Nursing Documentation-ADL Coding: The number of occurrences is a focus when coding Section G. Many times Section G is undercoded as the MDS Coordinator notes assist on one shift alone and assumes that only one instance occurred. When in fact, the aide may have interacted with the patient numerous times. These are the occasions in which interview and investigative strategies are critical to ensure accurate coding. This is indicated as patients may fluctuate from shift to shift, day to day. There is great value both clinically as well as financially with accurate documentation of ADL status. Clinically, it is important to have an accurate portrait of the patient in order to develop an appropriate plan of care. Financially, the impact is significant when accounting for the resources utilized by the patient.
The RAI Manual states: " While it is not necessary to know the actual number of times the activity occurred, it is necessary to know whether or not the activity occurred three or more times within the last 7 days." (Page 3-78 Revised December 2002 RAI Manual)
Example: $ Impact Accurate ADL Coding (30 day assessment)
RMX vs. RML = $442.64 - $406.00 = $36.64 x 30 days = $1,099.20 (potential)
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