This year Centers for Medicare and Medicaid (CMS) did not add any Minimum Data Set (MDS) data element items, but a few coding instructions were changed. These are small but important changes that can have a significant impact on data integrity and accurate MDS coding, care planning, reimbursement, and quality measures. This blog will review interview updates in Sections A, C, and D, clarification to capture shortness of breath in Section J, clarifications for coding related to pressure injuries and open lesion(s) on the foot in Section M, a change to instructions for coding Isolation in Section O, and clarifications for capturing skilled Respiratory Therapy in Section O.
Ethnicity and Race Interviews in Section A
For new residents, the Resident Assessment (RAI) Manual provides guidance for interviewing the residents, how to code the MDS when residents decline to respond or who are unable to respond, and when the medical record documentation can be utilized to code these items. Now we have guidance from CMS for subsequent assessments – if it has been less than a year since the resident was asked about their ethnicity and/or race, these items may be coded using the prior responses. If it has been a year or more since the resident was asked about their ethnicity and/or race, then we would need to ask the resident about their ethnicity and/or race.
BIMS Interview in Section C and PHQ-2 to 9© Interview in Section D
The RAI manual instructs staff to attempt to conduct these interviews with ALL residents during the look-back period of the Assessment Reference Date (ARD). Additional instructions include how handle situations such as when a resident needs an interpreter, when a staff assessment can be utilized in place of a resident interview, how to actually conduct the interview, what to code when a resident declines to respond or responses are nonsensical, and how to code the MDS items when the interview is not conducted during the look-back period. The RAI manual also includes guidance on administrating the BIMS and PHQ-2 to 9© interviews in writing. Now we have guidance for instances when multiple BIMS and/or PHQ-2 to 9© interviews are conducted during the look-back period. We are instructed to code the MDS with the BIMS and/or PHQ-2 to 9© interview(s) conducted closest to the ARD.
Shortness of Breath in Section J
The RAI manual instructs staff to interview the resident about their perception of shortness of breath or if the resident is unable to engage in specific activities due to shortness of breath. The manual also provides specific instructions for medical record review, staff and family/significant other interviews, and observations that should be conducted during the look-back period that would indicate the resident has shortness of breath. CMS has clarified that if the resident reports avoiding an activity (e.g., lying flat) due to shortness of breath, do not require the resident to perform the activity.
Pressure Injury and Open Lesion(s) on the Foot in Section M
With this October RAI manual update, CMS has clarified that the application of an advanced wound care dressing or skin substitute to a pressure ulcer is not a surgical procedure nor a graft or flap. The manual also clarified that if a resident has a pressure ulcer/injury that was documented on admission that subsequently closed (i.e., healed), and then opens again, the ulcer/injury should not be coded as “present on admission.”
At M1040C, Other open lesion(s) on the foot, the RAI manual clarification includes explanation that this item is designed to capture open lesions that are located on the foot and not otherwise captured in M1040A, Infection of the foot (e.g., cellulitis, purulent drainage), or M1040B, Diabetic foot ulcer(s). The manual notes open lesions on the foot can include but are not limited to cuts or fissures, and instructs not code open lesions that are otherwise captured in other Section M items. In this section, the manual reiterates that adhesive bandages (e.g., BAND-AID® bandages, wound closure strips) are not captured on the MDS as pressure injury care, surgical wound care, non-surgical dressings other than to feet, or as dressings to the feet.
Isolation in Section O
The RAI manual instructs staff to attempt to conduct these interviews with ALL residents during the look-back period of the Assessment Reference Date (ARD). Additional instructions include how handle situations such as when a resident needs an interpreter, when a staff assessment can be utilized in place of a resident interview, how to actually conduct the interview, what to code when a resident declines to respond or responses are nonsensical, and how to code the MDS items when the interview is not conducted during the look-back period. The RAI manual also includes guidance on administrating the BIMS and PHQ-2 to 9© interviews in writing. Now we have guidance for instances when multiple BIMS and/or PHQ-2 to 9© interviews are conducted during the look-back period. We are instructed to code the MDS with the BIMS and/or PHQ-2 to 9© interview(s) conducted closest to the ARD.
Respiratory Therapy in Section O
Instructions in the RAI manual to code skilled therapy time (i.e., time that requires the skills, knowledge, and judgment of a qualified therapist and all the requirements for skilled therapy are met) have not changed. The October update now notes that maintenance level/prophylactic incentive spirometry is often not a skilled intervention, but when the resident’s condition is complicated and/or the skills, knowledge, and judgment of the therapist are required for treatment, then those minutes associated with skilled therapy time may be recorded on the MDS. The use and rationale for all therapy modalities, whether skilled or unskilled, should always be documented as part of the individual resident-specific plan of care, and the therapy coding guidance from O0390, Therapy Services, should be utilized for coding O0400D, Respiratory Therapy. The RAI manual also includes updated examples of skilled vs non-skilled respiratory therapy services.