Isolation: Coding Requirements and Supporting Documentation

C.A.R.E.

Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency

This week’s hot topic is a resurfacing of the definition of coding of isolation.   We blogged about this in February, but it seems that questions continue to arise.  Let’s dig a little deeper into the RAI Criteria for coding Isolation with a focus on supporting documentation. 

Per the MDS 3.0 RAI User’s Manual, Isolation is coded only when the resident requires transmission-based precautions and single room isolation (alone in a separate room) because of an active infection (i.e., symptomatic and/or have a positive test and are in the contagious stage) with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission. 

Single Room Isolation can be coded only when all the following conditions are met: 

• The resident has active infection with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission.
• Precautions are over and above standard precautions. That is, transmission-based precautions (contact, droplet, and/or airborne) must be in effect.
• The resident is in a room alone because of active infection and cannot have a roommate. This means that the resident must be in the room alone and not cohorted with a roommate regardless of whether the roommate has a similar active infection that requires isolation.
• The resident must remain in his/her room. This requires that all services be brought to the resident (e.g. rehabilitation, activities, dining, etc.). 

Isolation is not coded under the following conditions: 

• If the resident only has a history of infectious disease such as “s/p MRSA” or “s/p C-Diff” with no active symptoms.
• If the precautions are standard precautions, because these types of precautions apply to everyone. Standard precautions include hand hygiene compliance, glove use, masks, eye protection and gowns.
• Urinary Tract Infections, Encapsulated Pneumonia and Wound Infections.

There are psychosocial risks associated with isolation and it is recommended that psychosocial needs are balanced with infection control. 

If a facility transports an isolated resident (i.e., meets the criteria for single room isolation) to another healthcare setting to receive medically needed services (e.g. dialysis, chemotherapy, blood transfusions, etc.) which the facility does not or cannot provide, the CDC Guidelines for transport of patients with communicable disease must be followed.  The facility may still code O0100M for single room isolation since it is maintained while the resident is in the facility. 

Finally, when coding for Isolation, the facility should review the resident’s status and determine if the criteria for a Significant Change of Status Assessment (SCSA) is met based on the effect the infection has on the resident’s function and plan of care. 

The definition and criteria of “significant change of status” is found in the RAI Manual Chapter 2. Regardless of whether the resident meets the criteria for an SCSA, a modification of the resident’s plan of care will likely need to be completed. 

The MDS 3.0 RAI User’s Manual provides clear instruction on the coding of Isolation. Documentation must support the medical necessity of Isolation. There must be: 

• An MD Order.
• Documentation to support the need for a private room.
• Documentation to support the need for the resident to remain in their room. 

If the isolation precautions continue for extended periods of time with no documentation to support medical necessity (or for conditions that are excluded, such as wound infections), the RUG Level will be classified into a lower RUG Category under audit. Documentation that supports coding of Isolation should state that all treatments, therapy and activities are provided in the patient’s room due to isolation precautions. Further information can be found in Chapter 3, Section O of the RAI User's Manual.

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