MDS Alert

Ask why the zeroes, 4's and 8's.

You know the old diagnostic adage, "When you hear hoofbeats, think horses--not zebras."

And in the SNF world, MDS codes of zero, 4 and 8 for activities of daily living (ADLs) often fall into the zebra camp, which means you need to double check that they describe a resident's actual status.

Good question: "Who comes into the building for whom you don't give oversight, encouragement or cueing?" for their ADLs, asks Diane Brown, CEO of Brown LTC Consultants in Boston.

Providing oversight, encouragement or cueing three or more times in the lookback counts as supervision for self-performance (G1A), which would be coded as a "1," not a "0."

Remember: You don't code a 0 for ADL support provided (G1B) if staff provided the resident "set-up help."

And set-up help involves help from person to thing: handing the person the trapeze or overhead bar or giving the person a bedpan, Brown explains.

Know When There's No Way a Resident Is an 8

Question any code of "8" for "activity did not occur during entire seven days" for a late-loss ADL, suggests Brown. Unless someone is on hospice, for example, it's unlikely that he didn't receive nourishment.

"Someone on strict bed rest may not transfer out of the bed," says Nathan Lake, RN, an MDS expert in Seattle. So a code of  "8" would be appropriate in that situation.

But even if someone is on dialysis and doesn't urinate, he will still have bowel elimination, adds Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.

Revisit 'Total Dependence'

Coding a resident as a "4" for total dependence in self-performance means the staff performed all of the ADL for the person 24/7 during the assessment lookback.

Tip: Home Quality Management stresses that staff should not code total dependence if the resident helps with any part of the ADL task, says Cleo Boulter, MSN, RN, VP of clinical reimbursement for the nursing home company in Palm Beach Gardens, FL.

Example: You would only code a resident as totally dependent in eating if staff fed him all food and liquids at all meals and snacks (including tube feeding delivered totally by staff), states the RAI user's manual.

The resident would not have initiated "any subtask of eating." That would include picking up finger foods, giving himself a tube feeding or assisting with the procedure at any meal.

Tip: The definition for G1h (eating) includes IV fluids. "Therefore, code G1hA = 4 (total dependence) rather than '8' for a resident who is receiving IV fluids or TPN," instructs the RAI manual.

Did you know? "There's no difference in dollars between total and extensive assistance," says Brown.