130A. Eating, GG0130B. Oral Hygiene, GG0130C. Toileting Hygiene, GG0130E. Shower/Bathe Self, GG0130F. Upper Body Dressing, GG0130G. Lower Body Dressing, and GG0130H. Putting On/Taking Off Footwear The Centers for Medicare & Medicaid Services (CMS) …
- I Spy… Behavioral SymptomsImagine you are eating dinner in a restaurant. It is a small, quaint place with a warm, homey atmosphere. A man in the corner picks up his fork and begins to tap it loudly against …
- TIP: CMS Offers New SNF QRP Section GG TrainingThe Centers for Medicare & Medicaid Services (CMS) is offering an updated web-based training series on the assessment and coding of section GG. This training is intended for providers in the following post-acute care (PAC) …
- Highlights from AAPACN’s 2021 NAC Work Time Study and Salary Report with Jessie McGillIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN talks with AAPACN curriculum development specialist, Jessie McGill, RN, RAC-MT, RAC-MTA, about some of the …
- Q&A: Can we code modified diet on section K if a resident has crushed medications but eats a regular diet?Question: Can we code modified diet on section K if a resident has crushed medications but eats a regular diet? Answer from Janine Cortesa RN, BSN: No, crushed medications would not be a mechanically altered …
- Q&A: A resident just returned during the interruption window. What OBRA assessments and tracking records do I need?Question: A resident on a Medicare Part A stay went to the hospital on 10/19 and returned on 10/20. He was admitted to the acute. This is my first time with an interrupted stay. Do …
- Q&A: Would you code a positive nasal swab for MRSA as a multidrug-resistant organism (MDRO) in section I?Question: Would you code a positive nasal swab for MRSA as a multidrug-resistant organism (MDRO) in section I? Answer from Heide Keen, RN, BSN, RAC-CT: Most often, we find that MRSA of nares is colonized …
- Section GG Web-based Training Module UPDATED (10/21)The Centers for Medicare & Medicaid Services (CMS) is offering an updated web-based training series on the assessment and coding of Section GG. This training is intended for providers in the following post-acute care (PAC) settings: Home Health Agencies (HHAs), …
- Get the Most Out of the BIMS in Care PlanningThe Brief Interview for Mental Status (BIMS) in MDS items C0200 – C0500 or, if appropriate instead, the Staff Assessment for Mental Status in items C0700 – C1000 is the basis of the cognitive level …
- Q&A: A resident unexpectedly discharged three days before his planned PPS Discharge. What do I need to do?Question: A resident unexpectedly discharged from the facility on 10/9 while on Medicare Part A. He had a planned PPS Part A Discharge scheduled for 10/12. Can I combine the PPS Discharge and OBRA Discharge, …
- Q&A: I found an error on a resident’s MDS that goes back to 2019. How do I correct this?Question: I have just found out a resident had a change of payer from Medicaid to Private Pay back in 2019 and the system still has their Medicaid information. How do I correct this and …
- FY 2024 (Calendar 2022) SNF QRP Data Collection and Final Submission Deadlines (10/21)An update to the Skilled Nursing Facility Quality Reporting Program (SNF QRP) Data Collection and Final Submission Deadlines for the Fiscal Year (FY) 2024 SNF QRP is available. This document has been updated to reflect …
- FY 2024 (Calendar 2022) SNF QRP Table: Required Reporting Elements to Meet the Minimum Threshold (10/21)SNF QRP Annual Update Table for Reporting Assessment-Based QM and Standardized Patient Assessment Data Elements An update to the Skilled Nursing Facility Quality Reporting Program (SNF QRP) Annual Payment Update (APU) Table for Reporting Assessment-Based …
- CMS MDS Item O0100 Web-Based Training (10/21)NEW TRAINING AVAILABLE – Section O: O0100. Special Procedures, Treatments, and Programs Web-Based Training for SNFs The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides an overview of …
- TIP: CMS Releases RAI Manual Errata Effective October 1, 2021CMS recently released a correction to the non-therapy ancillary (NTA) component of the Patient-Driven Payment Model (PDPM). This clarified that the presence of any, any combination, or all items M1040A, Infection to the foot, M1040B, …
- Common PDPM and MDS Coding Missteps with Jennifer LaBayIn 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, CRC, AAPACN’s newest curriculum development specialist, discuss some common …
- Q&A: If a resident expires during their assessment window, does the MDS assessment still need to be completed?Question: If a resident expires during their assessment window, does that MDS still need to be completed? For example, if a resident’s assessment window is 9/10 – 9/16 with an ARD of 9/16, but then …
- FY 2022 PDPM ICD-10 Mappings File REVISED (9/27/21)Download the Zip file: FY 2022 PDPM ICD-10 Mappings (ZIP) (revision posted 09-27-2021) From https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM
- SNF QRP Reporting Exceptions Granted Due to Hurricane Ida (9/21)The Centers for Medicare & Medicaid Services (CMS) is granting exceptions under certain Medicare quality reporting and value-based purchasing programs located in areas affected by Hurricane Ida to assist you while you direct your resources …
- 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 …
- 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 …
- 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 …
- FY 2022 ICD-10-CM Code Files and Official Coding Guidelines Effective Through March 31, 2022 (12/21)Note: In December 2021, the CDC announced that this update and coding guidelines are only effective through March 31, 2022. New files and guidelines go into effect April 1, 2022, and remain in effect through …
- MDS Validation Utility Tool (VUT) V3.6.0 – Effective 10/01/2021Release 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 …
- 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, …
- 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 …
- Recognizing Rejection of Care: MDS Coding Accuracy for E0800Rejection 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, …
- Use MDS Section B to Improve Holistic Discharge PlanningMDS 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, …
- Q&A: Is the date at V0200C, completion of the care plan, the same date as the actual care plan meeting with families?Question: Is the date at V0200C, completion of the care plan, the same date as the actual care plan meeting with families? Answer from Carol Maher, RN-BC, CPC, RAC-MT: The signature and date in V0200B …
- FY 2023 SNF QRP Annual Update Table for Reporting MDS Data, and Data Collection/Final Submission Deadlines (8/21)An update to the Skilled Nursing Facility Quality Reporting Program (SNF QRP) Annual Payment Update (APU) Table for Reporting Assessment-Based quality measures (QMs) and standardized patient assessment data elements to CMS is now available. This …
- MDS Section K Online Training: Height, Weight, & Nutritional Approaches for SNFs (8/21)The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides an overview of the assessment and coding of K0200: Height and Weight and K0500: Nutritional Approaches. This 30-minute course …
- Q&A: How do you determine “while a resident” or “while not a resident” when a resident goes out to the hospital and returns?Question: How do you determine “while a resident” or “while not a resident” when a resident goes out to the hospital and returns? Answer from Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: The …
- Introduction to the SNF QRP Web-Based Training From CMS (8/21)The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course for those who are new to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP). This course is designed to provide …
- The First Month as a New NACDuring their first days on the job, new nurse assessment coordinators (NACs) can expect paperwork and orientation videos as they are introduced to their role. But what should a new NAC expect by the end …
- Q&A: A resident converted from Managed Care to Traditional Medicare. How is a recent fall captured on the current 5-Day PPS assessment?Question: A resident admitted on a Managed Care plan in late April and elected Traditional Medicare Part A, effective June 1, 2021. In late May (5/29), he had a fall in the facility. I have …
- Q&A: If I have a combination of Total Dependence (4) occurring more than seven times during the look-back period, with the rest showing the Activity Did Not Occur (8), can I code Total Dependence (4) as the final code on the MDS?Question: The RAI User’s Manual states that, “The Rule of 3 does not apply when coding Independent (0), Total Dependence (4) or Activity Did Not Occur (8), since these levels must be EVERY time the …
- How to Take a Vacation When You’re the NACWith staffing shortages and specific, regulation-mandated job duties, nurse assessment coordinators (NACs) today may feel that taking time for vacation just isn’t possible. The NAC must ensure the facility has MDS assessments in place, makes …
- MDS Daily Startup for the NAC Backup ToolWhen the nurse assessment coordinator (NAC) goes on vacation, there’s a lot to keep track of while they are out of office. The MDS Daily Startup for the NAC Backup tool is intended to help …
- Q&A: If a patient uses a wheelchair in the facility but does not have plans to use it after discharge, should wheelchair items be coded on the 5-Day PPS assessment?Question: We are seeing some discrepancies in coding wheelchair items under section GG. If a patient uses a wheelchair the entire time they are in the facility, but recover such that they no longer need …