Long-Term Care Survey Alert

-Are you on top of the June 15 RAI manual revisions? The latest update replaced a May 1 version that never made out of the gate.

The good news: The Centers for Medicare & Medicaid Services did not revise the May update as much as anticipated, so facilities that had moved ahead with training will still be ahead of the compliance curve.

The June update did remove the May version's directive to code in M1 the ulcer staged closest to the assessment reference date. While that coding directive made sense, say industry experts, it didn't jibe with existing MDS data specs. For example, coding an improvement in staging for an ulcer at M1 would not have matched the "highest" staging being reported in M2, notes Peter Arbuthnot, regulatory industry analyst with American HealthTech Inc. in Jackson, MS.

Also gone: directions to date the attestation statement at AA9 to reflect the date the person completed collecting or coordinating data for an MDS section. Yet if you read the attestation statement, that's still the requirement, so make sure interdisciplinary staff date AA9 correctly.

Don't be misled: CMS also removed a directive presented in the rescinded May update directing providers to code a resident as independent in G1A when an activity occurred less than three times, regardless of his level of self-performance. Again, however, that's always been the case for coding a resident as independent.

CMS has clamped down on coding IVs in Section K5a and Section P. For example, "CMS bolded 'nutrition and hydration' at K5a in describing IV fluids to code, which includes fluids used to reconstitute IV medications. Experts maintain that CMS seems to be making the point that facilities should code the IV fluids at K5a only when they are administered for hydration.

To play it safe in coding fluids at K5a, "you really need a physician statement to indicate that the fluids are being given for nutrition or hydration - or have a diagnosis of dehydration in the medical record applying to the MDS lookback," says Cathy Sorgee, RN, a consultant with The Broussard Group in Lake Charles, LA.

In addition, you can no longer code IVs in K5a that are part of a routine "diagnostic procedure" according to the June update. The revised manual also forbids facilities from coding IV medication (including IV contrast material) or other treatments in P1 provided solely in conjunction with a surgical or diagnostic procedure and the immediate post-operative or post-procedure recovery period. (CMS added the underlined language).

The June update directs providers to code at T1c (projected days of therapy) the actual number of days of therapy ordered by the physician (in cases where the physician orders a limited number of days of therapy).

-The revised surveyor guidance for F501 (medical director) is a done deal - almost. CMS released a survey and certification letter on June 9 with a copy of the advance copy of the final changes to the interpretive guidelines in the State Operations Manual. The agency says it will delay final issuance until November 2005 to allow state survey agencies and providers time to complete training on the new guidance.

Read the survey and certification letter (S&C 05-34) and revisions to Appendix P of the State Operations Manual at www.cms.hhs.gov/medicaid/surveycert/letters.asp.

Editor's note: For details about the advance copy of the guidance and industry reaction, see the next Long-Term Care Survey Alert.