MDS Alert

Transfer this know-how to your team and watch ADL accuracy gleam.

Miscoding transfers pulls the RUGs out from under your SNF's bottom line and can lead to an inaccurate estimation of a resident's rehab or restorative potential and needs.

Undercoding, of course, tends to be more the norm and can cost your facility thousands of dollars a month.

Goal: Hone your coding skills to prevent miscoding in either direction. Read on to find out how.

Know before you code: Transfer involves how the resident moves between surfaces, i.e., to and from the bed, chair, wheelchair, standing position, according to the RAI user's manual. Exclude from this definition movement to/from bath or toilet, which is covered under toilet use and bathing.

Always double-check scores of limited assistance and a one-person assist. CNAs and nurses should know that if they bear any part of the resident's weight during a transfer, you count that toward extensive assistance. By contrast, limited assistance involves guided maneuvering where you don't bear any of the resident's weight, says Christine Twombly, RAC, a consultant with Reingruber & Company in St. Petersburg, FL. Limited assistance is what therapy calls contact guard, that is, light touch, she adds.

Beware: ADL flow sheets that ask CNAs to code the most help they provided during the shift, such as extensive assistance -- but not the frequency of that help -- can derail ADL accuracy, cautions Sheri Kennedy, RN, BA, MSEd, president of Knowledge Solutions.

Invariably, support provided for transfers is most commonly miscoded, says Nathan Lake, RN, MSHA, an MDS and long-term care expert in Seattle. If the resident requires a two-person assist even once during the lookback, say on the night shift, you must code that for support in Column B, he emphasizes.

Don't let Hoyer lifts inflate coding. "People sometimes want to code a two-person assist when they use a Hoyer lift, regardless if they have one or two staff persons helping with the lift," observes Gail Robison, RN, RAC-C, a consultant with Boyer and Associates in Brookfield, WI. But you should code the actual staff utilization, she says. "So if only one person assists the resident to transfer using a lift, then you code a one-person assist. If the facility's policy is to use two persons, then you code two."

Know the coding ropes for total dependence. To code total dependence, the resident can't have assisted with any of the ADL throughout the entire lookback, which requires 24/7 tracking. Total dependence may occur if the person is always transferred using a Hoyer lift -- or if he's on weight-bearing restriction after surgery, for example, and fully dependent on staff to transfer as a result, says Evonne Fillinger, RN, RAC-C, also with Boyer and Associates. Or the person may have suffered a severe stroke and is totally dependent on staff to get him out of the bed. "In that case, you'll usually see all the ADLs are 4 because he's unable to do any portion of them," she adds.

Exception: When the resident transfers using a stand-up lift, he is doing some portion of the transfer, which requires upper-body strength to perform, says Fillinger. "So you can't code total dependence in that case even if the person always requires use of the stand-up lift."

Compare transfer scores to toileting. "In coding transfers, you don't include those that occurred in transferring the resident to the toilet," reminds Patricia Boyer, RN, MSM, NHA, principal of Boyer and Associates. But logically, if the person requires a two-person assist to do that for toileting, he's probably going to need that amount of help to transfer out of the bed, she notes.

Remember: There's no payment difference between a 3 (extensive assistance) and 4 (total dependence) for transfer, toileting and bed mobility, says Twombly. But if the resident coded as 3 or 4 for self-performance had a score of 3 for support (a two-or-more person assist even once), the person will get a higher ADL index, which can result in him going in a higher-paying RUG.

"There is a difference in rehab potential, however, between someone coded as 3 [for extensive assistance] versus 4," Twombly points out. "If the person can do some small aspect of the ADL, the chances are that he can improve function and participate more," she says.