MDS Alert

CMS sheds some light on common coding quandaries.

Question: "Regarding MDS 3.0 G0110 (Activities of Daily Living (ADL) Assistance) 'talk with direct care staff from each shift that has cared for the resident,' many facilities utilize a data collection form for staff from all shifts to utilize during the observation period. Can this take the place of the staff interviews?"

Answer: "The expectation is a direct conversation with a staff member. Providers should develop their own processes to ensure that this expectation is met," according to a Q&A from the CMS training sessions for state representatives in March (www.cms.gov/NursingHomeQualityInits/Downloads/MDS30QandA.pdf).

Question: "Will there be a cutoff date when a facility will no longer be able to submit an MDS assessment or correction?"

Answer: "Assessments with ARD of 09/30/2010 must be an MDS 2.0. Assessments with an ARD of 10/01/2010 must be an MDS 3.0. CMS has not determined the cut-off date for when an MDS 2.0 record may not be modified or inactivated." (Ibid)

Question: "If the MDS is blank for restorative nursing yet the facility says that the resident receives ROM or is on the floor ambulation program, should the MDS coding be assessed as inaccurate?"

Answer: "In order for restorative nursing care to be coded on the MDS, the requirements under 'Steps for Assessment' on page O-23 must be met. If the requirements for restorative nursing care on page O-23 are not met, then the MDS would not be coded." (Ibid)

Question: "The manual says to code cleansing of the trach and/or cannula -- what if the resident does this care themselves?"

Answer: "Yes, you can code tracheostomy care in item O0100E if the resident performs this care for themselves." (Ibid)