MDS Alert

Use this list to make sure you're covering the bases in the update.

Check out the highlights of MDS coding instructions that nursing facilities must have in place on June 15.

G1hA (eating). Do not include assistance provided with eating/drinking during med pass.

G4A (functional limitation in range of motion). The focus should be on assessing the resident for functional limitations that impair
ADL functioning or place the resident at risk of injury.

J1c (dehydrated; output exceeds intake). Code this item if the resident has two or more of the following: (1) He usually takes in less than the recommended 1,500 ml of fluids daily; (2) the resident has one or more clinical signs of dehydration, including but not limited to the signs listed in the manual; and (3) resident's fluid loss exceeds intake. (CMS added the italic language to the directions.)

K5 (mechanically altered and therapeutic diets). Do not code enteral feedings as a mechanically altered diet. But do code them as a therapeutic diet, if they meet that definition (that is, a diet ordered to manage problematic health conditions).

M1 (ulcers). Code only pressure or circulatory-related ulcers in M1. Ditto for resolved ulcers in M3.

Where do you code a diabetic ulcer? To make that decision, "look at the wound's etiology to determine if it's pressure or circulatory related," advised Ellen Gay, a CMS health insurance specialist, in a presentation at the recent American Association of Nurse Assessment Coordinators conference in Chicago.

"The term 'diabetic ulcer' is not descriptive enough to determine the precise etiology," agrees Rena Shephard, RN, MHA, FACDONA, president of RRS Healthcare Consulting in San Diego. Thus, "the nurse, in consultation with the physician, should conduct a thorough assessment to determine the etiology of the ulcer in order to code it on the MDS appropriately and develop a treatment plan," she advises.

More key instructions: Don't code a debrided ulcer as a surgical wound. But "if a skin ulcer is repaired with a flap graft, code it as a surgical wound and not a skin ulcer. If the graft fails, continue to code it as a surgical wound until healed," states the revised RAI manual update.

Watch out: The June update removes the May version's directive to code in M1 the ulcer staged closest to the assessment reference date. That coding directive didn't jibe with existing MDS data specs. For example, coding an improvement in staging for an ulcer at M1 would not have matched the "highest" staging being reported in M2, notes Peter Arbuthnot, regulatory industry analyst with American HealthTech Inc. in Jackson, MS.

M5a and M5b. You can now code pressure-relieving, pressure-reducing and pressure-redistributing devices for the chair and bed. (Don't code egg-crate cushions and mattresses.)

P1b (respiratory therapy). A trained nurse may perform respiratory assessment and treatments when permitted by the state practice act. CMS added the phrase "... and the treatments when permitted by the state nurse practice act."

The problem: 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) per supervising helper or caregiver 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.

T1 (projecting days and therapy minutes). Project the days of therapy and minutes through day 15 (not day 14) although the physician order for therapy has to be within the first 14 days. (For more information about the June update's changes to K5a,
P1a and Section T1c, see p. 73.)

O4 (number of days the resident received antipsychotic, antianxiety, antidepressant, hypnotic or diuretic medication). The June update's revised appendix includes an updated list of these medications per classification.

Download the revised appendix at www.cms.hhs.gov/quality/mds20/2005Appendices.pdf. The update to chapters 1 and 3 is available at www.cms.hhs.gov/quality/mds20/2005Chap1And3.pdf.