October 1 is typically when the Centers for Medicare and Medicaid Services (CMS) institutes changes to the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) – and this year is no exception. CMS has rescinded a few things that were anticipated and added a few things that may be a surprise. Post-acute care providers will want to make sure that staff are aware of the updates and have processes in place to ensure a smooth transition from September into October.
What Has CMS Updated?
The updated RAI contains numerous reminders that “CMS expects a dash response to be rare,” meaning that CMS expects interviews and data collection to be completed whenever possible (dash coded items can impact quality measures as well as the Annual Payment Update). The revised manual also includes updated links to reference materials and web sites such as user manuals, pressure injury staging, medication/drug reference sites, CDC/APIC resources for isolation and vaccinations, and the State Operations Manual (SOM).
More notable updates:
- Data collection in Section A1250 Transportation is retiring, and the replacement will be A1255 Transportation. The Transportation questions will be applied only to assessments that are 5 day PPS assessments (A0310B = 01) and the Assessment Reference Date (ARD) at A2300 minus Admission Date (date this episode of care in this facility began) at A1900 is less than 366 days. This item is also getting an update to clarify that the question covers the past 12 months. Ask the resident, “In the past 12 months, has a lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?”
- D0150 Resident Mood Interview (PHQ-2 to 9) has updated instructions that “In the rare situation that the resident cannot provide a frequency, following a yes response to a symptom in Column 1, enter a dash in Column 2. CMS expects a dash response to be rare.”
- GG0130 Self Care items and GG0170 Mobility updated coding tips include “Assessment of the GG self-care and mobility items is based on the resident’s ability to complete the activity with or without assistance and/or a device. This is true regardless of whether or not the activity is being/will be routinely performed (e.g., walking might be assessed for a resident who did/goes/will use a wheelchair as their primary mode of mobility, stair activities might be assessed for a resident not routinely accessing stairs).” We also have the coding tips that “The assessment time frame is up to 3 calendar days based on the target date. During the assessment time frame, some activities may be performed by the resident multiple times, whereas other activities may occur only once.” Additional updated examples and coding tips cover subjects such as definition of “helper;” use of devices; eating; footwear; and mobility, including chair/bed transfers, car transfers, walking, and stairs.
- Section J Falls has several updates to coding tips and definitions. Of interest, facilities will want to pay close attention to the updated definitions of falls and fall-related injuries.
-
- The updated definition of falls reads, “Fall Unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g., onto a bed, chair or bedside mat) or the result of an overwhelming external force (e.g., a resident pushes another resident). An intercepted fall occurs when a resident would have fallen if they had not caught themself or had not been intercepted by another person – this is still considered a fall.”
- INJURY (EXCEPT MAJOR) now carries this information: “Includes, but is not limited to, skin tears, abrasions, lacerations, superficial bruises, hematomas, and sprains; or any fall-related injury that causes the resident to complain of pain.”
- MAJOR INJURY carries the updated information: “Includes, but is not limited to, traumatic bone fractures, joint dislocations/subluxations, internal organ injuries, amputations, spinal cord injuries, head injuries, and crush injuries.” We now have a coding tip that “Fractures confirmed to be pathologic (vs. traumatic) are not considered a major injury resulting from a fall.” CMS has included some updated examples that include falls in the therapy setting and specific examples of coding pathologic vs traumatic fractures.
-
- Section K has updated coding tips to help accurately code weight loss or weight gain. This includes weight comparison examples using timelines to help visualize the coding instructions.
- Coding tips in Section M that address pressure injuries on admit have been updated. This includes the instructions, “If a pressure ulcer/injury was unstageable on admission/entry or reentry and then becomes unstageable for another reason, it should be considered ‘present on admission’ at the new unstageable status. For example, if a resident is admitted with a deep tissue injury, but later the injury opens, the wound bed is covered with slough, and the wound is still unstageable, this wound is still unstageable, this wound would still be considered ‘present on admission.’”
- CMS has added coding tips for N0415 High-Risk Drug Classes: Use and Indication. This tip includes directions that “Facilities may wish to identify a resource that their staff consistently use to identify pharmacological classification as assessors should be able to identify source(s) used to support coding the MDS 3.0.” We also have CMS’ encouragement that “Assessors should consult the manufacturer’s package insert, which may contain the medication’s pharmacological classification. They can also work with the resident’s pharmacist to confirm the medication classification(s) for a resident’s medication(s).” CMS added gradual dose reduction (GDR) tips that includes an example of how the requirement to perform the GDR may be met per the SOM.
- Data collection in Section 0400 A-F Therapies is retiring, and the replacement will be O0390 Therapy Services. Instructions in this section are to indicate therapies administered for at least 15 minutes a day on one or more days in the last 7 days. The choices in this section include:
A. Speech-Language Pathology and Audiology Services
B. Occupational Therapy
C. Physical Therapy
D. Respiratory Therapy
E. Psychological Therapy
F. None of the above
To help ensure that this section is coded correctly, CMS has provided new Item Rationale, Planning for Care information, Steps for Assessment, Coding Instructions, and Coding Tips and Special Populations. This section contains a wealth of information that will provide direction, including information about skilled vs nonskilled services and the requirements that must be met for each type of therapy in order to capture these items on the MDS. It also contains the most extensive amount of new information in the updated RAI manual.
- The anticipated additions in Section R are removed from the RAI and MDS.
- Section X: Correction Request and Chapter 5 now contain updated information that guides MDS modifications, inactivations, MDS 3.0 Individual Correction Request and MDS 3.0 Individual Deletion Requests in iQIES with examples of MDS errors and the proper way to correct them. “The MDS 3.0 Individual Correction/Deletion or Move Request are distinct processes to address a few types of errors in a record in iQIES that cannot be corrected with a Modification or Inactivation Request.” Chapter 5 also includes information about how to complete the proper request in iQIES and the steps the State Agency will take upon receipt of the request.
StRategies for Keeping Up
Don’t delay preparation and training. Getting ahead of the changes will help ensure that critical data element changes are not overlooked. Missing updates on October 1 and after can cause negative ripple effects on accurate coding, care planning, reimbursement, and quality measures.
- Check in with the staff who are normally responsible for data collection and interviews. Make sure they have scheduled time to review the upcoming changes and have a plan to update their interview(s) and data collection item(s).
- Update your data collection tools. If you use paper documentation, get a copy of the up-to-date interview from your vendor, or copy the interview from the RAI manual. If you use an EHR, check with your vendor about updated forms, and add them to your forms or assessments library. Retire old forms so that on October 1, the correct form is in play and the chance of missing data is minimized. Make sure staff know the tools are updated and how/when to use them.
- Cross train staff so that all resident interviews can be completed when the normal staff are off. Other than the requirement that an RN signs for completion in Section Z, there is no rule in the RAI that says certain MDS sections must be completed by specific interdisciplinary team (IDT) members. The only real requirement for interviews and data collection is that the interviewer be trained to do it correctly and within the correct lookback period.
- Conduct a yearly MDS policy and procedure review – make sure your IDT members know their role and the changes to your policy.
- Create and implement an MDS audit schedule to review the accuracy of completion of new MDS items.
More Resources