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.
- How to Speak the Same Language for Section K Coding: NACs and SLPsWhen a nurse assessment coordinator (NAC) reviews the speech language pathologist (SLP) evaluation notes and encounters the term globus sensation, he or she may not even consider that the phrase could indicate a potential swallowing …
- Substantive Changes to the MDS Nursing Home Comprehensive (NC) Item SetOn Sept. 1, 2022, the Centers for Medicare & Medicaid Services (CMS) released the draft MDS Nursing Home Comprehensive (NC) Item Set version 1.18.11. Nursing homes will be required to implement the new item sets—with …
- Q&A: We have a resident for whom we are completing an Interim Payment Assessment (IPA). Would we also need to complete a Significant Change in Status Assessment (SCSA) at the same time due to these changes?Question: We have a resident for whom we are completing an Interim Payment Assessment (IPA). Would we also need to complete a Significant Change in Status Assessment (SCSA) at the same time due to these …
- Q&A: I am completing a Significant Change in Status Assessment (SCSA) for a resident who revoked hospice services. How should I code J1400 since hospice services were provided during the 14-day look-back period?Question: I am completing a Significant Change in Status Assessment (SCSA) for a resident who revoked hospice services. How should I code J1400 since hospice services were provided during the 14-day look-back period? I am …
- Two CMS Nursing Home Calls on Oct. 6: National Stakeholder Call and SNF/LTC Open Door ForumThere are two calls on Oct. 6. The first one is the Skilled Nursing Facility/Long-Term Care Open Door Forum and does not require registration. The second one is the National Nursing Home Stakeholder Call and …
- CMS to End RUGs Support for Medicaid Case-Mix on Oct. 1, 2023; Gives States Guidance re: PDPM (9/22)Guidance on Nursing Facility State Plan Payment and Upper Payment Limit Approaches in Medicaid Relying on the Medicare Patient-Driven Payment Model (SMD 22-005) “As stated at the beginning of this letter, CMS will no longer …
- jRAVEN Free MDS Software Updated to v1.8.2 (9/22)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 …
- FY 2025 (Calendar Year 2023) SNF QRP APU Table for the MDS Data Submission ThresholdA table providing the data elements that will be required to meet the Annual Payment Update (APU) minimum data completion threshold for the Fiscal Year (FY) 2025 Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) …
- FY 2025 (Calendar 2023) SNF QRP Data Collection and Final Submission Deadlines (9/22)A table providing the data collection time frames and final submission deadlines for the Fiscal Year (FY) 2025 Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is available. Note that the NHSN measure, Influenza Vaccination …
- FY 2024 (Calendar 2022) SNF QRP Data Collection and Final Submission Deadlines UPDATED (9/22)An updated table providing the data collection time frames and final submission deadlines for the Fiscal Year (FY) 2024 Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) is available. The FY 2024 update adds in …
- FY 2023 SNF QRP FAQs (9/22)An update to the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Frequently Asked Questions (FAQs) document is now available. This document has been updated to reflect the finalized policies for the SNF QRP in …
- A Conversation on Two Technical Expert Panels and the Future Unified Payment Model with Renee KinderIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Renee Kinder, MS, CCC-SLP, RAC-CT, executive vice president of clinical services with AAPACN Diamond …
- New Draft MDS 3.0 Nursing Home Comprehensive Item Set – How SNFs Should PrepareIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Jessie McGill, RN, RAC-MT, RAC-MTA, curriculum development specialist with AAPACN, discuss CMS’s recent release …
- TIP: CMS Posts Draft MDS Comprehensive (NC) Item Set for Oct. 1, 2023The draft Minimum Data Set (MDS) Nursing Home Comprehensive (NC) Item Set version 1.18.11 is now available. CMS plans to release the final version of the MDS Item Sets later in 2022, which will be effective beginning …
- Section G: Scheduled for Retirement October 2023The Activities of Daily Living (ADLs) in section G of the MDS are interwoven throughout the Care Area Assessments (CAAs), Quality Measures (QMs), and some state Medicaid reimbursement systems—and have been for years. Yet CMS …
- Q&A: If a resident is diagnosed with COVID-19 and an interim payment assessment (IPA) is completed, does the COVID diagnosis need to be coded at I0020b or I8000?Question: If a resident is diagnosed with COVID-19 and an interim payment assessment (IPA) is completed, does the COVID diagnosis need to be coded at I0020b or I8000? Answered by Melissa Brown, OTR/L, RAC-CT, CDP, …
- Q&A: Can I code a urinary tract infection (UTI) for a new admission from the hospital diagnosis if it’s within the 30-day look-back period?Question: Can I code a urinary tract infection (UTI) for a new admission from the hospital diagnosis if it’s within the 30-day look-back period? Answer by Vicki Gress, RN, RAC-CT: Yes, page I-13 of the …
- Q&A: If a resident goes out to the hospital and then is readmitted to the facility, do we have to complete a baseline care plan upon their readmission within 48 hours?Question: If a resident goes out to the hospital and then is readmitted to the facility, do we have to complete a baseline care plan upon their readmission within 48 hours? Answer by Carol Maher, …
- Appendix B State RAI Coordinator Contact List / RAI Manual Update (9/22)The September 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 …
- Assessing Dark Skin Tone: Advancing Excellence Resources (9/22)Advancing Excellence Collaborative for Long Term Care (AELTCC) has compiled a set of resources to assist nursing and direct care staff with strategies for identifying potential alteration in skin integrity specifically for individuals with dark …
- MDS Validation Utility Tool (VUT) v3.6.1 – Effective 10/1/2022An updated MDS Validation Utility Tool (VUT) v3.6.1 is now available. This release supports the valid FY2023 ICD codes for I0020B as well as the remapping of GG Discharge items when a dash is used …
- October 2023 MDS Item Set: No Section G and More Three-Day Look-BacksOn Sept. 1, 2022, the Centers for Medicare & Medicaid Services (CMS) released the draft MDS Nursing Home Comprehensive (NC) Item Set version 1.18.11, noting that it plans to post all of the final v1.18.11 …
- Draft MDS Nursing Home Comprehensive (NC) Item set version 1.18.11 (9/22)The draft Minimum Data Set (MDS) Nursing Home Comprehensive (NC) Item set version 1.18.11 is now available in the Downloads section below. CMS plans to release the final version of the MDS Item Sets later …
- FY 2023 – 2024 Parity Recalibrations Demand a Back-to-Basics ApproachFee-for-service Medicare Part A reimbursement is under significant pressure over the next two fiscal years due to a parity adjustment recalibration that will reduce aggregate payments by $780 million just in FY 2023 (Oct. 1, …
- Q&A: Can I code psychiatrist visits and orders in MDS items O0600 and O0700?Question: I have been coding psychiatrist visits and orders in MDS items O0600 and O0700. My consultant told me I can’t code this. I thought since a psychiatrist is a medical doctor that specializes in …
- Q&A: When coding K0510A, Nutritional Approach While Not a Resident, can I code IV hydration administered during a surgical procedure on the MDS?Question: When coding K0510A, Nutritional Approach While Not a Resident, can I code IV hydration administered during a surgical procedure on the MDS? Answer by Janine Cortesa, RN, BSN: Coding fluids here is only for …
- Q&A: Can Z codes be used as the primary diagnosis?Question: I was told that, as of the April update of this year, we are no longer allowed to use Z codes as the primary diagnosis. Is this true? Answer by Carol Maher, RN-BC, RAC-MTA, …
- FY 2023 ICD-10 codes for MDS V3.00.1 (FINAL) Data Submission Specs (8/22)An updated PDPM ICD Codes database for the MDS V3.00.1 (FINAL) Data Specifications is now available for download. The database contains two new tables. The table pdpm_icd_codes_FY2023 contains the allowed FY2023 codes for I0020B, while table …
- CMS: Part A Three-Day Hospital Stay Waiver Will Definitely End at COVID-19 PHE End (8/22)CMS has issued a new fact sheet with information about which COVID-19 Public Health Emergency (PHE) waivers and flexibilities have already been terminated, have been made permanent, or will end at the end of the …
- Onboarding Schedule for MDS Transition to iQIES: Provider Security Officials Schedule (8/22)CMS is excited to announce that we are preparing to release the Internet Quality Improvement Evaluation System (iQIES) for Minimum Data Set (MDS) submission in early 2023. Although the MDS submission functionality will not be …
- Don’t Shortcut the CAAsClinical education teaches nurses a process of problem identification. Encompassing assessment, nursing diagnosis, planning, implementation, and evaluation, it is often just called the nursing process. Many nurse assessment coordinators (NACs) may also recognize that the …
- TIP: CMS Announces Rollout for iQIES for Nursing FacilitiesOn the Aug. 4, 2022, Skilled Nursing Facility Open Door Forum, officials from the Centers for Medicare & Medicaid Services (CMS) announced the beginning of a training rollout for the Internet Quality Improvement and Evaluation …
- Q&A: A resident expired at the hospital but was not admitted as an inpatient. Do I need to complete an OBRA Discharge assessment or Death in Facility tracking record?Question: We had a resident code in the facility and was emergency transported to the hospital. The resident expired at the hospital but was never officially admitted to the hospital as an inpatient. Do I …
- Q&A: Can a nurse licensed in one state complete sections of the MDS for another state?Question: Can a nurse licensed in one state complete sections of the MDS for another state? Answered by Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC: Unless there is a compact between states, the nurse …
- Falsified MDSs and Nurse Staffing Hours the Focus of PA Indictments (8/22)PITTSBURGH – Five individuals and two for-profit skilled nursing facilities in Southwestern Pennsylvania have been indicted by federal grand jury in Pittsburgh on charges of conspiracy to defraud the United States and related health care …
- Tips to Achieve Supporting Documentation: Get the Information NACs Need to Code the MDSCompleting the MDS assessment requires documentation in the medical record to support nearly every item’s coding. When supporting documentation is in place, the MDS assessment process can be smooth and efficient. If it is not, …
- TIP: CMS Clarifies Schizophrenia Diagnosis Coding on the MDSIn mid-July, CMS posted the MDS 3.0 RAI User’s Manual (v1.17.1R) Errata (v2) which provided clarification on the Patient-Driven Payment Model (PDPM) mapping for skin problems to the feet for the nontherapy ancillary component and …
- Q&A: The physician documented “right sided weakness due to CVA,” but did not mention “hemiparesis.” Can I not code “hemiparesis” on the MDS?Question: A resident had a cerebrovascular accident (CVA) and a significant change in status assessment is being completed. The physician documented “right sided weakness due to CVA,” but did not mention “hemiparesis.” Can I not …
- Q&A: We discovered coding errors that go back to 2020. What is the requirement to correct these assessments?Question: We discovered coding errors that go back to 2020, when a resident first enrolled in hospice services. The prior staff member did not code hospice on any MDS assessment from that time and the …
- FY 2023 PDPM ICD-10 Mappings File (8/22)ICD-10-CM related mappings for the purposes of resident classification under the Patient-Driven Payment Model (PDPM) for Medicare Part A SNF stays. Updated all three mappings to FY2023 code list. Reflected all changes finalized in the …
- FY 2023 ICD-10-CM Codes and Official Coding Guidelines Effective Oct. 1, 2022 (8/22)2023 release of ICD-10-CM The FY2023 ICD-10-CM codes are to be used from October 1, 2022 through September 30, 2023. Note: This replaces the FY 2022 – April 1, release. These files listed below represent …
- FY 2023 SNF PPS Final Rule Press Release and Fact Sheet From CMS (7/22)Medicare Program: Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Quality Reporting Program and Value-Based Purchasing Program for Federal Fiscal Year 2023; etc. PDF 348 Pages (962 KB)Permalink Press release: CMS Acts to Improve the …
- Q&A: I’m new to MDS. Is there anything that needs to be completed on the MDS before the resident leaves for a planned discharge back to the community?Question: I’m new to MDS. Is there anything that needs to be completed on the MDS before the resident leaves for a planned discharge back to the community? Answered by Kim Steele RN, WCC, RAC-CT, RAC-CTA: …
- Q&A: How many days after the due date on a physician recertification can the physician sign and still be in compliance? Question: How many days after the due date on a physician recertification can the physician sign and still be in compliance? Answered by Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC: After the first recertification, …
- Medicare A2400C Algorithm with the NPE and Interrupted StayAAPACN has adapted the A2400C flow chart from section A of the RAI User’s Manual to show how A2400C impacts how the nurse assessment coordinator (NAC) schedules the PPS Part A Discharge assessment and how …
- Accurately Code Wounds in MDS Section M: How to Get Strong Supporting DocumentationIn many facilities, the wound nurse may not be doing weekly wound rounds because they are getting pulled to the floor, which can create a nerve-wracking situation for nurse assessment coordinators (NACs) trying to code …
- Section GG Education and Spot Audits Boost Coding QualityAny staff members, including nurses or certified nursing assistants (CNAs), who document for section GG (Functional Abilities and Goals) need to be trained on how to observe the resident in those areas, says Scott Heichel, …
- Tips for Developing Fall Prevention Care Plans with Mark CifarelliIn this podcast, Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, vice president of education and certification strategy for AAPACN, and Mark Cifarelli, PT, a physical therapist and director of clinical content development for Legacy …
- Q&A: Is a Significant Change in Status Assessment required if a resident on hospice experiences a decline following a fall?Question: We have a resident that is receiving hospice services who had a fall resulting in a fracture and the family has decided not to treat. The resident now has a decline in function, increased …
- Q&A: A long-term care resident returned from the hospital on a Medicare stay. Can I complete his Quarterly MDS while he is on a skilled level of care?Question: A long-term care resident recently went out to the hospital and returned on a skilled Medicare Part A stay. I have a PPS 5-Day assessment scheduled with an ARD on day 8 of the …
- MDS 3.0 Data Specs — New Errata Issued (7/22)Errata V3.00.8 for MDS V3.00.1 (FINAL) Data Submission Specifications Posted An updated errata for the MDS V3.00.1 (FINAL) Data Specifications is now available. Two issues have been added. Discharge performance Items in Section GG were …
- Baseline Care Plan: Connecting the Dots to the ComprehensiveUnlike the baseline care plan, the comprehensive care plan is largely MDS-based and analysis-driven, points out Mary Madison, RN, RAC-CT, CDP, a long-term care and senior living clinical consultant for Briggs Healthcare in Clive, IA. “It …
- Q&A: When a resident who elected hospice switches to a different hospice company, is a Significant Change in Status Assessment required?Question: When a resident who elected hospice switches to a different hospice company, is a Significant Change in Status Assessment required? Answer from Janine Cortesa, RN: RAI User’s Manual, page 2-23: An SCSA is required …
- Q&A: Can someone clarify the guidelines or protocol to use sepsis as the principal diagnosis in MDS?Question: Can someone clarify the guidelines or protocol to use sepsis as the principal diagnosis in MDS? Answer from Jeff Taylor: This is what I follow from the blog post, “Conquer Coding for Sepsis and …
- Q&A: When should a urinary tract infection (UTI) be coded at MDS item I2300?Question: I have a resident with an increase in confusion and a UA with C&S showing >=100,000 CFU/mL of Klebsiella. He has no other noted symptoms and advanced dementia, so he is unable to describe …
- Coding Diagnoses in MDS Section I: The Art of the Physician QueryThe coding instructions for MDS section I (Active Diagnoses) in the Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual require that every diagnosis coded in this section be documented by a physician or a …
- TIP: IV Fluids Given for Nutrition or Hydration in the Hospital Affect Special Care HighWhen considering assessment reference date selection, do not forget that IV fluids given in the hospital within the 7-day look-back period “while not a resident” may impact the Special Care High nursing category. Unlike the …
- Which Do I Follow? Federal vs. State Regulations for the MDSIn 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, QCP, CRC, curriculum development specialist for AAPACN, discuss some …
- Q&A: Do 48-hour care plan meetings need to be completed for readmissions?Question: Do 48-hour care plan meetings need to be completed for readmissions? Answer from Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC [email protected]: Assuming the resident already had the Admission MDS completed on their original …
- 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 …
- 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 …
- 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 …
- 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 …