MDS Alert

Here's how to stay in the cash flow with your coding at P1ac.

If you don't code a resident's IV medication on the MDS, you're throwing money out the assess-ment window.

Lots of money: Consultant Ron Orth, RN, discovered that one facility had lost $7,000 in the first three weeks under the new RUG-53 system. And the losses most often stemmed from "failure to obtain hospital records to identify IV medications--and not capturing the medications on the 5-day and 14-day MDS assessment," says Orth, president of Clinical Reimbursement Solutions in Milwaukee.

Remember: An IV med will put a resident who qualifies for a rehab RUG into one of the new higher paying rehab plus extensive services RUGs if he has an ADL score of at least seven. You can code even a single dose of IV medication if a resident received it within the 14-day lookback at P1ac. "IV medications can be coded anytime and anywhere" the resident received them during the lookback as long as they are not excluded, says Marilyn Mines, RN, BC, RAC-C, director of clinical services for FR&R Healthcare Consulting in Deerfield, IL (see "Brush Up On The RAI Manual Rules For Excluding IV Medications," included later in this issue).

The problem: Your best bet for validating IV meds is a medication administration record (MAR) from the acute-care stay. But "one of the biggest barriers to capturing IV meds or therapy is inability to get records from the acute-care setting," says Nancy Augustine, MSN, RN, a consultant with LTCQ Inc. in Lexington, MA.

Know When to Look for That Acute-Care IV

When you don't have the MAR or other documentation showing a resident received an IV med, ferret out IV medications using these four key strategies:

1. Look for telltale signs that a resident had an IV when you  do a skin assessment at admission. When a resident is admitted with Band-Aids and bruises, look to see when he had IVs--and when the IV was pulled, suggested Sheryl Rosenfield, RN, in a presentation on the MDS at the most recent American Association of Homes & Services for the Aging annual meeting in San Antonio.

2. Look for "red flag" diagnoses and health conditions on the 5-day or 14-day MDS that typically indicate someone may have received IV medications, suggests Augustine. These include pneumonia or certain infections, such as antibiotic-resistant ones, septicemia or wound infections, says Augustine. "Also look for dehydration with fever and/or vomiting," she advises.

In addition, residents may have received IVs or IV meds if they have diagnoses of COPD, myocardial infarction, a cardiac or respiratory arrest, drug toxicity or overdose, adds Mines. "A resident documented as having been comatose or non-responsive in the hospital may have received an IV and IV medication," she adds.

Tip: If you suspect that the resident had an IV med, scour any medical records for confirmation. For example, "the progress notes say the physician plans to start an IV antibiotic," says Orth. In such a case, follow-up with the nurses or other staff in the hospital to see if the resident did receive the IV med mentioned in the notes.

3. Check with the emergency department for residents who entered the hospital through the ED or received ED care during the SNF stay. "A lot of times a Medicare beneficiary will go to the emergency department before hospital admission," observes Orth. "And if the person has congestive heart failure, as an example, he may have received a single IV dose of a diuretic [in the ED] prior to hospital admission. Then the diuretic is given orally in the hospital."

4. Develop standardized systems to get the hospital information you need. Some facilities have access to electronic records--or they send a nurse to the hospital to see the resident before admission and copy records. But simpler solutions can also work.

For example, Loch Haven Nursing Home "has developed a check list" to fax to hospitals requesting certain parts of the resident's hospital medical record, including the history and physical, discharge summary and MAR, says B.J. Roberts, RN, an MDS nurse for the facility in Macon, MO. If the resident had an extended stay, the MDS staff may ask the hospital for records from the beginning and end of the stay--"and then progress notes and MARs where the resident had a change in condition, such as different medications," says Roberts.