MDS Alert

Remember to use sub-items when applying the third rule.

Applying the Rule of 3 to code item G0110 — Activities of Daily Living (ADL) Assistance is usually no picnic. But you can get a better grasp on those tricky rules if you learn by example.

MDS experts provided such examples in an instructional video published by the Centers for Medicare & Medicaid Services (CMS) on March 20 (www.youtube.com/watch?v=t-6e5NV4j6k&feature=youtu.be). These scenarios walk you through each Rule of 3, step-by-step:

Look for This to Code Under First Rule

The first rule states that the ADL must occur three times at any one level, explained Mary Pratt, RN, MSN, with the CMS Center for Clinical Standards and Quality, in the provider update video. “This means that if you have an ADL that has occurred at least three times and at any one level, that is the level that is coded, regardless of whether there are other levels that have occurred less than three times.”

Scenario #1: Mr. X received the following dressing assistance during the look-back period. Twice, Mr. X required guided maneuvering of his arms to put on his shirt. Four times he had pain in his shoulders and required the staff to assist him with his shirt by physically lifting each of his arms. This ADL occurred a total of six times.

How to code: In this scenario, the resident required non-weight-bearing assistance twice, and then required weight-bearing assistance four times. So the ADL component occurred three or more times at one level, weight-bearing, Pratt noted.

Therefore, the appropriate code to enter on the MDS is Extensive assistance (3), Pratt instructed. “Since the first Rule of 3 was met by the four episodes of weight-bearing assistance, the two episodes of non-weight-bearing assistance are not considered.”

Use Second Rule to Code Multiple ADL Levels

“In contrast to the first Rule of 3, the second Rule of 3 refers to when there are multiple levels where the activity occurred three times or more, not just one level,” Pratt explained.

Scenario #2: During the last seven days, Mrs. C required verbal cueing four times for hand placement during stand-pivot transfers from her wheelchair. She required weight-bearing assistance three times to help her rise from the wheelchair, steady, and help her turn with her back to the edge of the bed. After she was at the edge of the bed and placed her hand on the transfer bar, she was able to sit. She completed this transfer without assistance in 14 other occurrences during the look-back period.

How to code: In this scenario, there are four episodes of supervision, which involved verbal cueing. And then there are three episodes of weight-bearing assistance in which the staff had to physically support the resident during part of the transfer. So you would code Extensive assistance (3) on the MDS, Pratt answered.

Why? The ADL occurred a total of 21 times during the seven-day look-back period. The resident performed the ADL item more than three times at three different levels: Independent (0) 14 times; Supervision (1) four times; and Extensive assistance (3) three times. So in this case, you should look at the second Rule of 3, Pratt stated.

For the second rule, you’re looking for the ADL self-performance code that is most dependent, Pratt noted. You cannot use the independent code because there were seven episodes of the ADL that did not occur at the independent level. So these other seven episodes will determine how to code this scenario.

Important: Here, you must look closely at the definitions for each coding level. Supervision (1) means “oversight, encouragement or cueing,” while Extensive assistance (3) means “resident involved in activity, staff provide weight-bearing support.” Looking at these ADL self-performance coding level definitions, you can clearly conclude that “extensive assistance involves more staff assistance and therefore is the most dependent code,” Pratt said.

Pay Attention to Third Rule’s Sub-Items

The third Rule of 3 applies when the resident performs an ADL three or more times at multiple levels, but not three or more times at any one level, noted Lori Grocholski, MSW, LCSW, with CMS’s Center for Clinical Standards and Quality, in the provider update video. “Where the third Rule of 3 departs from the prior two rules is the addition of the last phrase, ‘but not three times at any one level.’”

And you must pay attention to the sub-items beneath the third Rule of 3 to code properly, Grocholski stressed. Here’s what the MDS 3.0 RAI Manual states:

“3. 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 seven-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 seven 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 Extensive assistance (3).

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).”

Scenario #3: Mrs. F was in the nursing home for only one day prior to transferring to another facility. Mrs. F received the following assistance for the eating ADL on the day she was in the nursing home. Twice she required weight-bearing assistance to help her lift her fork to her mouth. One time in the evening, the staff fed her because she could not scoop the food on her plate with the fork, nor could she lift the fork to her mouth.

How to code: Here, the ADL occurred three times in the look-back period, but not three times at any one level, Pratt said. “Looking at all of the ADL self-performance coding level definitions and the instructions for the Rule of 3, the appropriate code to termination is Extensive assistance (3).”

Reason: You would apply the third Rule of 3 for this scenario because the first and second rules do not apply. “The first Rule of 3 does not apply because, although the ADL occurred three or more times, it did not occur three times at any one level,” Pratt explained. And the second Rule of 3 does not apply because the ADL did not occur three or more times at multiple levels.

Because the ADL occurred three times at multiple levels, but not three times at any one level, you would use the third Rule of 3. And in sub-item “a” under the third rule, you would convert episodes of full staff performance to weight-bearing assistance, Pratt instructed.

You would convert the single episode of full staff performance to weight-bearing assistance and add it to the other two episodes of weight-bearing assistance, Pratt said. “Looking at sub-item ‘b’ of the third Rule of 3, this combination totals three episodes of weight-bearing assistance, and therefore yields the code Extensive assistance (3).”