MDS Alert

Question 1: How should we handle the transition for patients admitted before Oct. 1, 2016 but discharged after that date? Does CMS expect us to code Section GG on the discharge assessment?

Answer 1: The Centers for Medicare & Medicaid Services (CMS) will base the Fiscal Year (FY) 2018 Annual Payment Update (APU) on one quarter of data from Oct. 1, 2016 to Dec. 31, 2016.

This means that CMS will base FY 2018 compliance determinations on data submitted for admissions to the skilled nursing facility (SNF) on and after Oct. 1, 2016, and discharged from the SNF up to and including Dec. 31, 2016, according to a recently released CMS Q&A document (see www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/FAQ_October-2016.pdf).

Meaning: In terms of assessment types and item responses, this would mean that you would include a 5-Day PPS with an Admission Date (A1900) and/or Start Date of Most Recent Medicare Stay (A2400B) of Oct. 1, 2016, CMS explains. And you would include Part A PPS Discharge or OBRA/Part A PPS Discharge with a Discharge Date (A2000) and/or End of Most Recent Medicare Stay (A2400C) of Dec. 31, 2016.

CMS goes on to explain that the Assessment Reference Date (ARD) coded in item A2300 will determine the version of the MDS 3.0 that you should complete and submit. So if the ARD is on or after Oct. 1, 2016, you should use the current MDS 3.0 version 1.14.1 — this is the version that has all of the items required for the SNF Quality Reporting Program (QRP) submission including the new Section GG.

“We recognize that if the resident is admitted in September and discharged on or after Oct. 1, 2016, the SNF would submit a discharge record with GG data, while the admission data would not include Section GG,” CMS points out. “In this circumstance, the SNF can receive credit in the calculation of their APU threshold compliance determination when dashing Section GG in its entirely on discharge.”

Question 2: Will the use of a dash [-] on the weight item in the MDS count against our SNF for the QRP requirement, considering it’s a covariate for one of the quality measures?

Answer 2: Beginning with the FY 2018 payment determination, you must meet the requirement that 80 percent of all MDS assessments you submit must contain 100 percent of all data items necessary to calculate the SNF QRP measures, CMS states. Otherwise, your SNF will experience a 2-percentage-point reduction to its FY 2018 market basket percentage.

Bottom line: CMS requires the height and weight items for use in the calculation of the compliance threshold determination, so you should avoid the use of dashes for these items at all costs.

Question 3: What happens if our SNF initiates therapy on the day of admission or the day after, meaning we would not be able to capture resident performance over the three-calendar-day period, because therapeutic intervention would begin sooner? Potentially, we would have only one shift for assessing the resident’s self-care or mobility performance. Is this acceptable to meet the requirement for assessing “usual performance” in Section GG?

Answer 3: According to CMS, the three-day assessment period for the admission assessment includes Days 1 through 3 of the Medicare Part A stay, starting with the date in A2400B — Start of Most Recent Medicare Stay and the following two days, ending at 11:59 pm on Day 3. “The assessment should occur prior to the start of therapeutic intervention in order to capture the resident’s true admission baseline status,” CMS instructs.

You should code the resident’s functional status at admission based on a functional assessment conducted soon after admission. These scores should reflect the resident’s admission baseline status.

Rationale: “Therefore, as we suggest in the RAI Manual, this assessment should occur prior to the person benefiting from treatment interventions, if possible,” CMS states. “This is because therapy interventions can affect the resident’s functional status, and what [we] want to see on admission is the score that most reflects the resident’s status prior to any benefit from therapy.”

But this doesn’t mean that you should complete Section GG based on a single observation by a therapist in isolation on the day of admission, nor does it mean that CMS expects you to withhold therapy evaluations and treatment until you complete the functional assessment.

“CMS respects the interdisciplinary process, and if through that process, a person’s clinical functional assessment can be completed and usual performance determined on Day 1, it is acceptable to document that in Section GG,” CMS explains. “If this is accomplished by Day 2 or by Day 3, that is also acceptable.”

Key takeaway: If you notice that a resident’s performance for any of the activities in Section GG varies over the course of the day, you should ensure that you capture the resident’s usual status. So this determination may require a day or two to consult with other staff, even if therapy has already started, CMS notes.

Question 4: Should the Section GG performance coded on the 5-Day PPS Assessment reflect the resident’s baseline performance prior to SNF admission, or should it reflect the resident’s usual performance during the assessment period?

Answer 4: The three-day assessment period for Section GG in the admission assessment includes the day of admission and the two days following that day ending at 11:59 pm. This does not include the resident’s performance prior to admission to the SNF, CMS stresses.

Question 5: If a resident received oral gratification in addition to tube feeding, is the oral gratification provided counted for the eating activity?

Answer 5: If a resident is able to eat and drink, you should assess the resident for item GG0130A — Eating, according to CMS. You should code the score according to the amount of assistance/supervision that a helper provided for the oral gratification.

Question 6: If we coded a resident with 09 for any of the self-care or mobility items for admission performance, and the resident is not anticipated to improve, can we fill in the discharge goals with dashes?

Answer 6: “Yes, the use of a dash is acceptable when the clinician does not anticipate a discharge goal for the resident,” CMS states. You must have a minimum of one self-care (GG0130) or mobility (GG0170) goal coded per resident stay on the PPS 5-Day assessment for the function quality measure.

Your SNF’s APU won’t be affected if you submit at least one self-care or mobility goal. You may enter a dash for any other self-care or mobility goal not reported.