Long-Term Care Survey Alert

Watch out for updated coding instructions.

The Centers for Medicare & Medicaid Services’ (CMS’) latest update to the RAI Manual v1.12, makes some big changes to MDS coding. The majority of the changes released Sept. 15 fall in Chapter 3, Section A — Identification Information. Make sure you’re up to date before you complete your next MDS.

Pay Attention to Manual’s Major A0410 Overhaul

CMS revised the “Item Rationale” for A0410 — Unit Certification or Licensure Designation to now read:

• “In coding this item, the facility must consider Medicare and/or Medicaid status as well as the state’s authority to collect MDS records. State regulations may require submission of MDS data to QIES ASAP or directly to the state for residents residing in licensed-only beds.
• “Nursing homes and swing-bed facilities must be certain they are submitting MDS assessments to QIES ASAP for those residents who are on a Medicare and/or Medicaid certified unit. For those residents who are in licensed-only beds, nursing homes must be certain they are submitting MDS assessments either to QIES ASAP or directly to the state in accordance with state requirements.
•  “Payer source is not the determinant by which this item is coded. This item is coded solely according to the authority CMS has to collect MDS data for residents who are on a Medicare and/or Medicaid certified unit and the authority that the state may have to collect MDS data under licensure. Consult Chapter 5, page 5-1 of this Manual for a discussion of what types of records should be submitted to the QIES ASAP system.”

Also, the new “Steps for Assessment” for Item A0410 are:

1. “Ask the nursing home administrator or representative which units in the nursing home are Medicare certified, Medicaid certified or dually certified (Medicare/Medicaid).”

2. “If some or all of the units in the nursing home are neither Medicare nor Medicaid certified, ask the nursing home administrator or representative if there are units that are state licensed and if the state requires MDS submission for residents on that unit.”

3. “Identify all units in the nursing home that are not certified or licensed by the state, if any.”

And that’s not all — CMS also revised the “Coding Instructions” section in the RAI Manual for Item A0410:

• “Code 1, Unit is neither Medicare nor Medicaid certified and MDS data is not required by the State: if the MDS record is for a resident on a unit that is neither Medicare nor Medicaid certified, and the state does not have authority to collect MDS information for residents on this unit, the facility may not submit MDS records to QIES ASAP. If any records are submitted under this certification designation, they will be rejected by the QIES ASAP system.”
•  “Code 2, Unit is neither Medicare nor Medicaid certified but MDS data is required by the State: if the nursing home resident is on a unit that is neither Medicare nor Medicaid certified, but the state has authority under state licensure to collect MDS information for residents on such units, the facility should submit the resident’s MDS records per the state’s requirement to QIES ASAP or directly to the state. Note that this certification designation does not apply to swing-bed facilities. Assessments for swing-bed residents on which A0410 is coded ‘2’ will be rejected by the QIES ASAP system.”
• “Code 3, Unit is Medicare and/or Medicaid certified: if the resident is on a Medicare and/or Medicaid certified unit, regardless of payer source (i.e., even if the resident is private pay or has his/her stay covered under e.g., Medicare Advantage, Medicare HMO, private insurance, etc.), the facility is required to submit these MDS records to QIES ASAP. Consult Chapter 5, page 5-1 of this Manual for a discussion of what types of records should be submitted to the QIES ASAP system.”

Follow New Coding Instructions for A1100A & A1700

Additionally, CMS revised the “Coding Instructions” for Item A1100A — Does the resident need or want an interpreter to communicate with a doctor or health care staff?

• “Code 0, no: if the resident (or family or medical record if resident unable to communicate) indicates that the resident does not want or need an interpreter to communicate with a doctor or health care staff. Skip to A1200, Marital Status.”
• “Code 9, unable to determine: if no source can identify whether the resident wants or needs an interpreter. Skip to A1200, Marital Status.”

And you’ll notice that the “Coding Instructions” section for Item A1700 — Type of Entry looks different in the updated RAI Manual:

• “Code 1, admission/entry: when one of the following occurs:

1. Resident has never been admitted to this facility before; OR

2. Resident has been in this facility previously and was discharged return not anticipated; OR

3. Resident has been in this facility previously and was discharged return anticipated and did not return within 30 days of discharge.”

• “Code 2, reentry: when all three of the following occurred prior to this entry; the resident was:

1. Admitted to this facility, AND
2. Discharge return anticipated, AND
3. Returned to facility within 30 days of discharge.”

Also, under “Coding Tips and Special Populations” for Item A1700, CMS made the following revision:

OLD: 

• “Swing bed facilities will always code the resident’s entry as an admission, ‘1’, since an OBRA Admission assessment must have been completed to code as a reentry. OBRA Admission assessments are not completed for swing bed residents.”

NEW:

• “Both swing bed facilities and nursing homes must apply the above rules when determining whether a patient or resident is an admission/entry or reentry.”

Check Out Other Section A Changes

CMS also changed the URL contained in the last bullet under Item Rationale for Item A1500 — Preadmission Screening and Resident Review (PASRR):

• “Please see www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Institutional-Care/Preadmission-Screening-and-Resident-Review-PASRR.html for CMS information on PASRR.” 

In addition to the changes, there is a new item in Section A, A1900 — Admission Date, which is defined as “the date this episode of care in this facility began.” This is different from the item A1600 — Entry Date in that A1900 houses the date the resident started his current episode of stay.  

The difference between stay and episode is “a stay is a set of contiguous days in the facility,” while an episode is a “series of one or more stays that may be separated by brief interruptions in the resident’s time in the facility.” Per the information posted at www.qtso.com/download/mds/MDS_30_Jan_23_2014_Vendor_Call_Speaker_Notesv4.pdf, an episode continues until the resident discharges with return not anticipated, the resident dies in the facility, or the resident’s return is anticipated, but he does not return within 30 days.  

Basically the admission date in A1900 will remain the same, but the dates in A1600 may change if the resident has discharges and returns.

Finally, CMS changed the Item Rationale for A2200 — Previous Assessment Reference Date for Significant Correction:

• “To identify the ARD of a previous comprehensive (A0310 = 01, 03, or 04) or Quarterly assessment (A0310A = 02) in which a significant error is discovered.”

Resources: To view the new RAI Manual v1.12, go to www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Scroll down to the “Downloads” section at the bottom of the page. From there, you can access the full sets of chapters, sections and appendices, as well as the change tables.

For a direct link, you can access the change tables at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-RAI-Manual-v112-and-Change-Tables_October-2014.zip, and the replacement manual pages at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-RAI-Manual-v112-Replacement-Manual-Pages-and-Change-Tables_October-2014.zip.