MDS Alert

Know when to complete an SCSA vs. an SCPA.

After reviewing prior assessments and records, you’ve discovered coding errors, and you need to correct them. What do you do?

Here are some illustrative scenarios, from a December 2013 educational session presented by the Oklahoma State Department of Health Quality Improvement and Evaluation Service (QIES) Help Desk staff:

How to Correct Erroneous Records

Scenario 1: You submit an MDS record and later you modify it. Then, you discover that the earlier record was correct after all. The later (active) version of the record is in error.

Answer 1: You can correct a modification only by the submission of an additional modification request.

Scenario 2: You completed a Discharge Assessment on a resident. Later, you discovered that you submitted the discharge on the wrong resident.

Answer 2: In A0050 — Type of Record, code “Inactivate existing record” (3).

When to Code A0050 = 2

Scenario 3: You discover that a valid MDS assessment contains many miscoded items for all the interview sections and the Activities of Daily Living (ADLs) items on the admission assessment that was transmitted and accepted in the database.

Answer 3: You must modify the assessment. First, retrieve the erroneous assessment and correct it based on software guidelines. Then, complete item A0050 as “Modify existing record” (2) and correct the items in error for Section X — Correction Request. Submit the record.

Keep in mind that you may also need to complete a Significant Correction to Prior Assessment (SCPA).

Scenario 4: When entering the assessment into the facility’s software, the Assessment Reference Date (ARD) was inadvertently entered as “10/02/2013,” instead of the intended “10/12/2013.” Then, the interdisciplinary team (IDT) completed the assessment based on the correct ARD of Oct. 12, 2013, making the seven-day look-back period Oct. 6 through Oct. 12.

Answer 4: This would be an acceptable use of the modification process to modify item A2300 — Assessment Reference Date to reflect Oct. 12, 2013.

When an OBRA Assessment Contains Errors

Scenario 5: You discover that a valid OBRA assessment contains inaccurate information. The assessment has been transmitted and accepted into the Assessment Submission and Processing (ASAP) database. No other assessment has been performed since the error occurred.

The IDT reviewed the resident’s record and determined that the prior assessment errors were significant errors. Upon further review, the IDT found significant changes also occurred with the resident’s condition since the last assessment.

Answer 5: Complete a Significant Change in Status Assessment (SCSA). If you identify a significant change in status during the process of completing any assessment except Admission and SCSAs, code and complete the assessment as a comprehensive SCSA instead.

Scenario 6: You discover that a valid OBRA assessment contains inaccurate information. The assessment has been transmitted and accepted into the ASAP database. No other assessment has been performed since this one. The IDT reviewed the resident’s record and determined that the assessment errors were not significant errors.

Answer 6: In this case, you would modify only. If the only errors in the OBRA comprehensive or quarterly assessment are minor errors, the only requirement is to correct the record and submit it to the QIES ASAP system.

What to Do for Multiple Errors

Scenario 7: You found three errors in a resident’s first assessment, where A0310A — Federal OBRA Reason for Assessment is “None of the above” (99) and A0310B — PPS Assessment is “5-day scheduled assessment” (01):

1. Incorrect Social Security Number (SSN);

2. Incorrect Gender; and

3. M0300C — Stage 3 Pressure Ulcers is coded as “0” when it should’ve been “2.”

No other assessment has been completed. The assessment is valid and was accepted by the ASAP.

Answer 7: You would modify only. If the assessment was for Medicare purposes only (A0310A = 99 and A0310B = 01 through 07) or for a discharge (A0310A = 99 and A0310F = 10 or 11), no SCSA or SCPA is required.

Scenario 8: You found three errors in a resident’s assessment where A0310A is “Admission assessment (required by day 14)” (1) and A0310B = 1:

1. Incorrect SSN;

2. Incorrect Gender; and

3. M0300C = 0 when it should’ve been 2.

The assessment is valid and was accepted by the ASAP database. No other assessment was completed since this error. The IDT determined this was a significant error but no significant change in the resident’s condition occurred.

Answer 8: Modify the record and complete an SCPA. Remember that a “significant error” is an error in an assessment where:

1. The resident’s overall clinical status is not accurately represented (i.e., miscoded) on the erroneous statement; and

2. The error has not been corrected via submission of a more recent assessment.

Best bet: When entering your assessment data, don’t fall into the trap of routinely overriding the software warning stating “a significant change assessment is required.” Keep in mind that this could mean you need to complete an SCSA to assist your resident in obtaining the highest practical level of well-being and care.