MDS Alert

Is your facility using these often-overlooked approaches?

Having inaccurately coded MDSs is like relying on a misleading map that will lead you down a path of F tags and compliance problems.

Solution: This three-pronged approach will help ensure each MDS complies with the RAI user's manual coding requirements and reflects a consistent picture of the resident and his care.

Strategy No. 1: Always code the MDS based on the RAI manual instructions rather than the MDS form verbiage. The RAI manual has been updated numerous times over the years, whereas the MDS form itself has not.

Examples: Section M1 on the MDS form still says to code ulcers regardless of cause. Yet that instruction hasn't been accurate for a long time, advises Rena Shephard, RN, RAC-MT, MHA, president of RRS Healthcare Consulting in San Diego, and founding chair and executive editor for the American Association of Nurse Assessment Coordinators. Instead, "code at M1 pressure ulcers and ulcers caused by a circulatory problem (ischemic and venous)," she says.

Another discrepancy is with G1g (dressing): The MDS form only includes street clothes while the RAI manual has been updated to include all items of clothing, including pajamas and housedresses, Shephard notes.

Item J1c can also mislead you if you rely on the MDS form alone to code it, Shephard points out. J1c on the MDS just says, "dehydrated; output exceeds input." But the RAI manual instructions for that item actually include three indicators, and you code J1c if a resident has two of them (see p. 3-138 of the RAI user's manual).

Strategy No. 2: Make sure you're using the latest RAI manual, and seek help from the state RAI coordinator when needed. The Centers for Medicare & Medicaid Services updates the RAI user's manual from time to time, so make sure your facility is using the latest version, advises Clara Boland, RN, PhD. Boland is part of the team that works with nursing facilities on MDS-related issues as part of the Quality Improvement Project for Missouri.

In fact, CMS just updated chapter 3 of the RAI manual effective January 2008 (see p. 36 of this issue). To download the latest version, go to http://www.cms.hhs.gov/NursingHomeQualityInits/20_NHQIMDS20.asp#TopOfPage.

More advice from the front lines: Don't give ambiguous RAI manual instructions your own spin. The RAI manual is difficult to interpret in places, Boland says. "In those instances, code for exactly what the manual says, not what you think it says. And if you're still not sure [how to code], then go to your state RAI coordinator."

Strategy No. 3: Identify and address inconsistencies on the MDS before submitting the assessment to the state repository. Some facilities have software that can do this. But performing some quick manual checks to see if things add up can also identify instances where you didn't take credit for care or discrepancies between items.

Examples: See if you coded diabetes in Section I but no protective foot care in Section M, suggested Christie Teigland, PhD, in a presentation on the MDS at the March 2007 American Medical Directors Association annual meeting. If you coded a pressure ulcer, did you code dietary supplements and a turning and repositioning program? If you flag and address inconsistent items on your MDS before you submit that data to the state, you are going to save yourself a lot of headaches and have better care plans, Teigland said.

Surveyors may catch this discrepancy: Consultant Susan LaBelle, RN, MSN, with LTCQ Inc. in Lexington, MA, says her company sometimes finds instances where the facility documents that a resident is participating in the care plan. Yet he's coded in Section C as someone who lacks the ability to communicate with others.

Create a safety net: Sun- Bridge Pine Lodge Care and Rehabilitation uses MDS software that has a "consistency check." The facility also submits completed MDSs to a company with a computerized program that further checks for consistency among items, reports Rose Mary Mihaliak, RN, clinical case manager for the facility in Beckley, WV.