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MDS Alert

RAI Compliance:

Don't Be Caught Off Guard by the April RAI Manual and MDS

Published on Thu Feb 23, 2012

Beware this condition in Section M.

Is your SNF on top of these April 1 MDS coding changes?

Judy Wilhide Brandt, RN, BA, RAC/MU-MT, notes that the revised Section M includes skin tears (M1040G) and moisture associated skin damage or MASD (M1040H). (See the April RAI manual descriptions and instructions on page 15 of this issue.)

"Moisture associated skin damage is taught as part of wound care classes," says Ron Orth, RN, RAC-MT, NHA, CPC, president of Clinical Reimbursement Solutions in Milwaukee, Wis. "And with our population in nursing facilities, it's a prevalent skin issue."

Watch out: "Skin excoriation (redness and soreness) from fecal and urine contamination could be mistaken for a Stage 1 pressure ulcer but is not due to a pressure problem," observes Peggy Dotson, RN, BS, principal of Healthcare Reimbursement Strategy Consulting in Yardley, Pa. And "if you categorize it as a pressure ulcer, you have to institute all kinds of pressure prevention and management," she says. "And you may be missing the real cause of the problem."

"Frequent changes of briefs and diligent skin care can cut down on MASD," says Brandt, of Judy Wilhide MDS Consulting in Virginia Beach, Va. "You can get actual harm under F309 if the MASD is avoidable," she warns.

Key: "If a wound isn't getting better with treatment, you need to get someone to the bedside who can make a diagnosis," advises Brandt. "You can have five different wounds on the bottoms of patients with incontinence that have five different causes and need different treatments to help them get better," she adds. "It's important to get help to delineate what's going on in 'the diaper area,' if you will, and I'm happy that the addition of MASD [to Section M] will call some attention to it."

Keep This Section K Change On the Radar Screen

"Coding in Section K for nutritional approaches will have two columns for whether the nutritional approaches were delivered 'while a resident' or 'while not a resident,'" says Orth. "This leads me to believe CMS may change the RUG system to coincide with that," he adds.

"Right now if you code IV fluids, those can be given in the hospital and it still qualifies toward the Special Care High RUG category," Orth says. And "regardless of how you code IV fluids [on the revised April MDS], it still goes toward your RUG category. You can also count tube feedings provided in the hospital," Orth adds. "But usually if someone received tube feedings in the hospital, they are getting them in the facility."

"IV fluids are Special Care High and that can make a huge impact depending on the level of therapy the resident is receiving, as the person might case mix index maximize into the Special Care High RUG category based on getting IV fluids outside the facility," Orth observes. "I don't know if CMS is going to change the RUG system, but it seems like the first step is to change to two-column coding and then change the RUGs..."

2 More Changes ...

"CMS put weight gain back in [the MDS] for clinical reasons," says Brandt. See the coding instructions for K0310 (weight gain) on page 15 and below.

"In Section N, CMS has gone back to asking for the number of days the patient received [medications] versus whether they received them or not," says Orth. (See page N-4 of the April RAI manual.) "Obviously [CMS] wants to collect data that people are receiving the meds. For the most part, diuretics are given daily as most people are probably on maintenance doses. Antibiotics and some of the other medications may or may not be given on a daily basis," Orth adds.

Get the Scoop on Section Q

The revised Section Q has "major changes in intent and content," says Marilyn Mines, RN, RAC-CT, BC, senior manager of clinical services for FR&R Healthcare Consulting Inc. in Deerfield, Ill.

Teresa Mota, BSN, RN, CALA, CPEHR, reports that a new item, Q0490, "allows for residents to decline answering the return to community item (Q0500B) as long as there is documentation in the medical record that supports the [resident's decision] not to be asked this question between comprehensive assessments." (See the revised Section Q on page 17 of this issue.) "If Q0490 is coded '0' (No), then the facility must proceed to the next item. If it is coded '1' (Yes), then as long as there is documentation in the medical record as described above, the assessment would continue with item Q0600, Referral," adds Mota, senior program coordinator for Healthcentric Advisors (formerly Quality Partners of Rhode Island) in Providence, R.I.

"Another new item, Q0550, allows providers to ask Q0500B on ALL assessments (not just comprehensive assessments)," Mota instructs. "Again, this request would have to be supported by the medical record (see Q0500A). Q0550B records the information source for the answer to Q0500A," she notes.

"Other skip patterns were adjusted, as well, so that the flow of items is more clear and concise," says Mota. "The new item and skip patterns were pilot tested by several providers and subsequently approved by CMS."

The updated manual, which includes numerous other changes, can be downloaded at www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage.

Brandt says that she "expected more RAI manual revisions because CMS is having training" in St. Louis, Mo., in March. "But hopefully it will be basic training that we all need all the time in addition to training on changes."

Good advice: "A lot of people use their software for MDS instructions where they click on a section and that can be helpful, but you need to read all of the chapters," says Brandt. "Using the software alone is very fragmented. Every day I introduce the manual to people who have been doing the MDS for a long time."

Editor's note: Watch for an MDS Alert article on unplanned discharge assessments after the March training.

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