MDS Alert

UTI proved to be a surprise.

CMS went on a roll this spring in posting revised MDS 3.0 RAI manual chapters, including chapter 3, which provides the directions for completing the MDS.

"The May/June versions of the RAI [manual] are what everyone has to accept as the best it gets until after implementation," says Peter Arbuthnot, regulatory analyst for American HealthTech in Jackson, Miss. "Obviously, we can look forward to more updates after implementation."

Most of the changes are relatively minor, but UTI didn't fit that bill. The updated UTI coding instructions differ from what CMS discussed as being the change in the MDS 3.0 training for states and providers, observes Rena S hephard, MHA, RN, RAC-MT, C-NE, founding chair and executive editor of the American Association of Nurse Assessment Coordinators and president and CEO of RRS Healthcare Consulting Services in San Diego. "Now the instructions for coding UTI are what they are for the MDS 2.0 except the resident also has to have had a medication or treatment[for UTI] within the last 30 days," says Shephard.

"Thus, the definition for coding UTI is a UTI diagnosis in the last 30 days, symptoms of UTI during the  ookback period, significant laboratoryfindings ... and a medication or treatment in the lookback period," she adds (see the sidebar on coding UTI below for the verbatim instructions).

Also in S ection I : The updated manual extends the time for the physician or physician extender to write or renew the diagnosis to a 60-day lookback, according to Joan Brundick, BSN , RN, the state RAI coordinator for Missouri. The previous manual version allowed only 30 days.

The instructions now read: "The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days."

Check O ut A dditional Changes in Sections C, D, E, and Z Section C: Clarification about doing the BIMS in writing. While the RAI manual previously said you could do the Brief Interview for Mental Status (BIMS) in writing, the updated version "makes it very clear" that you can only do so when writingis the resident's primary method of communication, says Elisa Bovee, OTR/L, director of education and training for Harmony Healthcare International in Topsfield, Mass.

Section D: More flexibility for when to do the mood interview. The manual clarifies that the mood interview should preferably be done on the day of or before the ARD, says Bovee. That word "preferably" gives facilities a little more flexibility, she points out. Other changes, says Marty Pachciarz, RN, managing director of clinical services for the Polaris Group in Beaverton, Ore., include:

Section E: A new psychosis example. "A resident carries a doll which she believes is her baby and the resident appears upset. When asked about this, she reports she is distressed from hearing her baby crying and thinks she's hungry and wants to get her a bottle."

Answer: "E0100A would be checked and E0100B would be checked. Rationale: The resident believes the doll is a baby, which is a delusion and she hears the doll crying which is an auditory hallucination," states the manual.

Section Z: Coding tips for section signatures. "Two or more staff members can complete items within the same section of the MDS," the manual states. "When filling in the information for Z0400, any staff member who has completed a subset of item within a section should identify which item(s) he/she completed within that section."

CMS rewrote the instructions for the "rule of 3" in coding self-performance for activities of daily living. But the rewrite didn't constitute a change, in Pachciarz's view. (For the updated ADL algorithm and manual verbiage, see page 82.)

Editor's note: The above changes are only a sampling of those in the updated RAI manual. See the next MDS Alert for changes to therapy coding in Section O.