MDS Alert

Yes, you can code a dash but ... here's the rest of the story.

Putting a dash at W2b for "unable to determine" why a resident hasn't received his influenza vaccination may improve MDS accuracy when none of the coding options fits a particular scenario. But a dash won't exclude a resident from the influenza vaccination post-acute and chronic-care quality measures posted on the Nursing Home Compare Web site. So here's what you need to do to keep your QMs in line.

1. Know the coding low-down. A Q&A on the qtso.com Web site says the facility should code a dash for "unable to determine" if none of the reasons at W2b explains why the resident hasn't received the flu vaccine in the facility during the current flu season (Oct. 1 through March 31). The coding options at W2b are:

1. Not in facility during this year's flu season

2. Received outside of this nursing facility

3. Not eligible

4. Offered and declined

5. Not offered

6. Inability to obtain vaccine. (This item refers to declared shortages as defined by the RAI users manual. Thus, you wouldn't code it if the facility simply hadn't received its vaccine supply yet.)

W2b thus doesn't give the option for coding a scenario where the facility offered a resident the vaccination but didn't have the time or vaccine to give it before the ARD. In that case, the facility could code a "dash" instead of option "5," which says the staff didn't offer the vaccination. Putting a dash might also be appropriate on an admission assessment when the facility hasn't had a chance to determine if the resident received the flu shot at another site, notes Nathan Lake, RN, an MDS software developer in Seattle.

2. Nail down how the new influenza vaccination QM works.  MDS assessors fear coding "not offered" when the facility has offered the vaccine but doesn't have it by the ARD might "adversely affect" the vaccination QM score, says Rena Shephard, RN, MHA, RAC-C, FACDONA, president of RRS Healthcare Consulting in San Diego.

Yet the "QM is looking at the most recently completed influenza season," Shephard emphasizes. Thus, the QMs posted now on the Nursing Home Compare Web site include MDS information from last year's flu season, she points out.

Looking at the definition of the QM, "the numerator includes anyone who received the vaccination during the most recently completed flu season," Shephard says. That includes residents coded as having received the vaccine in the facility (W2a =1) or outside of the facility (W2b = 2) from Oct. 1 through March 31.

The denominator includes residents who had a valid MDS target record (assessment or discharge) in the "influenza vaccination reporting period" of Oct. 1 through June 30.

Know the exclusions: Residents are excluded if they satisfy any one of the following on the selected target assessment or target discharge:

• Resident wasn't in the nursing facility during the flu season (W2b = 1).

• He wasn't eligible for the vaccination (W2b = 3) due to contraindications (allergy to eggs or other vaccine component, a physician order not to immunize, or acute febrile illness, although "the resident should be vaccinated if the contraindications end," according to the RAI user's manual.

• The vaccine was offered but he declined it (W2b = 4).

• The facility wasn't able to obtain the vaccine (W2b = 6) due to a declared shortage.

The bottom line: Residents aren't excluded from the measure if there is a dash indicating inability to determine at the end of the flu season, Shephard emphasizes.

3. Take a proactive approach to boost the percentage of residents immunized during the flu season and coded as having received the vaccination. "As long as the facility administers the vaccine at some point during the flu season, the quality measure will reflect that the resident received it," says Shephard.

A lot of facilities are "incorporating questions into the admissions process" to determine "whether the person has received vaccinations and, if not, is eligible to receive them," Shephard notes.

Focus on the unvaccinated: Lake believes "the easiest way to keep track of the vaccination is to document if you have given it" -- or if the person has received it somewhere else. "Then focus on those people" who haven't been vaccinated, Lake suggests.

If the person declines the vaccination(s), document the information provided to the resident or his surrogate about the risks and benefits of declining the vaccine, advises Shephard.

Good question: Should the physician write an order not to immunize to support coding the resident isn't eligible for the vaccine?

Yes, says Shephard. "The medical record should reflect the medical contraindications to the use of the vaccine for the particular resident."

Editor's note: For an in-depth look at the pneumococcal vaccination quality measures, see the February 2007 MDS Alert.