Harmony Healthcare Blog

Medicare Versus MMQ ADL Documentation

Posted by Kris Mastrangelo on Mon, Dec 01, 2014


Edited by Kris Mastrangelo

ADL documentation is a critical component in capturing an accurate and appropriate rate of reimbursement for services rendered. Both Medicare (PPS RUG) and Medicaid (MMQ) use ADL assistance provided to generate a rate for reimbursement. Although both systems utilize ADL data, definitions and levels of assistance provided are different. Skilled Nursing Facilities often struggle to capture an accurate picture of the care provided for both Medicare and Medicaid.


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It is important that healthcare professionals discourage the practice of cueing staff to code “expected” levels of patient performance and staff support.  It is important that CNA care cards not be used to code ADL flow sheets. Cueing and prompting staff is strictly forbidden for MMQs and can result in loss of ADL points for MMQ if identified by an MMQ auditor. Variations in function from shift to shift and day-to-day are an expected occurrence with the geriatric population experiencing effects of acute and chronic conditions.

The Medicare RUG is based on an ADL score that is calculated from the MDS. Only the late loss ADLs of bed mobility, transfer, eating and toilet use contribute to the ADL score. The following definitions of self performance are used for MDS coding of late loss ADLs.

  • Independent:  No staff intervention.
  • Supervised:  Verbal cues or visual oversight.
  • Limited Assist:  Hands on assist that includes contact guard or guided maneuvering.
  • Extensive Assist:  Hands on assist that includes any weight bearing support or dependence in a portion of the sub-task.
  • Total Dependence:  Full staff performance or in other words, the patient did not participate whatsoever in performing the task.
  • Number of Assists to provide care (one verses two or more).

MMQs are based on points that are assigned for levels of care provided. The following ADL areas are used to contribute to the total MMQ Score:

  • Personal Hygiene and Bathing
  • Mobility (ambulation or wheelchair)
  • Eating
  • Positioning
  • Dressing
  • 2 assist provided for positioning, transfers or ambulating

Definitions for MMQ are:

  • Independent:  No staff intervention.
  • Assist-Includes all of the following:  Continual supervision, hands on assist that includes contact guard or guided maneuvering, Hands on assist that includes any weight bearing support or dependence in a portion of the sub-task.
  • Total Dependence:  Full staff performance or in other words, the patient did not participate whatsoever in performing the task.
  • 2 assist provided for positioning, transfers or ambulating.

Facilities frequently choose to use MMQ friendly ADL flow sheets. It is critical that MDS Coordinators have a clear understanding of MMQ definitions of ADLs and levels of assist. The MDS Coordinator must interview caregivers and assess each patient for accurate coding. Assist on MMQ flow sheets may be supervision, limited or extensive assist. The MDS Coordinator must determine if episodes of hands on assist were provided and what type of support was provided (guided maneuvering versus weight bearing support). 

Given toilet use and bed mobility are not used directly for MMQ scoring, these items require special attention when coding from MMQ friendly flow sheets. Bed mobility for MDS purposes assesses how the patient moves to and from a lying position, turns side to side and positions body while in bed. All activities occurring on the mattress are assessed. Patients positioned by staff are lifted by staff. Lifting requires weight bearing support and is equivalent to extensive assist for MDS purposes. Toilet use for MDS purposes assesses how the resident uses the toilet room (or commode, bedpan, urinal), transfers on/off toilet, cleanses, changes pads, manages ostomy, manages catheter and adjusts clothes. Toilet transfer ability is also included. These items must be assessed through staff interview and/or observation of the patient.

Given the Medicaid population in most facilities, MMQ friendly flow sheets are used to support the level of care provided and to ensure the facility receives accurate and appropriate reimbursement for the care being provided. With a clear understanding of both the MMQ and MDS definitions, facilities can accurately capture care provided for both Medicare and Medicaid patients.  Thee definitions for both systems should be reviewed frequently. The MDS Coordinator should also interview staff as part of the assessment process. An MDS note can be used to clarify information obtained during staff interviews.

If you need help with ADL Coding or staff training, please click here to contact Harmony Healthcare International or call us at (800) 530-4413. 

 

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Tags: ADL, MDS, MMQ,

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