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RAI Compliance:

Master Latest Wave Of MDS Coding Changes For May 1 Implementation

Published on Thu Apr 14, 2005

Update affects ADLs, therapy, restorative, wound coding and more.

If you feel as if you're already running in place to keep pace with RAI manual changes, the Centers for Medicare & Medicaid Services recently turned up the treadmill.

The May 2005 RAI manual update contains 55 pages of changes.

The good news: CMS gave facilities more than a month's head start to digest the menu of revisions, which the agency posted on its Web site on March 28 with an effective date of May 1. Previous manual updates went into effect immediately.

Why CMS' change in modus operandi? "The agency heard 'you guys' about the challenges of having to implement changes a day after they are posted," said CMS' Ellen Gay, in addressing MDS nurses and other attendees at the March 2005 American Association of Nurse Assessment Coordinators annual conference in Chicago. Gay highlighted the changes:

Section G (physical functioning and structural problems):

  •  ADL self-performance for eating. Do not include eating and drinking during med pass.

  •  Coding "independent" in G1A (self-performance). Code "0" for independent when the activity occurred fewer than three times in the lookback period, regardless of the level of self-performance. If the person did the activity one or two times, don't code an "8"' (for activity didn't occur during the entire seven-day lookback) because it did occur, said Gay. 
     
  •  G4A: Functional Limitation in Range of Motion. The clarification instructs facilities coding G4A to focus on functional limitations (particularly in ability to perform ADLs).

    The update clarifies that coding G4A is a two-step process:

    1. Is there a limitation in active or active-assisted range of motion? If no, code "0." If yes, proceed to the next question.

    2. Does the limitation interfere with function or place the resident at risk of injury? If yes, code "1" (limitation on one side) or "2" (limitation on both sides).

    When there's no muscle activity at all (the resident can't assist with range of motion at all), use the no-information code, Gay advised conference participants. 

    The clarification will help providers stay focused on the intent of G4A. "A resident could have an elbow contracture and not be able to straighten his arm but still be able to feed himself and perform other ADLs," comments Marilyn Mines, RN, BC, director of clinical services for FR&R Healthcare Consulting Inc. in Deerfield, IL.
     
    Care plan tip: While G4A focuses on functional limitation, "for care planning and rehabilitation purposes, you would want to look at a structural problem (e.g., a contracture) because the resident may need restorative nursing or rehabilitative therapy to ensure the contracture" doesn't get worse or impair functional status, Gay explained.

    Coding tip: Don't code in G4 how the resident functions with a prosthesis, Gay advises. "You can, however, code that in G1."

    Section K (oral/nutritional):

  •  K5a (parenteral/IV). Code fluid at K5a only when you're providing it for nutrition or hydration. "Do not include fluids used to reconstitute IV meds unless they're for nutritive purposes," cautioned Gay. (You would, however, count the fluids as part of intake and output records, say nursing experts.)

  •  K5c (mechanically altered diet). Do not include enteral feeding formulas in coding this item.

  •  K5e (therapeutic diet). Code enteral feeding formulas here only when they meet the   definition of a therapeutic  diet (one used to manage a problematic health condition).

    Section P (special treatments and procedures):
  •  P1b (respiratory therapy). A trained nurse may perform the respiratory assessment and the treatments coded in P1bd when permitted by the state nurse practice act (CMS added the phrase "... and the treatments when permitted by the state nurse practice act"). 

    Most state nurse practice acts are fairly generic and don't specifically address provision of RT services, says Cheryl West, director of government affairs for the American Association for Respiratory Care. And that puts the ball in the facility's court, to some extent, for determining appropriate training and credentialing for nurses to provide various RT services, caution risk management experts.

  •  P3 (restorative nursing). The RAI manual update clarifies that facilities cannot have more than four residents in any kind of group (not just exercise groups) if they want to count the activity as restorative nursing in P3.

  •  P3b (range-of-motion - active). This item includes active and active-assisted range of motion. "To code ROM as passive, it must be truly passive," Gay told AANAC attendees. 

    Section T (therapy supplement for Medicare PPS):

  •   T1c and d (estimate of num- ber of days/minutes of therapy). Base the estimate of therapy on the first 15 days of the resident's stay. The physician order for therapy (coded at T1b) has to be within the first 14 days.

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