Harmony Healthcare International (HHI) Blog

MDS Updates October 2017


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

4-Reimbursement.jpgSection G (Functional Status):  CMS has added four new bullet points to the Coding Tips and Special Populations section for G0110 (Activities of Daily Living (ADL) Assistance): 

  1. Some residents are transferred between surfaces, including to and from the bed, chair, and wheelchair, by staff, using a full-body mechanical lift. If the resident holds onto a bar, strap, or other device during the full-body mechanical lift transfer is not part of the transfer activity and should not be considered as resident participation in a transfer. 
  2. Transfers via lifts that require the resident to bear weight during the transfer, such as a stand-up lift, should be coded as Extensive Assistance, as the resident participated in the transfer and the lift provided weight-bearing support.
  3. How the resident turns from side to side, in the bed, during incontinence care, is a component of Bed Mobility and should not be considered as part of toileting.
  4. When a resident is transferred into or out of bed or a chair for incontinence care or to use the bedpan or urinal, the transfer is coded in G0110B, Transfers. How the resident uses the bedpan or urinal is coded in G0110I, Toilet use. (page G-9 – G-10) 

Section I (Active Diagnoses):  Change in coding for I2300 (Urinary Tract Infection (UTI) (Last 30 Days)). Effective Oct. 1, UTI should be coded only if both the following criteria are met in the last 30 days: 

  1. It was determined that the resident had a UTI using evidence-based criteria such as McGeer, NHSN, or Loeb in the last 30 days, and
  2. A physician-documented UTI diagnosis in the last 30 days. 

The RAI User’s Manual further states that providers must use a tool that is linked to their Infection Prevention and Control Program. 

Section M (Skin Conditions):  In Section M (Skin Conditions), CMS has clarified that mucosal ulcers are not to be coded in M0210 (Unhealed Pressure Ulcers).  Mucosal pressure ulcers are not staged using the skin pressure ulcer staging system because anatomical tissue comparisons cannot be made. 

Mucosal ulcers may include ulcers related to nasogastric tubes, nasal oxygen tubing, endotracheal tubes, urinary catheters, for example. 

Section N (Medications):  Section N includes several new items to include: 

  • N0410H (Opioid Medications Received); and 
  • N0450 (Antipsychotic Medication Review)

    • N0450A (Did the Resident Receive Antipsychotic Medications Since Admission/Entry or Re-entry or the Prior OBRA Assessment, Whichever Is More Recent?);
    • N0540B (Has a Gradual Dose Reduction (GDR) Been Attempted?);
    • N0450C (Date of Last Attempted GDR);
    • N0450D (Physician Documented GDR as Clinically Contraindicated); and
    • N0450E (Date Physician Documented GDR as Clinically Contraindicated). 

Physician documentation indicating dose reduction attempts are clinically contraindicated must include the clinical rationale for why an attempted dose reduction is inadvisable. The decision should be based on the determination that tapering the medication would not achieve the desired therapeutic effects and the current dose is necessary to maintain or improve the resident’s function, well-being, safety, and quality of life. 

In cases where a resident is or was receiving multiple antipsychotic medications on a routine basis, and one medication was reduced or discontinued, record the date of the reduction attempt or discontinuation in N0450C, Date of last attempted GDR. 

If multiple dose reductions have been attempted since admission/entry or reentry or the prior OBRA assessment, record the date of the most recent reduction attempt in N0450C, Date of last attempted GDR. GDRs must be addressed or attempted as follows: 

  • Within the first year in which a resident is admitted on a psychotropic medication or after the facility has initiated a psychotropic medication: 

    • GDR attempts in two separate quarters with at least one month between the attempts.
    • The GDR must be attempted annually thereafter unless clinically contraindicated. 
  • Non-pharmacological approaches must be attempted and documented 

    • instead of using psychotropic medications,
    • along with use of psychotropic medications, and
    • while GDR is attempted. 

Section P (Restraints and Alarms):  The new item P0200 (Alarms) has a 7-day look-back period and includes the following sub items: 

  • P0200A (Bed Alarm);
  • P0200B (Chair Alarm)
  • P0200C (Floor Mat Alarm)
  • P0200D (Motion Sensor Alarm)
  • P0200E (Wander/Elopement Alarm)
  • P0200F (Other Alarm) 

The RAI User’s Manual (page P-8) defines an alarm as “any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected.  These may include bed, chair and floor sensor pads, cords that clip to the resident’s clothing, motion sensors, door alarms, or elopement/wandering devices.”

  • Do not code a universal building exit alarm applied to an exit door that is intended to alert staff when anyone (including visitors or staff members) exits the door. 
  • While often used as an intervention in a resident’s fall prevention strategy, the efficacy of alarms to prevent falls has not been proven; therefore, alarm use must not be the primary or sole intervention in the plan. 
  • Adverse consequences of alarm use include, but are not limited to, fear, anxiety, or agitation related to the alarm sound; decreased mobility; sleep disturbances; and infringement on freedom of movement, dignity, and privacy. 
  • When the use of an alarm is considered as an intervention in the resident’s safety strategy, use must be based on the assessment of the resident and monitored for efficacy on an ongoing basis, including the assessment of unintended consequences of the alarm use and alternative interventions.

It is further instructed that the alarm device must be assessed to determine if it also has the effect of a restraint.  The RAI Manual instructs that if an alarm meets the criteria as a restraint it must be coded as both P0100 (Physical Restraints) and P0200 (Alarms).

Evaluate whether the alarm affects the resident’s freedom of movement when the alarm/device is in place. For example, does the resident avoid standing up or repositioning himself/herself due to fear of setting off the alarm? 

Section Q (Participation in Assessment and Goal Setting):  There is an overall heightened emphasis on resident-centered care.  The intent statement for Section Q (Participation in Assessment and Goal Planning) has been revised, stressing the importance providing the resident with an opportunity to be provided information in available community supported services to live in the least restrictive setting possible.  

Section Q revised instructions: 

  • Q0300 (Resident’s Overall Expectation): This item is individualized and driven by the resident with a focus on the resident’s expectations.  It is not based on whether the staff considers discharge a realistic expectation. 
  • Q0400 (Discharge Plan): It is the resident’s right to be provided information regarding resources as requested
  • The Resident’s Preference to Avoid Being Asked Question Q0500B) must be supported in the medical record.  It further clarifies that the resident is to be informed that they can change their mind regarding possible return to the community at any time with a referral to the Local Contact Agency (LCA) regardless of the MDS schedule. 
  • This item identifies the resident’s desire to speak with someone about returning to community living to obtain additional information about services and supports that would be available to support community living. It is further clarified that this is a request for information and not a request for discharge.

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