MDS Alert

4 strategies keep eating scores from dinging the RUGs.

To boost paltry RUG scores, home in on coding residents' eating at G1h, which is one of the most undercoded ADLs.

These key strategies will keep your eating scores on the mark so your facility receives fair reimbursement for this time-consuming care task.

Strategy No. 1: Develop systems to ensure the MDS team always captures IV fluids at K5a, which automatically gives the resident a total ADL score of 3 for eating. In fact, the resident who received IV fluids within the seven-day lookback gets the score of 3 even if you coded him as "supervised or independent" in eating in Section G, adds Jan Zacny, RN, a consultant with BKD Southern Missouri.

Yet "people often overlook the ADL impact of failing to capture IV fluids at K5a," observes Diane Brown, CEO of Brown LTC Consultants in Peabody, MA.

Tube feedings also give you an ADL score of 3, if the person meets the [RAI manual's] caloric and fluid requirements" for coding the tube feeding, adds Zacny

Strategy No. 2: Capture limited and extensive assistance if staff provides them during the lookback. If the staff "peg" a resident as someone who is fairly independent in eating, they may overlook instances of ADL assistance that could result in at least limited assistance instead of a "1" for supervision.

Remember: If the CNAs use their hand to guide the person's hand with utensils to his mouth (without using their own muscles to bear the weight of the resident's hand) three or more times in the seven-day lookback, that counts as limited assistance. And that will give you an eating ADL index score of "2"

If the CNAs actually bear the weight of the person's hand with the utensil in guiding it to the person's mouth or lifting it initially to get the person started, count that as one instance of extensive assistance, advises Bet Ellis, RN, a consultant with LarsonAllen in Charlotte, NC. "If the CNAs provide three or more instances of weight-bearing assistance in helping the person to eat, then the MDS nurse would code a 3 for extensive assistance."

Know when to code head support: You can't count support provided to assist the person in eating or drinking during med pass, says Ellis. But if you lifted the resident's head with your hand to help him reach a straw or drink during a meal, count that as weight-bearing support, she says.

Look for this key clue that you're undercoding: Zacny has seen instances where the family comes in and spoon-feeds a resident, which is documented in the medical record. "Usually, if the family is spoon feeding the resident, he isn't eating well without that help -- and staff are usually providing it a few times in the lookback," she says.

"But they don't document it and the MDS will say the person is independent or requires supervision."

Good question: Can you code ADL assistance provided by the family during the lookback if it's documented in the medical record? "Yes, you should," says Rena Shephard, RN, MHA, FACDONA, RAC-C, president of RRS Healthcare Consulting in San Diego.

Strategy No. 3: Count ADL assistance with eating provided in the dining room. CNAs and nursing staff may assume residents who eat meals in the dining room are more independent than they actually are, cautions Sheryl Rosenfield, RN, a consultant with Zimmet Healthcare Group in Morganville, NJ.

While you can't code general supervision in the dining room, if staff provided "any cueing or hands-on assistance" for a particular resident, use that to determine coding at G1h, advises Marilyn Mines, RN, BC, RAC-C, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL.

Real-world tip: To code eating accurately, MDS coordinator Diane Maberry actually goes to the dining room and watches how residents feed themselves during the seven-day lookback period.

If Maberry isn't sure in a particular instance, she asks the CNAs how much help they provided. Sometimes staff helps the person get started but has to completely feed the person once he gets too tired to continue, Maberry notes. If the staff provides such assistance three or more times in the lookback, the MDS team codes a "3" (extensive assistance) for self-performance. If staff completely feeds the person every meal during the lookback, the facility codes that as a "4," says Maberry, with Windsor Place in Daingerfield, TX.

Remember: A code of "4" for total dependence means the resident didn't participate in any part of the ADL for the entire lookback period.

Strategy No. 4: Make sure the support score coded in column B is accurate and jibes with the self-performance score. While the RUG grouper only looks at self-performance in calculating the ADL index for eating, "accurate coding in the support area is no less important," says Mines.

"Several federal programs are auditing MDS information for accuracy and reimbursement," Mines points out.

"In addition, some of the case-mix states do look at support provided in addition to self-performance in their Medicaid calculations."

Look for inconsistencies: These would include a self-performance score of 2, 3 or 4 and a support score of 0 or 1, advises Mines.

You wouldn't expect to see a support score of 3 for a two-person assist in coding support provided for eating, Mines adds.