MDS Alert

CMS official explains rationale for coding stance on POA pressure ulcers.

A resident with a pressure ulcer present on admission goes back to the hospital and returns with his pressure ulcer unchanged. Would you code the decubitus as POA on the readmission assessment?

Not according to the RAI User's Manual, although the instructions have "generated questions from clinicians," says Jennifer Pettis, RN, WCC, RAC-MT, a consultant with Harmony Healthcare International in Topsfield, Mass.

The manual states: "If a resident who has a pressure ulcer is hospitalized and returns with that pressure ulcer at the same stage, the pressure ulcer should not be coded as 'present on admission' because it was present at the facility prior to the hospitalization."

Explaining the reasoning behind the manual instructions, CMS' Thomas Dudley noted in a Nov. 9 webinar on RUG-IV and MDS 3.0 that CMS is looking to trend the pressure ulcer data over time rather than just looking at a single assessment.

CMS will be able to track across different MDS assessment and will know which pressure ulcers "were truly present on admission" when a resident first enters the nursing facility or transfers from the hospital, etc., versus pressure ulcers that actually occurred in the nursing home, Dudley explained. He also noted that CMS "is looking at what happens not only in the nursing home but [also] ... in the hospital and other care settings" (see "Find Out How Nursing Homes and Hospitals Are Collaborating to Combat Pressure Ulcers" on page 141 of this issue).

During the webinar, CMS staffers reminded participants of the coding instructions for isolation or quarantine for active infectious disease at O0100M:

"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. Do not code this item if the resident only has a history of infectious disease (e.g., MRSA or C-Diff with no active symptoms), but facility policy requires cohorting of similar infectious disease conditions.

Do not code this item if the 'isolation' primarily consists of body/fluid precautions, because these types of precautions apply to everyone."

A caller asked if facilities are still allowed to cohort patients with like infections (such as C. difficile), which the Centers for Disease Control & Prevention guidelines allow you to do.

A CMS staffer's answer: "You can cohort but if you cohort you can't code it on their assessments as isolation."

Here's an instruction that no doubt sounds familiar from the MDS 2.0 days. You code a medication in Section N0400 based on its pharmacological classification. "Do not code 'off label' use of medications," Dudley stressed.

Quoting from the RAI User's Manual, Dudley noted, for example, that "oxazepam may be used as a hypnotic, but it is classified as an antianxiety medication. It would be coded as an antianxiety medication."

In discussing the start of therapy OMRA, CMS' Ellen Berry reminded people listening to the webinar that the therapy evaluation counts as the first therapy day. "If the evaluation requires two days to be completed, it's the first day you started the evaluation," she said.

A caller asked if what counts as the therapy start date differs when you do a short-stay assessment. The answer is that the therapy start date date is the date of the therapy evaluation on any assessment.

"The MDS 3.0 captures the therapy start date," which is the day of the evaluation but the evaluation minutes don't count toward the RUG classification, which has always been the case, says Glenda Mack, MSPT, CWS, CLT, senior director of Clinical Operations for PeopleFirst Rehabilitation in Louisville, Ky. "It is common, however, for the therapist to provide some therapy treatment along with the evaluation, but not always," Mack adds.

Editor's note: For a comprehensive look at the start of therapy OMRA, see the next MDS Alert.