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Harmony Healthcare Blog

The Votes Are In For RUG-IV

Posted by George Kitsakos on Dec 14, 2010 9:53:00 AM

The Votes Are In For RUG-IV

During the CMS Open Door Forum, December 9, 2010 Sheila Lambowitz, Director of the Division of Institutional Post Acute Care for the Centers for Medicare & Medicaid Services stated "We're not going to have to reprocess [RUG-IV] claims," "We're not going to have to change to a new [temporary]  grouper."  She went on to say that passage of the bill "gives us some clarity to move forward and work on transition issues and make sure we have the RUG-IV and MDS 3.0 system working properly."

Additionally this legislation extends Medicare's Therapy Cap Exception process until December 31, 2011. Therapy caps apply an annual cap per beneficiary on expenses incurred for both outpatient physical therapy and speech therapy services combined and a separate cap for outpatient occupational therapy services under Medicare Part B. For CY 2011, the therapy cap amount has increased slightly from $1,860 to $1,870. 

The Medicare and Medicaid Extenders Act of 2010 also eliminates the expected 25% reduction in Medicare payments to physicians that was to be initiated in January 2011.  This is great news for the LTC industry. 

"This agreement is an important step forward to stabilize Medicare, but our work is far from finished," President Obama said in a statement. He added that it's time "for a permanent solution that seniors and their doctors can depend on."

Additional information on this soon to be law can be obtained on the United States Senate Committee on Finance site: http://finance.senate.gov/legislation/details/?id=9f97aa2e-5056-a032-52d4-8db158b12b11

CMS Speaks: CMS has posted the following guidence for facilities regarding coding Section A, 0310E to report if the assessment is the fist assessment since the most recent admission.

MDS 3.0 Coding Clarification for Item A0310E - CMS has re-evaluated the guidance outlined in the "MDS 2.0 to MDS 3.0 Transition Document" dated October 2010 for the coding of item A0310E. The transition document indicated that the item should be coded as "1" for the initial MDS 3.0 assessment for all existing residents; however, this guidance was overlooked on many of the assessments that were submitted.

During the November 9, 2010 National Provider Call direction was provided indicating that assessments that were coded as a "0" would need to be corrected and resubmitted.

CMS has reconsidered the matter and has concluded that providers Do Not need to submit corrected assessments where item A0310E may have been miscoded. Providers should follow the directions outlined in Chapter 3 Section A of the MDS 3.0 RAI Manual for the coding of A0310E from this point further.

MDS 3.0, RUG-IV

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Topics: CMS, MDS 3.0, RUG-IV;

Understanding the New Care Area Assessments

Posted by john routhier on Nov 2, 2010 2:18:00 PM

Understanding the New Care Area Assessments

First a quick note about last week's CMS SNF Open Door Forum: Regarding the Hybrid RUG-III System vs. RUG-IV, CMS is paying close attention to any acts of Congress aimed at repealing the RUG-IV delay. If the repeal does not go through then CMS will have to institute the Hybrid RUG-III system. CMS has begun development of the Hybrid RUG-III grouper in the case that the Senate does not pass the repeal. As we wait for the Senate to make a final decision, Harmony recommends the SNF continue to reserve funds from RUG-IV payments to offset Hybrid RUG-III adjustments in the Spring of 2011.  

Care Area Assessments: The Care Area Assessment is similar to a Resident Assessment Protocol (RAP) from MDS 2.0.

The Care Area Assessment process is a decision facilitator, which means it should lead to a more thorough understanding of the areas of concern that have been triggered by the MDS for further review. The MDS alone is not a comprehensive assessment. The MDS is used for preliminary screening to identify potential resident issues, conditions, strengths, and preferences. The Care Area Assessmentrepresents the assessment based on what was triggered by the MDS for the Care Area Assessment for review. The Care Area Assessment expands your assessment findings from the MDS, and then "charts your thinking."

The first step in the process of completing a Care Area Assessment is to identify what MDS items triggered and the Care Area Assessment and why. This can be done through review of Chapter 4, although frequently MDS software will detail these items. It is helpful to determine why these MDS items triggered the Care Area Assessment in order to focus your assessment and ensure that what triggered is actually assessed. Different types of triggers can change the focus of the Care Area Assessment review. There are four types of triggers:

1.      Potential Problems: These factors suggest the presence of a problem that warrants additional assessment and consideration of a care plan intervention.

2.      Broad Screening Triggers: These factors assist staff in identifying hard-to-diagnose problems. Because some problems are often difficult to assess in the elderly nursing home population, certain triggers have been broadly defined and consequently may have a fair number of false positives (i.e., the resident may trigger a Care Area Assessment that is not automatically representative of a problem for the resident).

3.      Prevention of Problems: These factors assist staff in identifying residents at risk of developing particular problems.

4.      Rehabilitation Potential: These factors are aimed at identifying candidates with rehabilitation potential.

Harmony will continue this discussion in next week's newsletter. Harmony Regional Consultants can provide sample Care Area Assessments during monthly site visits. 

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Topics: CMS, RUG-IV;, New Care Area Assessments, RUG-III Hybrid

Alert-CMS Updated Option 2 Payment Risk

Posted by john routhier on Oct 5, 2010 12:09:00 PM

ALERT! CMS Updated Option 2 with Payment Risk
 
In the final hours prior to October 1, CMS made a last minute change to the payment implications for Option 2 in the Transition Plan.  The change in instruction for Option 2 of the Transition Plan varies from what was originally taught by CMS on August 24, 2010.  Providers need to be aware that under Option 2 if the patient does not remain in the facility for at least one day for each of the actual billing periods, that the MDS is representing then there is risk for no payment or payment at the default rate.
Further, on September 23, 2010 CMS posted a retraction to page O-17 in Chapter 3 of the RAI manual.  Per CMS the September 13, 2010 posting of Section O contains a formatting error  on page O-17 under the coding tips for item O0400 that may result in mis-coding of the item.
The bulleted list at the top of the page should read as follows:
Set-up time shall be recorded under the mode for which the resident receives initial treatment when he/she receives more than one mode of therapy per visit.
•  Code as individual minutes when the resident receives only individual therapy or individual therapy followed by another mode(s)
•  Code as concurrent minutes when the resident receives only concurrent therapy or concurrent therapy followed by another mode(s)
• Code as group minutes when the resident receives only group therapy or group therapy followed by another mode(s)
Please discard page O-17 of Chapter 3 Section O of your existing MDS 3.0 RAI Manual and replace it with the following page of this document.
https://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp
A transition document is posted on the CMS website designed for the MDSC in terms of transitioning and completing the MDS 3.0 assessment for the first time.
http://www.cms.gov/NursingHomeQualityInits/downloads/MDS30TransitionFromMDS20.pdf

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Topics: CMS, MDS 3.0, RAI Manual, Section O

CMS Updates MDS 3.0 RAI Manual

Posted by john routhier on Aug 18, 2010 9:24:00 AM

CMS Updates MDS 3.0 RAI Manual 

October 1, 2010, is a mere 45 days away.  CMS continues to post updated versions of select sections of the RAI manual for MDS 3.0.  Facility staff must review any of the RAI manual materials obtained prior to August 12, 2010, for accuracy as CMS updated the manual once again.  The training materials page on the CMS website has the following information:

A new naming convention is now being used for the MDS 3.0 RAI Manual. 

  • Any sections or chapters that have had revisions will now have an updated version number along with the month and year that the information was revised (e.g. MDS 3.0 Chapter 4 V1.03 August 2010). Subsequent revisions of any section or chapter of the manual will have updated version numbers (e.g. V1.04, V1.05, etc...)
  • Any sections or chapters that have NOT been revised will have the same version number, month, and year that that version was last published (e.g. MDS 3.0 RAI Manual Chapter 3 Section A V1.02 July 2010). However, you will notice that the "day" has been dropped from the file name now that we do not have frequent updates to the manual.
  • Any changes from the previous version of all Chapter 3 Sections are now listed at the beginning of each respective section.
    • MDS 3.0 RAI Manual Chapter 4 has been reposted and is available for download  in the file labeled "MDS 3.0 RAI Manual August 2010."
    • MDS 3.0 RAI Manual Chapter 3 Updates: V1.03 of the following sections - A, C, D, E, F, G, K, M, O, P, X, and Z.

Harmony highly recommends that a facility representative frequently visit the CMS training materials page to obtain any further updated material in this manual.

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Topics: CMS, MDS 3.0

MDS 3.0 RAI Manual Updates

Posted by john routhier on Jun 29, 2010 10:18:00 AM

 MDS 3.0 RAI Manual Updates   CMS has been working diligently to get the final version of the RAI manual completed and posted on the website. Over the last several weeks updated Sections and chapters of the MDS 3.0 RAI manual have been posted on the CMS website, located on the MDS 3.0 Training Materials page. In addition, CMS is posting Training slides and Instructor slides which coordinate with every Section. June 18, 2010 marks the most recent post of training materials by CMS.  The updated Sections of the MDS on the CMS site now include: B, C, D, E, F, G, H, I, J, K, L, N, P, Q, S, V, X and Z. CMS also posted an updated version of Chapter 4 on June 18. Facilities who have printed the manual will now need to update their printed version.  The sections posted by CMS can be downloaded onto a desktop computer for easy access.  The long awaited training video was posted within the last week on the CMS Training Materials page, but CMS has since deleted the link as the file was too large and facilities experienced difficulty downloading the file.  Harmony will monitor the CMS site and provide an update when this video can be obtained through the CMS site.

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Topics: CMS, MDS 3.0, RAI Manual, MDS 3.0 seminar

MDS 3.0 RAI Manual Updates

Posted by john routhier on Jun 22, 2010 10:33:00 AM

  MDS 3.0 RAI Manual Updates   CMS has been working diligently to get the final version of the MDS 3.0 RAI manual completed and posted on the website. Over the last several weeks updated Sections and chapters of the MDS 3.0 RAI manual have been posted on the CMS website, located on the MDS 3.0 Training Materials page. In addition, CMS is posting Training slides and Instructor slides which coordinate with every Section. June 18, 2010 marks the most recent post of training materials by CMS.  The updated Sections of the MDS 3.0 on the CMS site now include: B, C, D, E, F, G, H, I, J, K, L, N, P, Q, S, V, X and Z. CMS also posted an updated version of Chapter 4 on June 18. Facilities who have printed the manual will now need to update their printed version.  The sections posted by CMS can be downloaded onto a desktop computer for easy access.   The long awaited training video was posted within the last week on the CMS Training Materials page, but CMS has since deleted the link as the file was too large and facilities experienced difficulty downloading the file.  Harmony will monitor the CMS site and provide an update when this video can be obtained through the CMS site. 

For MDS 3.0 Seminars in your area click here

Topics: CMS, MDS 3.0

MDS 3.0 Section G: Part II Functional Status

Posted by john routhier on Jun 8, 2010 2:52:00 PM

 MDS 3.0 Section G: Part II Functional Status:  The updated MDS 3.0 Section G in the upcoming MDS 3.0 contains a specific evaluation for balance during transitions and walking. If staff have not systematically documented the resident's stability in these activities at least once during the 7-day look-back period, the manual provides step-by-step instructions to evaluate the patient's ability to move from seated to standing, walking, turning around, and transfers. Harmony recommends that the interdisciplinary team discuss execution of the transitions and walking assessment to assure inter-rater reliability. This assessment can be completed by either nursing or rehab.
Coding is based on four levels of performance by the patient.
· Code 0, steady at all times
· Code 1, not steady, but able to stabilize without staff assistance
· Code 2, not steady, only able to stabilize with staff assistance
· Code 8, activity did not occur
Assessment for Range of Motion can be coded based on staff observations of the ROM activity.  This can be used to determine whether or not a resident can actually perform the activity, regardless of whether or not the movement was "on command," provided the movement fits the criteria specified and occurred during the 7-day look-back period. The assessment for the resident's ROM is done at the shoulder, elbow, wrist, hand, hip, knee, ankle, foot, and other joints unless contraindicated (e.g., recent fracture, joint replacement or pain). Depending on the resident's cognitive level, use the direction most appropriate for assessing limitations in ROM such as:
  • Asking the resident to follow your verbal instructions for each movement. 
  • Demonstrating each movement (e.g., ask the resident to do what you are doing). 
  • Actively assisting the resident with ROM exercises. 

In MDS 3.0 Section G, the assessment of Functional Rehab Potential is done only on the first assessment (OBRA or PPS) since the most recent admission. Ask if the resident thinks he or she could be more self-sufficient given more time. Ask staff who routinely care for or work with the resident if they think he or she is capable of greater independence in at least some ADLs. Disagreement between staff beliefs and resident beliefs should be explored by the interdisciplinary team.

Find MDS 3.0 Seminars in your area or more information on MDS 3.0 Section G click here

Topics: CMS, MDS 3.0, MDS 3.0 Section G

MDS 3.0 Section M: Coding Section M

Posted by john routhier on Jun 2, 2010 4:10:00 PM

MDS 3.0 Coding of Section M


With this busy season upon us, we have received an early holiday gift from CMS of the RAI manual for the MDS 3.0. This week chose to discuss coding Section M, Skin conditions in the following article as there are significant changes to the type of coding done in this section, definitions of altered skin and additional instructions and guidance provided for identification and evaluation of skin conditions.
MDS 3.0 Section M now consists of the following subsections:
M0100. Determination of Pressure Ulcer Risk
M0105. Risk of Pressure Ulcers
M021. Unhealed Pressure Ulcer(s)
M0300 Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage
Unstageable
 Non-removable dressing
 Slough and/or eschar
 Deep tissue
M0610. Dimensions of Unhealed Stage 3 or 4 Pressure Ulcers or Eschar
M0700. Most Severe Tissue Type for Any Pressure Ulcer
M0800 Worsening in Pressure Ulcer Status Since Prior Assessment
M0900. Healed Pressure Ulcers
M1030. Number of Venous and Arterial Ulcers
M1040. Other Ulcers, Wounds and Skin Problems
M1200. Skin and Ulcer Treatments
This section has undergone a complete overhaul.  Careful review of the RAI manual for MDS 3.0 Section M is necessary to have a clear understanding of the rational, steps for assessment and coding instructions.  For example the MDS 3.0 requires facilities to assess each patient to determine the risk factors present for pressure ulcer and the actual risk of pressure ulcers.  The coding of these subsections will then determine how to proceed with additional coding in MDS 3.0 Section M.

 

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Topics: CMS, MDS 3.0, ADL Coding, Section M, Skin Conditions, RAI

MDS 3.0 Section G

Posted by john routhier on Jun 1, 2010 10:07:00 AM

MDS 3.0 Section G
 
MDS 3.0 Section G will have a chang on Functional Status:  Items in this section assess the need for assistance with activities of daily living (ADLs), altered gait and balance, and decreased range of motion. In addition, on admission, resident and staff opinions regarding functional rehabilitation potential are noted. The RAI manual states that individualized care plans should address strengths and weakness, possible reversible causes such as de-conditioning, and adverse side effects of medications or other treatments. These may contribute to needless loss of self-sufficiency. In addition, some neurologic injuries such as stroke may continue to improve for months after an acute event. A resident's potential for maximum function is often underestimated by family, staff, and the resident. Individualized care plans should be based on an accurate assessment of the resident's self-performance and the amount and type of support being provided to the resident. Coding in this section is aimed at capturing how the resident actually performed and not how the resident is capable of performing. This section requires a 7 day look back of documentation in the medical record, discussion with direct care staff on all shifts and observation of the resident. The RAI manual directs the assessor to ask probing questions of staff and interview staff to get the most accurate picture of the patient during the 7 day look-back window. A flow diagram is provided on page G-6 of the manual to assist with decision making for accurate coding.
 
The RAI manual contains newly published instructions for the Rule of Three.
 
Instructions for the Rule of Three: 
When an activity occurs three times at any one given level, code that level.
 When an activity occurs three times at multiple levels, code the most dependent.
Example, three times extensive assistance (3) and three times limited assistance (2), code extensive assistance (3).
Exceptions are as follows:
Total dependence (4)-activity must require full assist every time.
Activity did not occur (8)-activity must not have occurred at all.
When an activity occurs at various levels, but not three times at any given level, apply the following:
When there is a combination of full staff performance and extensive assistance, code extensive assistance (3).
When there is a combination of full staff performance, weight-bearing assistance and/or non-weight-bearing assistance, code limited assistance (2).  
If none of the above are met, code supervision.
 
Coding levels of care in column one and column two in MDS 3.0 Section G does not differ from coding on the MDS 2.0. Harmony continues to encourage facilities to provide regularly scheduled educational sessions to assist staff in delineating between limited and extensive assistance.
 
When reviewing residents with tube feeding, TPN, or IV fluids it is important to accurately code extensive assistance (1 or 2 persons): if the resident with tube feeding, TPN, or IV fluids did not participate in management of this nutrition but did participate in receiving oral nutrition. This is the correct code because the staff completed a portion of the ADL activity for the resident (managing the tube feeding, TPN, or IV fluids). 
 

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Topics: CMS, MDS 3.0, ADL Coding, RAI Manual, MDS 3.0 Section G, IV Fluids, Section G

CMS MDS 3.0 Timeline Update

Posted by john routhier on May 27, 2010 5:12:00 PM

A new CMS MDS 3.0 timeline was posted:

http://www.cms.gov/NursingHomeQualityInits/downloads/MDS302010ImplementationTimeline.pdf

 

CMS has also posted updates to chapters P, N. L and I. (Restraints, Medications, Oral dental and Diagnosis)

The changes are subtle. For example, Section I, (diagnosis) we already heard about the change from 30 day review to 60 day review.

It is worth going to the webpage and checking out the Training Slides for MDS 3.0 that they posted.

http://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp#TopOfPage

 

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Topics: CMS, MDS 3.0, MDS 3.0 Timeline

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