MDS Alert

Revision clarifies when it's OK to code isolation for infection.

Wondering whether you can code isolation for a resident cohorted in a room with another resident? CMS addressed that issue and more in another round of MDS 3.0 RAI User's Manual revisions released on Sept. 13.

CMS clarified that a resident has to be in a separate room by himself in order to code isolation at O0100M. The instructions direct you to "code only when the resident requires strict isolation or quarantine alone in a separate room because of active infection (i.e., symptomatic and/ or have a positive test and are in the contagious stage) with a communicable disease, in an attempt to prevent spread of illness."

While the modification helped clarify how to code this item, which is a RUG-IV Extensive Services qualifier, it also triggered some objections in the nursing home industry.

"Some facilities have expressed concern that they cannot code cohorting of patients who have the same contagious disease" at O0100M, says Teresa Mota, RN, CALA,RAC-CT, senior program coordinator for Quality Partners of Rhode Island. Their reasoning? The Centers for Disease Control & Prevention recommends cohorting as "an effective way to mitigate the spread of infection," Mota says. But item O0100M "is only looking at isolation or quarantine, as this level of care requires more effort and is more costly to deliver," she observes.

Another concern: Others have pointed out that facilities use their single rooms not only for isolation but also to provide respite and hospice care, Mota relays. The concern there is that a facility may not have a private room available for a current resident who requires isolation beyond standard precautions. Cohorting would be an alternative in that case, Mota says, "but if no private room is available and there is no one to cohort the resident with," the facility will have to "utilize a double room and lose revenue for the second bed."

The good news: "CMS is considering these concerns and will monitor specific items as data are being submitted by facilities," Mota reports.

In Chapter 3, Section O, CMS clarified that "only the time a therapy aide spends on set-up preceding skilled therapy may be coded on the MDS (e.g., set up the treatment area for wound therapy) and should be coded under the appropriate mode for the skilled therapy (individual, concurrent, or group) in O0400. The therapy aide must be under direct supervision of the therapist or assistant (i.e., the therapist/assistant must in the facility and immediately available)."

Many in the industry had requested the clarification about the supervision required for therapy aides performing set-up, says Glenda Mack, MSPT, CWS, CLT, senior director of clinical operations for PeopleFirst Rehabilitation in Louisville, Ky.

Therapy aides, therapy assistants, or therapists can provide set-up, which the manual now defines as "the time required to adjust equipment or otherwise prepare the treatment area for skilled rehabilitation services..." Record set-up time "under the mode for which the resident receives initial treatment when he/she receives more than one mode of therapy per visit," states the revised manual.

CMS changed the coding tips for IV fluids (Chapter 3,page K-9), which now say that you can code IV fluids at K0500 if required to prevent dehydration "if the additional fluid intake is specifically needed for nutrition and hydration. Prevention of dehydration should be clinically indicated and supporting documentation should be provided in the medical record."

Section M (Skin Conditions)

On page M-9, the manual clarified coding instructions for M0300B where you enter the date of the oldest stage 2 pressure ulcer. The revision directs the facility to "make every effort to determine the actual date that the Stage 2 pressure ulcer was first identified whether or not it was acquired in the facility. If the facility is unable to determine the actual date that the Stage 2 pressure ulcer was first identified, (i.e., the date is unknown), enter a dash in every block."

With this round of revisions, CMS' Sheila Lambowitz acknowledged the pain associated with ongoing change. The message, she said in a Sept. 15 SNF/LTC Open Door Forum: "Hang in there." Lambowitz noted that CMS had a choice of holding off and giving SNFs "breathing room for six months to a year" or trying to release the changes early. "We thought you might as well go through the pain fast and get to a position where you feel comfortable you know what is going on," she said.