MDS Alert

What the manual tells you to do when Rule of 3 fails to provide answer.

The recent clarifications of the “Rule of 3” have probably helped you to better grasp how and when to apply the various steps. But don’t feel bad if you’re still struggling with the complicated process, because you’re certainly not alone. Let a few scenarios help shine a light.

Background: In the latest significant updates of the Resident Assessment Instrument (RAI) manual, which were effective on Oct. 1, the Centers for Medicare & Medicaid Services (CMS) made a valiant effort in clarifying the notoriously confusing “Rule of 3” used in Item G0110 — Activities of Daily Living (ADL) Assistance (see MDS Alert Vol. 11, No. 10, page 109: “How The ‘Rule of 3’ Is Changing — Again”).

And thankfully, the revised manual offers up a plethora of helpful scenarios and examples that can give you the understanding you need to correctly code ADLs more easily.

Get the First Rule of 3 Down Pat

Step 1 on the Rule of 3 reads: “When an activity occurs three or more times at any one level, code that level.”

Example 1: During the seven-day look-back period, Mr. Smith required assistance while dressing six times. Twice, Mr. Smith required guided maneuvering of his arms to put on his shirt (non-weight-bearing assistance). Four times, Mr. Smith required the staff to assist him to put on his shirt due to shoulder pain. During these four instances, the staff had to physically assist Mr. Smith by lifting each of his arms (weight-bearing assistance).

How to code: The appropriate code to enter on the MDS for G0110G — Dressing is Extensive Assistance (3).

Why? Although Mr. Smith required only limited (non-weight-bearing) assistance twice during the seven-day look-back period, the four times that the staff had to lift his arms are considered weight-bearing assistance, the manual states. Not only was the weight-bearing assistance the highest level of dependence, but it also occurred three or more times at that level during the look-back period. This “is consistent with the ADL Self-Performance coding level definition of Extensive Assistance and meets the first Rule of 3.”

Understand the Second Rule of 3

Number 2 for the Rule of 3 reads: “When an activity occurs three or more times at multiple levels, code the most dependent level that occurred three or more times.”

Example 2: During the seven-day look-back period, Mrs. Jones required verbal cueing for hand placement while performing stand-pivot transfers to her wheelchair. This occurred four times. Three times, Mrs. Jones required weight-bearing assistance to help her rise from the wheelchair, steady her and help her turn with her back to the edge of the bed. In the 14 other instances during the seven-day look-back period, Mrs. Jones was able to complete this activity without assistance.

How to code: The appropriate code to enter for G0110B — Transfer is Extensive Assistance (3).

Why? The four times that Mrs. Jones required verbal cueing are considered Supervision, while the three times that involved weight-bearing assistance would be Extensive Assistance. “The first Rule of 3 does not apply because the ADL activity occurred three or more times at multiple levels, not three or more times at any one level,” the manual explains. Therefore, this scenario meets the second Rule of 3, so you must “apply the most dependent level that occurred three or more times.”

Although out of the 21 times the ADL activity occurred during the look-back period Mrs. Jones required no assistance on 14 occasions, she did require assistance on seven occasions. This scenario indeed meets the definition of Extensive Assistance, because “the activity occurred at least three times and there was weight-bearing support provided three times.”

Scenario Teaches You the Third Rule of 3

The third Rule of 3 reads: “When an activity occurs three or more times and at multiple levels, but not three times at any one level, apply the following:

• “a. Convert episodes of full staff performance to weight-bearing assistance when applying the third Rule of 3, as long as the full staff performance episodes did not occur every time the ADL was performed in the 7-day look-back period. It is only when every episode is full staff performance that Total Dependence (4) can be coded. Remember that weight-bearing episodes that occur three or more times or full staff performance that is provided three or more times during part but not all of the last 7 days are included in the ADL Self-Performance coding level definition for Extensive Assistance (3).
• “b. When there is a combination of full staff performance and weight-bearing assistance that total three or more times — code Limited Assistance (2).

“c. When there is a combination of full staff performance/weight-bearing assistance and/or non-weight-bearing assistance that total three or more times — code Limited Assistance (2).”

Example 3: Mrs. Brown was in your nursing home for only one day before transferring to another facility. Twice, Mrs. Brown required staff assistance to help her lift her fork to her mouth while eating. Once, the staff had to feed Mrs. Brown because she couldn’t scoop the food on her plate with her fork, nor could she lift the fork to her mouth. These three instances were the only occasions when Mrs. Brown ate during her one-day stay.

How to code: The appropriate code for G0110H — Eating would be Extensive Assistance (3).

Why? The two times that staff had to help Mrs. Brown lift her fork would be considered weight-bearing assistance, while the one time that staff had to feed her would be “full staff performance.” “The first Rule of 3 does not apply because even though the ADL assistance occurred three or more times, it did not occur three times at any one level,” the manual says. “The second Rule of 3 does not apply because even though the ADL assistance occurred three or more times, it did not occur three or more times at multiple levels.”

So for this scenario, the third Rule of 3 would apply because the ADL assistance occurred three or more times at multiple levels but not three times at any one level, the manual explains. To determine the correct code, you would rely on sub-item “a” under the third Rule of 3, which instructs you to convert episodes of full staff performance to weight-bearing assistance as long as the full staff performance episodes did not occur every time the resident performed the ADL in the seven-day look-back period.

Essentially, you would add the one episode of full staff performance to the two episodes of weight-bearing assistance, giving you a total of three episodes of weight-bearing assistance to code as Extensive Assistance.

Heed Another Third-Rule Lesson

Example 4: On the second day following Mr. Long’s nursing home admission, he was sent to the hospital. During the look-back period, Mr. Long was able to undress, put his bed clothes on and get into bed without assistance one time. Once, staff had to provide weight-bearing assistance to help lift Mr. Long’s right arm into his shirt sleeves when dressing in the morning, and another time staff provided non-weight-bearing assistance to help him button his shirt. And one time Mr. Long required full staff performance to put his pants on.

How to code: The appropriate code for G0110G — Dressing is Limited Assistance (2).

Why? Like the previous example, the third Rule of 3 would apply because the activity occurred three or more times at multiple levels, but not three times at any one level, the manual states. Sub-item “a” would not apply because if you convert the single episode of full staff performance to weight-bearing assistance, you would end up with a total of only two weight-bearing episodes and one non-weight-bearing episode. And sub-item “b,” which involves a combination of full staff performance and weight-bearing assistance totaling three or more times, would not work because you do not have enough weight-bearing episodes to consider it Extensive Assistance.

So you would turn to sub-item “c” in the third Rule of 3, because you have a combination of full staff performance/weight-bearing assistance and non-weight-bearing assistance that together total three times, the manual instructs. Relying on sub-item “c,” you would code Limited Assistance.

What to Do When Rule of 3 Provides No Answer

Example 5: Out of 20 times during the look-back period, Mr. North was able to toilet independently 18 times. Twice, he required staff assistance to pull the zipper up on his pants (non-weight-bearing assistance).

How to code: The appropriate code for G0100I — Toilet Use is Supervision (1).

Why? Examining each Rule of 3 step, you would find that this scenario does not meet the criteria for any of them, because Mr. North required assistance only twice during the seven-day look-back period. Even though the ADL occurred three or more times, it did not occur three times at multiple levels or three times at any one level. Also, none of the codes would apply.

For instance, coding Independent (0) would be inaccurate because Mr. North would have had to complete the ADL without any help or oversight from staff every time, the manual says. And Limited Assistance (2) would not apply because even though the assistance was non-weight-bearing, staff provided it only twice. Activity Occurred Only Once or Twice (7) would not apply, because although staff provided assistance only two times, the activity itself actually occurred 20 times.

Therefore, you would find your answer in the final instruction for the Rule of 3 in the manual, which reads: “If none of the above are met, code supervision.”

Resource: To access the revised RAI manual, go to www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html. Scroll to the bottom of the Web page and click on the links in the Downloads section.