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ADL CODING:

Don't Let Missing ADL Points Dock Your RUG Scores

Published on Sun Feb 15, 2009

Make sure these common examples stay on the RAI radar screen.

Certain types of ADL help can all too easily go unnoticed or staff may fail to document the assistance during the lookback. And if that happens systematically, your facility will be losing a ton of money.

Key example: A resident who uses the toilet independently needs help tucking in and straightening clothing, which counts as limited assistance, says Jane Belt, MS,GCNS-BC, RAC-MT, consulting manager with Plante & Moran Clinical Group in Columbus, Ohio. Yet Belt sometimes sees situations where staff fails to count that assistance when coding toileting on the MDS.

You can also include helping the person clean up after toileting, which staff often miss capturing on evenings and nights, says Cindy MacQuarrie, RN, MSN, managing consultant with BKD LLP in Kansas City, Mo. Changing an incontinent resident's pad or diaper also counts as part of toileting, she adds.

Also be on the lookout for these instances of assistance for the late-loss ADLs:

Eating: If the resident doesn't finish eating, and staff provides hands-on assistance or cueing at the end of the meal, make sure to count that ADL help, advises Sheryl Rosenfield, RN, RAC-CT, BC,director of clinical services for Zimmet Healthcare Services in Morganville, N.J. Or look to see if the staff should be providing that extra ADL help, she says.

"Appropriate care leads to more accurate ADL coding."

Bed mobility and transfer: Sometimes staff blends the tasks of transfer and bed mobility, which can result in under-coding the latter, cautions Belt. "The definition of transfer is 'surface to surface,'" Belt says."So transfer ends when the resident's bottom is put on the edge of the mattress." After that, everything else the staff does to help get the resident into bed and properly positioned there -- such as swinging his legs up into bed and putting him in the right place on the mattress, etc. -- counts as bed mobility, Belt adds.

Good question: Does your staff routinely document bed mobility on the evening and night shifts when they help residents reposition and get comfortable in bed? Residents who are up during the day may need help with bed mobility on those shifts when they are tired and in bed, says MacQuarrie. "Yet evening and night shift staff will say, 'This is what we do' or 'the resident is always like that.'" But that assistance needs to be documented and captured on the MDS, she stresses. The same holds true for transfers. A person may only require a one-person assist during the day, but need a two-person assist at night-time, observes Pam Campbell, RN, a consultant with LTC-Solutions Inc., based in Cape Girardeau, Mo.

Not just a Medicare issue: "In some of the Medicaid case-mix states, reviewers are looking very closely at documentation for ADLs," cautions MacQuarrie.

Example: AMedicaid reviewer in one facility found that assistance for self-performance scoring wasn't documented three times in the lookback period for a resident who obviously needed that particular level of assistance. And since the reviewer did not find documentation to support that level of assistance, she downcoded the ADL, which changed the RUG level and affected the Medicaid payment, MacQuarrie reports.

Resource: To improve ADLassistance and coding for eating, check out "Dining Observation Tool Measures Amount, Quality Of ADL Assistance," in the Vol. 6, No. 5 MDS Alert, available in the Online Subscription System. If you haven't yet signed up for this free service, call 800-508-2582.

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