MDS Alert

Use these strategies to survey-proof your coding and documentation.

The MDS tells surveyors a tale about residents taking antipsychotic medications, so make sure the tale has a happy ending by avoiding unnecessary drugs (F329-F331).

Start by making sure you code residents' antipsychotic meds during the seven-day lookback. The government's MDS watchdog, DAVE, has identified shortfalls in accurate coding of antipsychotics and other drugs in Section 04, according to a Centers for Medicare & Medicaid Services Oct. 29 Webcast on coding MDS sections I, J and O.

Remember: Code a medication based on its pharmacological classification, not how it's used.

Next take a look at your percentile scores on quality indicator (QI) No. 19 (antipsychotic drugs without a psychotic or related condition) and make sure you've coded or checked excluded diagnoses and conditions. Residents with schizophrenia and other non-organic psychoses, Tourette's and Huntington's, or those with hallucinations, are excluded  from the QI's denominator (see Clip 'N Save Check Out The Exclusions, Risk Adjustments For QI 10 chart for details).

Of course, facilities most often prescribe antipsychotics to treat residents' dementia-related behavioral or psychotic symptoms. "And organic (dementia-related psychoses) won't exclude a resident from the QI," instructs Cheryl Field, MSN, RN, CRRN, a consultant with LTCQ Inc. in Lexington, MA.

Yet OBRA rules allow facilities to use antipsychotics to treat dementia-related psychotic or behavioral symptoms if the symptoms are causing the person functional impairment or distress, endangering him or others - or interfering with essential care.

Watch out: Simply checking Alzheimer's disease or dementia in I1 won't suffice in surveyors' eyes as a reason for administering an antipsychotic. So make sure the physician documents the specific diagnosis for dementia-related psychotic or behavioral symptoms in the medical record, advises Christine Twombly, RNC, chief clinical consultant with Reingruber & Co. in St. Petersburg, FL. "Then record the ICD-9 code in Section I3 of the MDS," she adds.

Follow these additional tips to keep your QIs on track and surveyors off your back.

1. Know the Risk Adjustment

Surveyors will also look to see if the resident treated with antipsychotics for dementia-related behavioral symptoms flags as high or low risk on QI No. 19. "Residents who exhibit both cognitive impairment and behavior problems on the most recent assessment are considered as being at high risk to receive antipsychotic medications," explains Bet Ellis, RN, a consultant with Larson- Allen Health Care Group in Charlotte, NC.

Check your coding: For purposes of the QI, cognitive impairment is defined as any impairment in daily decision making (B4 > 0) and short-term memory problems (B2a =1). Any one of three behavioral indicators or symptoms in E4 will get the cognitively impaired resident into the high-risk category for receiving antipsychotics: verbal abuse, physical abuse or socially inappropriate/disruptive behavior.

2. Re-evaluate 'Low-Risk' Residents on QI

If a resident flags as low risk for taking an antipsychotic on QI No. 19, take a closer look at the behavioral assessment and coding in E4 - and any interventions used before prescribing the medication, suggests Cynthia Best, RN, director of clinical support and compliance officer for Danville, IL-based Provena Seniors Services' nursing facilities.

The resident with cognitive impairment may actually be displaying socially inappropriate behavioral symptoms that the MDS team hasn't recorded in E4. The RAI user's manual defines socially inappropriate/ disruptive behavioral symptoms as "disruptive sounds, excessive noise, screams, self-abusive acts, sexual behavior or disrobing in public, smearing or throwing food or feces, hoarding and/or rummaging through other's belongings."

Sidestep this pitfall: Staff who care for a resident on a regular basis may get used to how the person "usually" behaves and no longer consider it to be socially inappropriate  - even though it meets the definitions in E4. "Staff will reason, 'That's just how Mary acts,' and no longer benchmark the behavior" against societal norms, cautions Diane Brown, CEO of LTC Brown Consultants in Boston. So consider having staff chart what's different about the resident's behavior once they obtain a behavioral baseline assessment. Using a "charting by exception" method in this case helps you home in on any changes from usual behavioral patterns, Brown notes. "The resident may show an improvement, which staff can tie to the medication or a behavioral or environmental intervention."

3. Go through the OBRA-required assessment

Just because a resident appears to be at high risk for receiving an antipsychotic doesn't mean the physician should automatically order one. "The intent of the regulations for antipsychotic medications is to assure that the facility has carefully assessed the cause of the person's behavioral symptoms," says Field.

For example, a proactive pain assessment approach geared to people with cognitive impairment can reduce a facility's use of behavioral medications, reports Kimberly Malin, RN, director of nursing, Hillhaven Assisted Living Nursing and Rehabilitation Center in Adelphia, MD. The interdisciplinary staff in her facility carefully assesses residents with dementia for underlying painful conditions and does a thorough behavioral assessment. "Then we look at the impact of the pain medication regimen on the resident's behaviors," Malin says.