AGING AND DISABILITY SERVICES ADMINISTRATION

Questions and Answers
from "Back to the Future - The MDS Section AA-V and Beyond" October, 2002
Marjorie Ray, RN RAI Coordinator

The Revised Long Term Care RAI User's Manual, December, 2002 is the CMS reference for many of the responses listed below.

Q-1 If the Physician has written, "Dietary Supplement" behind an order for multivitamin or Vitamin C, for example, do you code this as a medication or dietary supplement?

Section K is entitled "Nutritional Approaches". Item K5f, Dietary Supplement between meals is defined as, "Any type of dietary supplement provided between scheduled meals (e.g., high protein/calorie shake, or 3 p.m. snack for resident who receives q. a.m. dose of NPH Insulin). Per this definition, a vitamin is not considered a nutritional approach, but is considered a medication and would be coded in Section O, item 1.

Q-2 Do you count Rx ointments, creams, treatment debridements that are documented on the treatment administration record (TRA) in Section O, item 1?

Section O is designed to capture the use of over the counter and prescription medications. Page 3-176 of the RAI Manual expands the definition of medications to include topical preparations, ointments, creams used in wound care (e.g., Elase) eye drops, vitamins and suppositories. Yes, these items may be counted in O-1.

Q-3 Thorazine is classified as an antianxitey and an antipsychotic in my drug book. Do I mark M4a and M4b?

The Section for these items is Section O, not Section M. The drug book that I referenced in the MDS training sessions lists Thorazine as an antipsychotic/neuroleptic/antiemetic medication. It is clear that different drug books classify some drugs differently. I would double check with your facility consultant pharmacist first to determine what the drug classification is that they use. Both Table A in the RAI User's Manual Psychotropic Drug RAP and Appendix E list Throazine as an antipsychotic drug for classification. You should choose one standard reference for drug classification and stick with that for coding.

Q-4 Do you count Oxygen as a medication?

No.

Q-5 If you have someone receiving Prolixin every month, and Haldol Deconate every 3 weeks, do you count these an antipsychotic medication and how would you code this in O4?

Both Prolixin and Haldol Deconate are classified as antipsychotic medications. If the injections were given prior to the observation period, they each could be coded in O1, number of medications. If the actual injections were given during the observation period, they each could be counted in O3. Page 3-180 of the RAI Manual states that if the resident uses long-lasting drugs that are taken less often than weekly (e.g., Prolixin or Haldol), given every few weeks or monthly enter a "1" in O4.

Q-6. Who gets the MPAF? I had one with an incorrect RUG but I sent it in anyway, I was sure it was a software error. Will it be corrected at the state level?

No corrections to data are made by the state. Once an MDS has been successfully transmitted, the only way corrections to the data can be made are by the facility using the error correction process. As long as the MDS entries are correct, the appropriate RUG group will be assigned to the resident's assessment.

Q-7 Is personnel file documentation required to support a "trained nurse" for respiratory therapy?

In the RAI manual on page 3-186-187, it states a, "trained nurse" refers to a nurse who received specific training on the administration of respiratory treatments and procedures. This training may have been provided at the facility during a previous work experience or as part of an academic program. Nurses do not necessarily learn these procedures as part of their formal nurse training programs." The facility needs to have some method of recording/verifying that nurses are indeed trained and qualified to provide the respiratory therapy.

Q-8 Can we count SVN's (small volume nebulizers) under respiratory therapy?

A SVN treatment can be counted if provided by a respiratory therapist or "trained nurse". Only the time the qualified professional spends with the resident can be counted.

Q-9 Would an inservice on respiratory assessment count for additional training for a licensed nurse related to being qualified to do respiratory therapy?

Please refer to the answer for question #7. An inservice on respiratory assessment alone may not be sufficient to address all areas needed to cover, "administration of respiratory treatment and procedures" as noted in the RAI manual discussion of respiratory therapy.

Q-10. If someone in a wheelchair has an alarm and does not get up because of the noise the alarm makes, is this not a trunk restraint or chair prevents rising?

The alarm is not restricting the resident's freedom of movement. Unless the attachment of the alarm cannot be removed easily and restricts the resident's freedom of movement or normal access to one's body, the alarm device would not meet the definition of a restraint. There is no place to code bed or chair alarms on the MDS 2.0. The use of these devices should be documented in the chart and on the care plan.

Q-11. How would you code an open cancer lesion? As a stage 2 ulcer?

All skin ulcers/open lesions should be coded in M-1. Code according to the appearance of the skin using the 4 stages identified in the RAI User's Manual. If the lesion appears as a "partial thickness loss of skin layers that present clinically as an abrasion, blister or shallow crater", a stage 2 coding would be appropriate. This would also be coded at M4c.

Q-12 During the assessment period, the resident had a stasis ulcer to the LE. On the first day of the assessment period, it was a Stage 3; by the 7th day, it had resolved. Would you code M1b and M3 as a "yes"?

All skin problems and lesions present during the current observation period should be documented. In the above scenario, Section M1 would be coded at item "c", as ulcer was staged as a "3" on the first day of the assessment period. Since the ulcer was resolved during the past 90 days, M3 would also be coded as "yes" using a code of 1. Documentation in the medical record should support this coding.

Q-13 Does G1aA-Bed Mobility, include pulling a resident up in bed?

The RAI User's Manual definition of bed mobility is, "How a resident moves to and from a lying position, turns side to side, and positions body while in bed." If a resident needs to have their body re-positioned (e.g., pulled up) due to sliding or wiggling down or side ways, this would qualify to be coded in G1aA. The actual code would depend on the resident's performance during all shifts over the entire 7-day assessment period.

Q-14 Which do you count in Section G- (a) The resident is tube fed, but does not participate with the tube feedings; or (b) The resident also feeds himself or herself 25% of the meal 3x/day independently?

In order for a resident to be coded totally dependent in eating, all food and liquids at all meals and snacks would have to be fed to the resident by staff. Because the resident does feed themselves independently 25% of a meal 3x/day, but does not do any of the tube feedings, the coding would most likely be a 3 for self-performance and a 2 for support provided (if it took 1 staff to administer the tube feedings).

Q-15 If a resident with severe osteoarthritis cannot totally open his/her hand in assessing G4(A), but does all ADL's independently (even buttons) how would you code? Limitation in ROM is defined as limitation that interferes with daily functioning or places the resident at risk of injury.

Since this is a functional assessment, while the resident may not be able to totally open his/her hand, there may be a limitation to the hand as well as partial loss of voluntary movement. As far as the resident being independent with dressing (G1gA) they can be independent, but still have a limited ROM and/or partial loss of voluntary movement(G4(A).

Q-16 If a resident has a change in the 30 or 180 day time period and then returns to current status, is that considered deterioration, i.e., mood-one incident of crying or dietary-a weight loss?

For those items that ask you to look specifically at a resident's condition now as compared to 30 days ago and then 180 days ago, you are comparing two distinct points in time (today vs. 30 days ago, and today vs. 180 days ago). In Section E1, you are asked to record any indicators observed in the last 30 days, so even one episode of tearfulness would be recorded and coded as a "1". For Section E3, if a resident had 1 episode of crying in E1, and had no indicators 180 days ago, then the mood would be considered to have deteriorated.
This same logic applies to those items that ask you to compare the resident's status now as compared to 90 days ago, you are looking at a snapshot of "today" as compared to the picture 90 days ago, (B6, C7, E3, E5, G9, and H4 for example)

Q-17 I have a real concern about only going back to a date in time and not looking at the period of time. As a consultant, I am concerned that people will not be coded correctly because people are not encouraged to look at all the weights in a given time period.

The MDS must be coded based on the CMS instructions, which are to compare the current weight with the weight 30 days ago and 180 days ago. Then calculate weight gain or loss in percentages during each of those specific time periods. The documentation of the identification and evaluation of weight changes is good clinical practice. The significance of those changes for the resident should be reflected in that documentation. The evaluation of the significance of weight gain or loss over a specific time frame is a crucial part of the assessment process. However, if the resident is losing or gaining a significant amount of weight, the facility should not wait until the 30 or 180-day time frame to address the problem. See also the interpretive guidelines for F325, F326 and F272 in the LTC regulations as well as the Nutritional RAP.

Q-18 The dear administrator letter this summer included a flow chart indicating that re-entry tracking forms were required for all readmissions whether discharged as a code 6, 7 or 8. Is this correct?

The flow chart that accompanied the "Dear Administrator" letter of 6/14/2002 was a Washington State modification of the CMS flow chart for tracking forms that was part of the May, 2002 CMS Q&A document. At the time of this letter, the nursing home rates department indicated that they needed the information from the re-entry tracking forms for payment purposes. Since the issuance of the June letter, it has now been determined that the re-entry tracking form is not required to be submitted for a resident who was discharged with a code of "6", return not anticipated. If a resident later returns to the facility after they have been discharged, they will be treated as a new admission and information for this stay period will begin from the date of the current admission.

Q-19 Related to a Medicare re-admission, in the tracking forms flow chart mentioned in Q-18, the chart indicates that AA8b is coded a 05 when the discharge tracker is coded as a "7". This is the only instance identified on the flow chart for using the code of 05, was this intentional? Could AA8b be coded an 05 when the discharge tracking form had been coded as an 8?

Yes, AA8b can be coded as 05 when the discharge tracker was coded as an 8. This was inadvertently left off the flow chart. A new flow chart has been developed.
Q-20 When a resident is admitted as Medicare part A, then discharges to the hospital prior to the initial MDS (AA8a=0, AA8b=1) the discharge tracking form is coded as an 8. When the resident returns to the facility, still on Medicare part A how would AA8b be coded?

AA8b would be coded as an 05, and the original AB1 date would be retained. The return/readmission date would be entered in A4. The OBRA initial assessment would be due no later than day #14 after the re-entry date.
If the resident was out of the nursing facility for more than 90 days and then returned, do not code this as a re-entry but treat as a new admission with a new AB1 date. AA8b would be coded as a 1 if the resident was on Medicare part A for this new admission.

Q-21 With an invalid Medicare assessment (i.e., forgot to mark the assessment as a quarterly) why can't you amend the hard copy and re-submit or recopy the information onto another form and code it as a quarterly?

A Medicare assessment would not be considered invalid because you forgot to code it as a quarterly. It was valid for Medicare purposes, thus it was a valid assessment. Technically, inactivations are only to occur for invalid assessments or "the event did not occur."
However, if your software system retained the entire 500+ item assessment you could copy this information onto another form and submit it as a quarterly.

If the MPAF form was used for the Medicare assessment, then only those items that are required to be submitted for Medicare PPS are gathered (along with some identification items and Quality Measure information) and you would not be able to simply copy the previous MDS information onto a quarterly form. Washington requires a full MDS minus the RAPs to be completed on a quarterly basis.

It is the responsibility of the facility to assure that all information, including the reason(s) for assessment, is accurate prior to transmitting the data to the state database.