MDS Alert

Manual contains substantive revisions to hospice benefit instructions.

The updated RAI Manual v1.12 released on Sept. 15 certainly contained a plethora of changes to the MDS item sections in Chapter 3 (see MDS Alert Vol. 12, No. 9, pages 97, 102 and 103). But don’t overlook the many revisions to Chapter 2 of the manual. Here are the most important updates.

Follow Revised Instructions for Assessment-Retention, Discharges

On page 6 (Section 2.4) of Chapter 2, the Centers for Medicare & Medicaid Services (CMS) made a revision to the instructions under “Responsibilities of Nursing Homes for Reproducing and Maintaining Assessments:”

“After the 15-month period, RAI information may be thinned from the clinical record and stored in the medical records department, provided that it is easily retrievable if requested by clinical staff, State agency surveyors, CMS, or others as authorized by law. The exception is that demographic information (Items A0500-A1600) from the most recent Admission assessment must be maintained in the active clinical record until the resident is discharged return not anticipated or is discharged return anticipated but does not return within 30 days.”

On page 10 (Section 2.5), CMS added the following bullet point to the “Discharge” definition:

• Resident is transferred from a Medicare- and/or Medicaid-certified bed to a noncertified bed.
  

On page 12 (Section 2.5), CMS revised the following reference under the “Item Set” definition: “Printed layouts for the item sets are available in Appendix H of this manual.”

On page 18 (Section 2.6), the manual tweaked the wording of a bullet point in the “Assessment Management Requirements and Tips for Comprehensive Assessments” section (eighth bullet):

• “In the process of completing any OBRA Comprehensive assessment except an Admission and a SCPA …”

Look for Hospice Benefit Changes

On page 21 (Section 2.6) of the manual, CMS clarified how to handle hospice election:

“If a resident is admitted on the hospice benefit (i.e. the resident is coming into the facility having already elected hospice), or elects hospice on or prior to the ARD of the Admission assessment, the facility should complete the Admission assessment, checking the Hospice Care item, O0100K. Completing an Admission assessment followed by a SCSA is not required. Where hospice election occurs after the Admission assessment ARD but prior to its completion, facilities may choose to adjust the ARD to the date of hospice election so that only an SCSA is not required.”

And on page 22 (Section 2.6), CMS added a bullet point and revises another under “Assessment Management Requirements and Tips for Significant Change in Status Assessments,” which begins on page 20:

• If a resident is admitted on the hospice benefit but decides to discontinue it prior to the ARD of the Admission assessment, the facility should complete the Admission assessment, checking the Hospice Care item, O0100K. Completing an Admission assessment followed by a SCSA is not required. Where hospice revocation occurs after the Admission assessment ARD but prior to its completion, facilities may choose to adjust the ARD to the date of hospice revocation so that only the Admission assessment is required. In such situations, an SCSA is not required.
  
• “The ARD must be less than or equal to 14 days after the IDT’s determination that the criteria for a SCSA are met (determination date + 14 calendar days).”

Beware of Deletions Changing Admission Guidelines

CMS also deleted Example 2 on page 27 (Section 2.6). And on page 30, the revised RAI manual reads:

• “The ARD of an assessment drives the due date of the next assessment. The next non-comprehensive assessment is due within 92 days after the ARD of the most recent OBRA assessment (ARD of previous OBRA assessment — Admission, Annual, Quarterly, Significant Change in Status, or Significant Correction assessment — + 92 calendar days).
• “While the CAA process is not required with a non-comprehensive assessment (Quarterly, SCQA), nursing homes are still required to review the information from these assessments, determine if a revision to the resident’s care plan is necessary, and make the applicable revision.”

On page 33, CMS deleted the following two bullet points under “Admission (Item A1700=1):”

- “is readmitted after a discharge prior to completion of the OBRA Admission assessment; or”
- “for swing-bed facilities, the Entry tracking record will always be coded 1, Admission, since these providers do not complete an OBRA Admission assessment.”

Admission (Item A1700=1) now reads:

• Entry tracking record is coded an Admission every time a resident:

- is admitted for the first time to this facility; or
- is readmitted after a discharge return not anticipated; or
- is readmitted after a discharge return anticipated when return was not within 30 days of discharge.

Also on page 33, CMS revised the instructions for “Reentry (Item A1700=2):” 

1 Entry tracking record is coded Reentry every time a person:

- Is readmitted to this facility, and was discharged return anticipated from this facility, and returned within 30 days of discharge. See Section 2.5, Reentry, for greater detail.

See New Example for Discharge Return Not Anticipated

Additionally, CMS added an example of “Discharge-return not anticipated” on page 35:

2. Mr. K was transferred from a Medicare-certified bed to a noncertified bed on December 12, 2013 and plans to remain long term in the facility. Code the December 12, 2013 Discharge assessment as follows:

A0310F=10
A2000=12-12-2013
A2100=2

CMS revised portions of the instructions under “Assessment Management Requirements and Tips for Discharge Assessments” on pages 36 and 37:

• For a Discharge assessment, the ARD (Item A2300) is not set prospectively as with other assessments. The ARD (Item A2300) for a Discharge assessment is always equal the Discharge date (Item A2000) and may be coded on the assessment any time during the Discharge assessment completion period (i.e., discharge date (A2000) + 14 calendar days).
  
• The use of the dash “-” is appropriate when the staff are unable to determine the response to an item, including the interview items. In some cases, the facility may have already completed some items of the assessment and should record those responses or may be in the process of completing an assessment. The facility may combine the Discharge assessment with another assessment(s) when requirements for all assessments are met. 
  
• For unplanned discharges, the facility should complete the Discharge assessment to the best of its abilities.
  

Get Your EOT/COT OMRA Processes in Order

CMS added a bullet point under “End of Therapy (EOT) OMRA” on page 48 (Section 2.9):

• For purposes of determining when an EOT OMRA must be completed, a treatment day is defined exactly the same way as in Chapter 3, Section O, 15 minutes of therapy a day. If a resident receives less than 15 minutes of therapy in a day, it is not coded on the MDS and it cannot be considered a day of therapy.
  

The RAI manual also contains a revised bullet point under “PPS Scheduled Assessment and Change of Therapy OMRA” on page 58 (Section 2.10):

• The ARD must be set within the window for the scheduled assessment and on day 7 of the COT observation period. If both ARD requirements are not met, the assessment may not be combined.

On pages 75 and 76 (Section 2.13), CMS deleted the section “Resident Leaves the Facility and Returns During an Observation Period,” replacing it with the following paragraph:

If the beneficiary experiences a leave of absence during part of the assessment observation period, the facility may include services furnished during the beneficiary’s temporary absence (when permitted under MDS coding guidelines: see Chapter 3).

Bottom line: Understanding that these recent updates will affect when certain assessments are required is important, stresses Marilyn Mines, RN, BC, RAC-CT, MDS Alert consulting editor and senior manager of clinical services for FR&R Healthcare Consulting Inc. in Deerfield, Ill. “Be aware of your facility layout: know where the certified versus non-certified beds are located.”

“Also consider internal communication,” Mines advises. “Do you as the MDS Coordinator know when a resident elects or revokes hospice benefits? Who keeps track of how long the resident has been out of the facility, in particular as it relates to a discharge return anticipated?” Knowing the answers can keep you compliant with the recent manual updates.

Resources: To access the RAI Manual v1.12 replacement pages and change tables, go to www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Scroll down to the bottom of the web page and click on the links in the “Downloads” section.