MDS Alert

Hint: What's good for Medicaid can also pay off for Medicare.

Beware: Medicaid agencies in some case-mix payment states may be recouping payments by cracking down on supportive ADL documentation requirements for the MDS.

"Some states are taking the stand that if the CNAs don't have the verbatim ADL definition or question in front of them, [Medicaid] has a right to recoup money," cautions Peter Arbuthnot, regulatory analyst for American HealthTech Inc. in Jacksonville, MS. And "this approach could spread to other states."

States have established requirements mandating nursing facilities to use coding language that mirrors the intent of the RAI definition and instructions for coding the MDS, says Patty Padula, RN, a consultant for Myers & Staffuer in Indianapolis, which does MDS-related Medicaid reviews in nursing homes.

Example: Indiana published supportive documentation requirements saying the late-loss ADLs require 24/7 documentation during the seven-day lookback with signatures/initials and dates (more than one set) to "authenticate the services provided." The requirements apply to assessments dated on or after Dec. 11, 2007.

Short-cut ADL keys a problem: The Indiana guidelines also caution that if a nursing facility uses an ADL grid to record self-performance, the key to self-performance and support must mirror the MDS key. Padula saw the "ADL shortcut keys filter in about three years ago." The forms evolved as consultants and others tried to simplify the RAI manual verbiage for CNAs, she adds.

Whether Medicare or Medicaid is the payer, the support documentation for ADLs in G1 should reflect the actual RAI manual nomenclature for both self-performance and support, advises Bet Ellis, RN, manager for healthcare at LarsonAllen in Charlotte, NC.

Yet Ellis sometimes sees staff document that the resident needed a one-person assist, for example, for the shift, which is used to code Column B. "But there's no mention of the resident's self-performance requirements.

"Some case-mix states are actually looking for a documented description of the type of assistance that staff provided," Ellis adds. For example, "a brief description of how the staff person applied TED hose during dressing can support weight-bearing assistance occurring daily, which would be coded as extensive assistance for the lookback period."

Avoid this approach: Some facilities are having CNAs chart ADLs once a shift, observes Rena Shephard, MHA, RN, RAC-MT, president of RRS Healthcare Consulting in San Diego. But the coding instructions direct you to code based on all of the episodes of the activity that occurred. Thus, she doesn't see how a code of "3" for the shift, for example, tells you how many times the activity occurred. Was it one instance of weight-bearing assistance -- or three instances, which could be required to code extensive assistance on the MDS? Shephard asks.

Document across the lookback: Once you know the resident has received three or more instances of weight-bearing assistance and one instance of a two-person support, you know what to code for the lookback, Shephard says. But it's important for CNAs "to continue to record and document all instances of ADL help because you want to promote consistency." Also, before you can code a resident as being totally dependent, you have to ensure that staff performed the entire activity for all of the seven-day lookback, Shephard adds.

Interviewing CNAs can help inform coding decisions. And to help nurses do that, Shephard has developed a form that includes interview questions. For example, the MDS nurse might ask the CNAs: "Did the resident need for you to touch him to help with the ADL? If so, did you physically guide him or actually have to take on some of the person's weight?" says Shephard.