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.
- Writing MDS Supplemental Notes: How NACs Can Ace This RoleThe COVID-19 pandemic is quite diminished but still a concern in some nursing homes due in part to SARS-CoV-2 variants, as well as unvaccinated staff. With the public health emergency worsening the already significant staffing …
- Avoid These 5 Common Mistakes NACs Make Coding I0020Bby Carol Maher, RN-BC, RAC-MTA, RAC-MT, CPC ICD-10-CM coding is not a skill nursing school conveys to students, yet it is one that nurse assessment coordinators (NACs) must acquire to perform their diagnosis coding duties …
- Care Area Assessments: Don’t Let CAAs Be the Missing Link in the RAI ProcessThe care area assessment (CAA) process sometimes mistakenly gets lumped under the “required but not critical to resident care” label of regulatory paperwork. While working the CAAs is indeed a mandatory step in the Resident …
- Q&A: Do I need to complete a Significant Change in Status Assessment (SCSA) for a resident who had expected improvements in in all ADLs, but discharge is now delayed?Question: We had a resident come in with a leg fracture four months ago. At that time, he required extensive assist. He worked with therapy and became independent in functional activities by the end of …
- Appendix B RAI User’s Manual State RAI Coordinator Contact List (5/21)The May 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 [i.e., regional office] contacts. To ensure accurate formatting, use …
- H0400 – H0600: Keys to Coding Bowel MDS ItemsAs a group, the bowel MDS items H0400 (Bowel Continence), H0500 (Bowel Toileting Program), and H0600 (Bowel Patterns) impact nursing homes on multiple levels, including the following: The Nursing Home Quality Initiative Quality Measures (NHQI …
- Q&A: A patient admitted under Original Medicare Part A. Within a couple of hours, his family decided to take him home. What assessments are needed?Question: A patient admitted under Original Medicare Part A. Within a couple of hours, his family decided to take him home. What assessments are needed? Answer from Carol Maher, RN-BC, CPC, RAC-MT: Since the resident …
- Q&A: A resident returned following a hip fracture from a fall. Would his primary diagnosis be the S-code for the fracture, or the Z-code for aftercare?Question: A resident returned following a hip fracture from a fall. Would his primary diagnosis be the S-code for the fracture, or the Z-code for aftercare? Answer from Jennifer LaBay RN, RAC-MT, RAC- MTA, CRC: …
- Cognitive & Mood Assessment Four-Course Training Series for SNFs (5/21)By CMS The Centers for Medicare & Medicaid Services (CMS) is offering web-based training that provides an overview of the general and key clinical considerations important for conducting standardized cognitive and mood assessments. This four-course …
- O0100: Learn Potential Coding Issues With This High-Impact MDS ItemMDS item O0100 (Special Treatments, Procedures, and Programs) has 12 sections with two columns (24 total subitems) that identify specific services the resident received either while not a resident (column 1) or while a resident (column …
- Q&A: In gathering information for a 5-Day MDS, I noted that the patient had a drug-to-drug interaction. How is this coded in N2001-N2003, drug regimen review and follow up items?Question: In gathering information for a 5-Day MDS, I noted that the patient had a drug-to-drug interaction. This was not identified on the initial medication review. In answering N2001, should I say “No” since this was not …
- MDS Items D0200 and D0300 Coding: Resident Mood Interview (PHQ-9) Video Tutorial (4/21)NEW TRAINING AVAILABLE – Resident Mood Interview (PHQ-9) for the Skilled Nursing Facility (SNF) Setting Video Tutorial CMS Resident Mood Interview (PHQ-9) for the SNF Setting Video Tutorial The Centers for Medicare & Medicaid Services …
- MDS Item M1200: Think Past Checkmarks With Skin and Ulcer/Injury TreatmentsMDS item M1200 (Skin and Ulcer/Injury Treatments) in section M (Skin Conditions) can impact payment under the Patient-Driven Payment Model (PDPM) in the Medicare Part A skilled nursing facility prospective payment system (SNF PPS), as …
- MDS Data Collection for the NAC ToolDo you have an organized approach to collect MDS data during the 7- and 14-day look-back periods? AAPACN’s MDS Data Collection for the NAC tool provides an organized approach to gathering supporting data from the …
- Q&A: A therapy director is instructing the therapists to add minutes under section O for donning and doffing of PPE. Is this correct?Question: A therapy director is instructing the therapists to add minutes under section O for donning and doffing of PPE. He is using section O of the RAI User’s Manual listed below to justify this …
- Q&A: A resident claims that she has no pain during the scripted interview, but the medication administration record (MAR) shows use of PRN pain medication daily. How do I code the MDS?Question: During an interview with a resident who has cognitive impairment, she claims that she has no pain, but the MAR shows use of PRN pain medication daily. Should I still code “no pain” on …
- Q&A: How are you gathering admission function scores for section GG when the observation period is the ARD plus two previous days for assessments like the Interim Payment Assessment (IPA)?Question: In our facility, therapists record function scores within the first 3 days after admission. How are other facilities gathering admission function scores for section GG when the observation period is the ARD plus two previous …
- Pitfalls of Missing Shortness of Breath DocumentationChronic conditions and comorbidities are common among both long-term residents and short-term patients in skilled nursing facilities (SNFs). However, when the symptoms from these chronic conditions become part of the resident’s normal routine, they may …
- Coding N2001 – N2005: Part A Drug Regimen ReviewMDS items N2001 (Drug Regimen Review), N2003 (Medication Follow-up), and N2005 (Medication Intervention) are the primary drivers of the Skilled Nursing Facility Quality Reporting Program (SNF QRP) Quality Measure (QM), Drug Regimen Review Conducted With …
- Q&A: Per the CDC guidelines, how many Pneumococcal vaccines do our residents need to be considered up to date?Question: Per the CDC guidelines, how many Pneumococcal vaccines do our residents need to be considered up to date? We have some with only one vaccine and some with two. If they only have one …
- MDS Item C1310: Keys to Navigating the CAMThe Confusion Assessment Method (CAM) is a standardized cognitive assessment that determines whether a resident has signs and symptoms of delirium. The CAM is located in MDS item C1310 (Signs and Symptoms of Delirium), which …
- Q&A: I was told that if the resident needs two staff members in section G, then in GG they are automatically marked as dependent for that task. Is this correct?Question: I was told that if the resident needs two staff members in section G, then in GG they are automatically marked as dependent for that task. Is this correct? Answer: Remember that section G …
- Want Better Care Plans? Look at the CAAsAs the COVID-19 pandemic eases, directors of nursing services (DNSs) may want to turn their attention to the care area assessments (CAAs) in the Resident Assessment Instrument (RAI) process, suggests Barbara Bates, RN, MSN, RAC-CT, …
- Emergency Preparedness: Healthcare Cybersecurity Readiness and Response (2/21)As part of our nation’s critical infrastructure, healthcare facilities large and small must be proactive and move quickly to protect themselves from cyberattacks that could directly impact the health and safety of patients and the …
- CMS Section N: Medications – Drug Regimen Review Web-Based Training (2/21)The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides an overview of the assessment and coding of the Drug Regimen Review standardized patient assessment data elements (SPADEs) found in the …
- Check Your Data: Updated Data Process Will Impact CASPER/SNF QRP Provider Demographic Data (2/21)CMS will be transitioning to a new data source for a provider’s demographic data for all five Post-Acute Care (PAC) provider types (Skilled Nursing Facilities / Nursing Facilities (SNF/NFs), Home Health Agencies (HHAs), Inpatient Rehabilitation …
- Final PDPM Grouper DLL V1.0009 (Supporting Info Updated) Effective Oct. 1, 2020February 4, 2021 An update to the PDPM Grouper DLL package was posted. This is NOT a change to the previously posted DLL file itself, just supporting information. The documentation file was updated, as there were …
- FY 2021 MDS 3.0 Data Specs — New Errata Issued (2/21)February 4, 2021 An updated errata (V3.00.7) was posted for the FINAL version (v3.00.1) of the MDS 3.0 Data Specifications, currently in production. The resolution to issue 17 in the previous errata was flawed, as …
- NACs, Need More Time? Four Areas to Gain EfficienciesThe nurse staffing shortage that simmered in long-term care—and throughout the entire healthcare field—for years finally boiled over in 2020 as a result of the COVID-19 pandemic, with nursing homes nationwide reporting sometimes crisis-level staffing …
- Section G Coding Still Matters: Keep It AccurateMDS section G (Functional Status) is not used in the Patient-Driven Payment Model (PDPM) under the Medicare Part A Skilled Nursing Facility Prospective Payment System (SNF PPS), nor is it used in the Skilled Nursing …
- How to Triage the RAI/MDS ProcessEarly 2021 could be challenging for the nation’s nursing homes. Recent trends in infection rates combined with the slow rollout of the COVID-19 vaccine have the potential to make the coming months “the deadliest of …
- Q&A: Do parenteral or IV fluids count under Special Care High for while a resident and while not a resident?Question: I need clarification on parenteral or IV fluids. Do they count under Special Care High for while a resident and while not a resident (in hospital)? I have been watching the On Demand PDPM Essentials workshop …
- Q&A: In the past 30 days, but prior to admission, a resident had a diagnosis of UTI and was treated with antibiotics. Should I code UTI on the MDS?Question: In the past 30 days, prior to admission, a resident had a diagnosis of UTI and was treated with antibiotics. However, the culture showed no growth. Should I code UTI in the past 30 …
- Q&A: How should we be coding B0200, Hearing, when speaking loudly due to face shields and masks?Question: How should we be coding B0200, Hearing? The reason I am asking is because of face shields and masks. When I wear an N95 mask, I have to speak very loudly so the resident …
- Section M: Skin Conditions – Assessment and Coding of Pressure Ulcers/Injuries: CMS Web-Based Training (1/21)The Centers for Medicare & Medicaid Services (CMS) is offering a web-based training course that provides an overview of the assessment and coding of pressure ulcers/injuries. This 90-minute course is intended for providers in …
- jRAVEN 1.7.7 Free MDS Submission Software Updated (1/21)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 …
- FY 2021 ICD-10 Code Lookup File for MDS Item I0020B (1/21)The lookup files containing the allowable ICD codes for item I0020B for FY2021 have been updated to contain the following ICD-10 codes , as well as remove M35.8: The new ICD-10 codes may be used for …
- FY 2021 PDPM ICD-10 Mappings (1/21)FY 2021 PDPM ICD-10 Mappings (ZIP) (effective 1/1/2021) The Mappings file contains: Mapping of the ICD-10-CM Recorded in Item I0020B of the MDS Assessment to PDPM Clinical Categories Mapping of Comorbidities Included in the PDPM SLP …
- MDS 3.0 Provider User’s Guide Updated, Including Validation Rpt Error Messages (1/21)The MDS 3.0 Provider User’s Guide provides information and instructions pertaining to the QIES ASAP MDS 3.0 system to Long Term Care (LTC) facility and Swing Bed (SB) hospital users who are required to submit …
- MDS Validation Utility Tool (VUT) v3.5.0 (1/21)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 …
- FY 2021 ICD-10-CM Code Update and Official Coding Guidelines Updated With New COVID-19 Codes (12/20)In response to the national emergency that was declared concerning the COVID-19 outbreak, the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is implementing 6 new diagnosis codes into the …
- “Two” Many Cooks in the Kitchen: Where Dietary and MDS MixMDS accuracy is no joking matter, but who can resist a good dietary-related pun? I decided I would take a whisk and go for it. While nutrition has always played a key roll in the …
- Q&A: Our facility has a “COVID-19 unit” that is one large room divided by curtains. Can isolation be coded for these residents?Question: Our facility has a “COVID-19 unit” that is one large room divided by curtains. There are five sections in the room and each section has two beds. Can we code for isolation when a …
- AHRQ Evidence-Based Practice: Interventions for Breathlessness in Patients With Advanced Cancer (11/20)This report from the Agency for Healthcare Research and Quality is available in PDF only (Evidence Summary [371.3 KB]; Report [5.9 MB]). People using assistive technology may not be able to fully access information in these files. For additional assistance, …
- Capturing Resident Voice and Choice in Activity Care PlansConstructing person-centered care plans takes time, effort, and person-specific focus on including the resident’s voice and choice. This is especially important when developing care plans from information gathered under section F, Preferences for Customary Routines …
- OBRA Assessments: What to Watch Out for During the COVID-19 PandemicSkilled Nursing Facility Prospective Payment System (SNF PPS) MDS assessments rightfully get a lot of attention during the COVID-19 public health emergency as nurse assessment coordinators (NACs) continue to try to obtain accurate Medicare Part …
- OBRA Scheduling Tools for Calendar Year 2021AANAC offers two great tools to assist nurse assessment coordinators (NACs) schedule OBRA assessments. Be prepared for 2021 with these two tools that are free to members: The Static OBRA Scheduling Tool is a 4-page …
- Making the Most of Resident Interviews“Knock, knock?” “Who’s there?” When the nurse assessment coordinator (NAC) walks into the room, the resident rolls his eyes and unenthusiastically says, “Oh, it’s you. Blue. Sock. Bed.” The scripted resident interviews can be redundant …
- Q&A: A resident had a fall with a fracture and delayed healing. Can I code aftercare in I8000?Question: We have a resident who fell in their room, resulting in a right fractured patella, non-displaced. However, there was delayed healing due to noncompliance (the resident refused to wear a brace and continued to …
- BIMS MDS Coding Video Tutorial (10/20)The Centers for Medicare & Medicaid Services (CMS) is releasing a video tutorial to assist providers in Inpatient Rehabilitation Facilities and Skilled Nursing Facilities with standardized data assessment guidance and assessment strategies for the cognitive …
- Confusion Assessment Method (CAM) MDS Coding Video Tutorial (10/20)The Centers for Medicare & Medicaid Services (CMS) is releasing a video tutorial to assist providers in Skilled Nursing Facilities with standardized data assessment guidance and assessment strategies for the cognitive assessment known as the …
- Q&A: In section I, do we need a physician’s diagnosis for “risk of malnutrition,” or can we use the dietitian’s assessment to code in section I?Question: In section I, do we need a physician’s diagnosis for “risk of malnutrition,” or can we use the dietitian’s assessment to code in section I? Answer: Yes, you need a physician’s diagnosis. Please see …
- Q&A: A resident uses two half-siderails when in bed but is not able to remove the siderails once they are up. Should the siderails be coded as a restraint in section P?Question: We have a resident who is cognitively intact and requires extensive assistance with bed mobility and transfers. He does not get out of bed unless being assisted by staff. He uses two half bed …
- Section GG Data Collection Tool for OBRA AssessmentsIs your state collecting PDPM data on OBRA assessments? Use AANAC’s Section GG: Three-Day Performance Data-Collection Tool for OBRA Assessments to help guide your staff in documenting the resident’s performance during the window for each …
- Q&A: Our state is requiring PDPM data on OBRA assessments. Is section GG collected on only Medicaid residents or for all payer types?Question: Our state is requiring PDPM data on OBRA assessments. Is section GG collected on only Medicaid residents or for all payer types? Answer: For states that opted to collect PDPM data, including section GG, …
- CASPER Reporting User’s Guide for MDS Providers UPDATED (9/20)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 …
- Don’t Delay Using Health Literacy in Your Care Planning and Discharge Planning ProcessMrs. Elderberry is ready to go home. It’s been five long weeks of rehabilitation following a broken hip from that clumsy slip on a rug. Home. She’s wondering if her son actually watered her house …
- Q&A: If a resident discharges return anticipated and it is not an interrupted stay, should the therapy end date be dashed, or should the discharge date be entered in O0400?Question: If a resident discharges return anticipated and it is not an interrupted stay, should the therapy end date be dashed, or should the discharge date be entered in O0400? Answer: The therapy end …
- Q&A: If a resident has orders to receive an altered consistency of medications, would this be coded at K0510C, mechanically altered diet?Question: If a resident has orders to receive an altered consistency of medications, would this be coded at K0510C, mechanically altered diet? Answer: No. Crushed medications are not part of a diet. A mechanically altered diet …
- MDS Section L and Care Planning: Insights From a Speech-Language PathologistMDS item L0200 (Dental) often gets limited attention even though it fuels the Dental Care care area assessment (CAA), one of 20 CAAs that can be triggered in response to MDS coding (i.e., care area …
- Is Your State Considering PDPM Data Collection? Four Steps to PrepareThe Centers for Medicare and Medicaid Services (CMS) gave states the option to collect Patient-Driven Payment Model (PDPM) billing codes on OBRA assessments when not combined with a Medicare PPS 5-Day assessment, beginning Oct. 1, …
- Q&A: How do Part B minutes get captured on the MDS?Question: How do Part B minutes get captured on the MDS? Answer: Part B minutes should be captured on the MDS when you are completing OBRA assessments. Based on the assessment reference date (ARD), therapy …
- Q&A: If an alert and oriented resident wheels himself in and out of his room, to the dining room, and out onto the patio, is that wandering (E0900)?Question: If an alert and oriented resident wheels himself in and out of his room, to the dining room, and out onto the patio, is that wandering (E0900)? Answer: The RAI User’s Manual provides guidance …
- MDS Section J: Learn What ‘Major’ Surgery Means“Does this surgery count as a major surgery?” is one of the most frequently asked questions that nurse assessment coordinators (NACs) have about MDS items J2100 (Recent Surgery Requiring Active SNF Care) and J2300 – …
- Q&A: I had two residents trigger for dehydration on the CMS 802 Matrix. How is this triggered?Question: I had two residents trigger for dehydration on the CMS 802 Matrix. I read the explanation that this was because the resident takes in 1500 ml or less fluids per day. Does this come …
- FY 2021 SNF PPS Final Rule Released (7/20)On July 31, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1737-F] for Fiscal Year (FY) 2021 that updates the Medicare payment rates and the value-based purchasing program for skilled …
- Advance Care Planning: How to Have the ConversationEditor’s note: This is the third article in a multipart series about advance care planning and how to operationalize an effective program in nursing homes. Find the first article explaining the basics of what it …
- The Role the MDS and Care Planning Play in Reducing the Risk of Legal ActionDuring the first day of the AAPACN Virtual Conference, Gina D’Angelo, BSN, MBA, RN, NHA, CLNC, DNS-CT, RAC-CT, clinical consultant, legal nurse consultant, testifying expert, and president of GD Solutions, LLC, presented “Avoid the Slippery …
- Advance Care Planning: Seven Steps to Maximize EffectivenessAdvance Care Planning: Seven Steps to Maximize Effectiveness Editor’s note: This is the second article in a multipart series about advance care planning and how to operationalize an effective program in nursing homes. Find the …
- Section GG: Assessing Usual Performance During the COVID-19 PandemicThe Centers for Medicare & Medicaid Services (CMS) makes clear in the title of MDS section GG (Usual Performance and Goals) that the assessment subitems in items GG0130 (Self-Care) and GG0170 (Mobility) are designed to …
- Dehydration Monitoring and Care Planning Is a Must This SummerWith residents sometimes in isolation and wearing masks in various situations due to the COVID-19 pandemic, they are already more vulnerable to dehydration than normal, points out Teresa Remy, DSc, MHA, BSN, LNHA, RN, CDP, …
- Q&A: Can repositioning be coded as a non-pharmaceutical pain relief measure in section J of the MDS?Question: Can repositioning be coded as a non-pharmaceutical pain relief measure in section J of the MDS? Answer: Based on coding guidance from the RAI User’s Manual, page J-2, I would include repositioning as an …
- SNF QRP Data Reporting Requirements Back in Full Force July 1, 2020Reminder: · Quality Reporting Programs are expected to report their quality data to meet requirements starting Quarter 3, which begins July 1, 2020. The March 27, 2020 Medicare Learning Network Newsletter (MLN) Exceptions and Extensions …
- Advance Care Planning Basics: What Is It, and Why Does It Matter?Editor’s note: This is the first article in a multipart series about advance care planning and how to operationalize an effective program in nursing homes. The surveyor guidance under F578 (Request/Refuse/Discontinue Treatment; Formulate Advance …
- COVID-19: Many States Have Multiple State-Specific Section 1135 Waivers (6/20)CMS approved additional state Medicaid waiver requests under Section 1135 of the Social Security Act (Act). The waivers were approved within days of states’ submitting them, and offer states new flexibilities to focus their resources …
- Q&A: I understand that the Appendix C worksheets for the Care Area Assessment (CAA) review is optional, but what are the actual federal regulations to conducting and documenting the CAA?Question: I understand that the Appendix C worksheets for the Care Area Assessment (CAA) review is optional, but what are the actual federal regulations to conducting and documenting the CAA? Answer: Conducting a proper CAA …
- Q&A: Can I code O0100M, Isolation, if there is not an active COVID-19 diagnosis, but we are treating the new admission as if they had an active infection?Question: In our SNF, we are instructed to quarantine each new patient from the hospital and treat them as if they had an active infection for the first 14 days. We must do this even …
- October 1, 2020, Final Section S Items for the MDS 3.0 (6/20)October 1, 2020 Final Section S Items Revised [PDF 136 KB] (posted 06/04/2020) There are no new Section S items being added for 2020. There are revisions to the existing Section S items. Additional Items …
- PBJ Provider User Guide V3.0.1, Incl. Error Messages / Descriptions – UPDATED (5/20)This manual, updated to version 4.00.1 on May 27, 2020, explains how to connect to the PBJ system and submit data. It also defines error messages and descriptions, identifying errors by number, severity, error message, and …
- What the MDS Changes to Pressure Ulcers Means for Care ProcessesBy Emily Royalty-Bachelor, Staff Writer The way the nurse assessment coordinator (NAC) is tracking pressure ulcers may have changed, but that doesn’t mean the nursing team’s care process should. As part of its annual October updates …
- What Is That Annoying Noise?Visitors to nursing facilities often say, “What is that noise I keep hearing? It is so loud!” For those of us who work in the facilities, we get so that we hardly notice it. You …
- TIP: CMS Releases Final MDS Item Set for Oct. 1, 2020CMS Releases Final MDS Item Set for Oct. 1, 2020 CMS delayed the 1.18 updates that were slated for Oct. 1, 2020, which would have contained 59.5 changes to the MDS and recently released an …
- Q&A: A resident returned from an interrupted stay on the established 5-Day ARD. Should I keep the same ARD date or adjust it?Question: We have a skilled Medicare Part A resident with a 5-Day ARD on 5/16/20. She went out to the hospital for a blood transfusion on 5/15/20 2:30 pm but did not return until 5:45 pm …
- CMS COVID-19 Stakeholder Engagement Calls – Week of 5/18/20CMS hosts varied recurring stakeholder engagement sessions to share information related to the agency’s response to COVID-19. These sessions are open to members of the healthcare community and are intended to provide updates, share best …
- Release of Updated MDS With New Standardized SPADEs (and Supporting Training) Delayed Due to COVID-19 Public Health Emergency (5/20)CMS is delaying the release of the updated versions of the Minimum Data Set (MDS) needed to support the Transfer of Health (TOH) Information Quality Measures and new or revised Standardized Patient Assessment Data Elements …
- Q&A: Can intravenous immunoglobin (IVIG) infusion be coded as a transfusion in O01001, Transfusions?Question: Can intravenous immunoglobin (IVIG) infusion be coded as a transfusion in O01001, Transfusions? Answer: It is a blood product as included, so code it as a transfusion. RAI User’s Manual page O-4 states, …
- Q&A: Our new activity director would like to use the Preferences for Everyday Living Inventory (PELI) instead of the section F interview, please adviseQuestion: Our new activity director would like to use the Preferences for Everyday Living Inventory (PELI) instead of the section F interview. The RAI User’s Manual instructions seems clear that section F needs to be …
- Q&A: If we skill a resident for nursing only related to the COVID-19 infection and therapy is not involved, how do we code section GG? How would you code goals?Question: If we skill a resident for nursing only related to the COVID-19 infection and therapy is not involved, how do we code section GG? How would you code goals? Answer: The section GG …
- Q&A: I have heard that, due to the COVID-19 pandemic, MDS deadlines are not being enforced. Is this true?Question: I have heard that, due to the COVID-19 pandemic, MDS deadlines are not being enforced. Is this true? Answer: The waiver is pretty basic in its instructions and mentions MDS completion and submission …
- MDS Item I8000: Solve Common Coding Problems Under PDPMUnder the Patient-Driven Payment Model (PDPM), MDS item I8000 (Additional Active Diagnoses) is on every nurse assessment coordinator’s (NAC’s) radar thanks to its role as a source of ICD-10-CM diagnosis codes that can influence the …
- The Particulars of Coding Pre-Admission Data and PDPMWhen the nurse assessment coordinator (NAC) prepares to code the MDS, the process starts with data collected during the lookback period. However, one frequently-asked question is, “When can services that occurred prior to admission to …
- Section GG: CMS Training Videos for GG0130H, GG0170L, GG1070P (3/20)The Centers for Medicare & Medicaid Services is releasing three short video tutorials to assist providers with coding Section GG. These videos, ranging from 5 to 10 minutes, are designed to provide targeted guidance using …
- CMS Delays Implementation of the October 1, 2020 MDS 3.0 v1.18.1 Release (3/20)Mar 19, 2020 CMS is delaying the Minimum Data Set (MDS) 3.0 v1.18.1 release, which had been scheduled for October 1, 2020, in response to stakeholder concerns. The MDS item sets are used by Nursing …
- Q&A: If there is no clear documentation for anxiety, but the resident is taking Clonazepam for anxiety, can we code anxiety disorder (Item I5700) on Section I?Question: Regarding active diagnoses, if there is no clear documentation for anxiety, but the resident is taking Clonazepam for anxiety, can we code anxiety disorder (Item I5700) on Section I? Also, if there is no …
- Q&A: Following an interrupted stay, do we code the original therapy start date or do we code when therapy re-started on following the reentry?Question: A Medicare Part A resident returned to the SNF during the interruption window to continue their Medicare stay. Therapy originally started before the interruption, but the 5-Day ARD is after the resident returned. Do …
- Selecting ARDs: Bubble Gum, Bubble Gum…As a child, I can recall sitting in a circle, with legs crisscrossed, singing, “Bubble gum, bubble gum, in a dish, how many pieces do you wish?” to figure out who would be “It” in …
- 11 MDS Change Areas That Will Impact You October 1Nurse assessment coordinators (NACs) and other MDS assessors must be ready to code multiple new standardized patient assessment data elements (SPADEs) and other MDS items that will be required to meet the data submission threshold …
- Q&A: If a resident has signs and symptoms meeting the UTI surveillance criteria and a specimen was obtained prior to the ARD, but the physician diagnosis of UTI was not received until after the ARD, would you code UTI on the MDS?Question: If a resident has signs and symptoms according to the criteria following one of the evidence-based resources (i.e., McGeer) and a specimen is obtained on or prior to the ARD but the results do …
- Q&A: Does anyone have an IPA Policy?Question: Does anyone have an IPA Policy? Answer: This is a basic version which can be customized to add your specific facility routines and processes. Interested in reading more FAQs? Visit the AADNS Network where …
- How to Begin Prepping for October 1 MDS ChangesWith the implementation of the Patient-Driven Payment Model (PDPM) now fully under way for the Skilled Nursing Facility Prospective Payment System (SNF PPS), the Centers for Medicare & Medicaid Services (CMS) has begun turning the …