MDS Alert

How your ADL coding will now impact your quality scores.

With almost no advance notice, the Centers for Medicare & Medicaid Services (CMS) added six new quality measures (QMs) for nursing facilities — and the public will be able to see your scores on these new QMs online starting in April. Here’s what you need to know about the new measures and how your MDS coding will impact your scores.

Get to Know 6 New QMs

On March 3, CMS released “Further Improvements to the Nursing Home Compare Five-Star Quality Rating System,” which effectively added six new QMs that will become publicly available on the Nursing Home Compare website in April 2016. The six new QMs are:

1. Percentage of short-stay residents who were successfully discharged to the community (claims-based);
2. Percentage of short-stay residents who have had an outpatient emergency department visit (claims-based);
3. Percentage of short-stay residents who were re-hospitalized after a nursing home admission (claims-based);
4. Percentage of short-stay residents who made improvements in function (MDS-based);
5. Percentage of long-stay residents whose ability to move independently worsened (MDS-based); and
6. Percentage of long-stay residents who received an antianxiety or hypnotic medication (MDS-based).

Beginning in July 2016, CMS will start using these measures in calculating the Five-Star Quality Rating, except for the antianxiety/hypnotic medication measure. CMS is excluding this measure “due to concerns about its specificity and appropriate thresholds for star ratings.”

Claims-Based Measures Still Rely on Some MDS Data

The three claims-based QMs will include only Medicare fee-for-service residents and will use Medicare claims for the quality data. Keep in mind, however, that CMS will use MDS data in building stays and for some risk-adjustment variables, and eventually encounter data may allow CMS to include Medicare Advantage beneficiaries.

Also, these claims-based QMs are all short-stay measures that include only those residents admitted to your nursing home following an inpatient hospitalization. These QMs are risk-adjusted, using items from claims, the enrollment database, and the MDS, according to CMS.

“Percentage of short-stay residents who were successfully discharged to the community” uses MDS assessments to identify community discharges and then claims data to determine whether the discharge was successful. This is an episode-based QM that measures whether the resident is successfully discharged within 100 days of admission.

Crucial: Accuracy is extremely important when completing the discharge return not anticipated (DCRNA) assessment, stresses Marilyn Mines, RN, BC, RAC-CT, MDS Alert Consulting Editor and Senior Manager at Marcum LLP in Deerfield, Ill.

According to the QM, a successful discharge is one for which the resident was not hospitalized, was not readmitted to a nursing home, and did not die in the 30 days following discharge.

“Percentage of short-stay residents who were re-hospitalized after a nursing home admission” is a “stay-based” measure that includes both residents who were previously in a nursing home and those who are new admissions. This QM tracks hospitalizations that occur after nursing home discharge but within 30 days of the stay start date, including observation hospital stays but excluding planned readmissions and hospice patients.

Likewise, the “percentage of short-stay residents who have had an outpatient emergency department visit” QM has a 30-day timeframe, and considers all outpatient ED visits except those that lead to an inpatient admission, which are instead captured by the re-hospitalization QM.

Pay Attention to Coding Implications of MDS-Based QMs

Of the three new MDS-based QMs that CMS is adding to Nursing Home Compare, the antianxiety/hypnotic medication measure is already on a facility CASPER QM Report, but the other two measures are entirely new and use items on the MDS not used previously to calculate QMs, according to a March 9 analysis for Leading Age by consultant Judy Wilhide-Brandt, RN, BA, CPC, RAC-MT, C-NE of Judy Wilhide Consulting Inc.

The antianxiety/hypnotic medication QM measures the percentage of long-stay residents who receive such medications and has no risk adjustment. This QM also excludes residents who are receiving hospice care or have a life expectancy of less than six months at the time of the target assessment.

Beware: That’s why it’s important to ensure supportive documentation and proper coding of Item J1400 — Prognosis, Mines notes.

“Percentage of short-stay residents who made improvements in function” measures the percentage of short-stay residents who made improvements in function during their complete episode of care. CMS will base this QM on self-performance (Column 1 — Self-Sufficiency) in three mid-loss Activities of Daily Living (ADLs):

1. G0110B — Transfer;
2. G0110D — Walk in corridor; and
3. G0110E — Locomotion on unit.

Included in the QM are short-stay residents with improved mid-loss ADL functioning from the five-day assessment to the discharge assessment. CMS will base the QM on the DCRNA, but, like the antianxiety/hypnotic medication QM, will exclude residents receiving hospice care or who have a life expectancy of less than six months.

What Will Trigger Functional Improvement Measure

What this means: Your coding in Column 1 for these three ADLs will be totaled on the PPS five-day and again on the DCRNA, Wilhide-Brandt explained. “If the total number is lower on the DCRNA, the resident will trigger the measure.”

Example: For a resident, you coded on the PPS five-day assessment in Column 1:

• G0110B = 3 — Extensive assistance
• G0110D = 8 — Activity did not occur (code 7 or 8 to 4 — Total dependence)
• G0110E = 3
• Total score = 10

Then, you coded the DCRNA as in Column 1 as:

• G0110B = 3
• G0110D = 2 — Limited assistance
• G0110E = 3
• Total score = 8

Significance: “This lower score on the DCRNA will be counted as an improvement in function,” Wilhide-Brandt noted.

Independent Movement QM Rates Single ADL

“Percentage of long-stay residents whose ability to move independently worsened” rates the percentage of long-stay residents who experienced a decline in their ability to move around their room and in adjacent corridors over time. The data for this QM is based your coding of Column 1 for only the MDS item G0110E — Locomotion on unit.

The QM includes the resident’s ability to move around independently, whether a resident’s typical mode of movement is by walking or by using a wheelchair. The risk adjustment is based on ADLs from the prior assessment, and CMS measures a decline by an increase of one or more points between the target assessment and the prior assessment.

Translation: “If the self-performance number on the target is higher than the prior, the assessment will trigger the QM,” Wilhide-Brandt explained. Also, keep in mind that the lookback for all items in G0110 is seven days or since the last admission/reentry.

And remember that both the ADLs “walk in corridor” and “locomotion on unit” are location dependent,” Wilhide-Brandt noted. “Communities that actively encourage self-sufficiency when walking or wheeling in these locations are likely to fare better in showing improvement or lack of decline.”

Key: Your coding of Section G and the tracking of ADLs by CNAs regarding G0110 is critical, because so much of the data for calculating the functional improvement and independent movement QMs stem from these, Mines stresses.

Bottom line: While you’re waiting for CMS to publish the technical specifications so you can know exactly what the exclusions and covariates will be, you should begin now to improve accuracy when coding ADLs that are new to the QM process, Wilhide-Brandt advised. For more information on the new QMs, go to www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Downloads/Improvements-NHC-April-2016.pdf.