Harmony Healthcare Blog

PDPM Q & A: Respiratory, Diagnoses Codes, Shortness of Breath and More

Posted by Pam Duchene on Thu, Sep 12, 2019

Edited by Kris Mastrangelo

Quote of Pam Duchene


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

  1. Regarding nursing performing respiratory therapy. Assuming they have their competencies, can an LPN provide respiratory therapy or does it need to be an RN? Does the nurse need to present with the resident the entire 15 minutes?

    A licensed nurse (either RN or LPN) can provide respiratory therapy as long as they have demonstrated/documented competence.  However, you need to check the state practice act because some states are more stringent (New York) in that the LPN cannot perform assessments. “Competence can be developed through a course, or through undergraduate study.  The 15 minutes must be face to face time.  The minutes can be spread out over the 24-hour day.”

    From the RAI User's Manual (O-18):  Respiratory Therapy—only minutes that the respiratory therapist or respiratory nurse spends with the resident shall be recorded on the MDS. This time includes resident evaluation/assessment, treatment administration and monitoring, and setup and removal of treatment equipment. Time that a resident self-administers a nebulizer treatment without supervision of the respiratory therapist or respiratory nurse is not included in the minutes recorded on the MDS. Do not include administration of metered-dose and/or dry powder inhalers in respiratory minutes.
  2. If the facility gets the discharge H & P from the hospital, can they code diagnosis’s that are listed on the H  & P but signed off on from the hospital MD? Or do all diagnosis’s need to be signed off by the facility physicians or NP?

    The diagnoses from the H&P of the hospital can be listed as active diagnoses as long as they fit the description in the RAI User's Manual of an active diagnosis (I-7).

    Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident’s current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period (except Item I2300 UTI, which does not use the active diagnosis 7-day look-back. Please refer to Item I2300 UTI, Page I-8 for specific coding instructions).

    The diagnoses listed in the active diagnoses should be signed off by the MD or NP.
  1. Regarding coding SOB when lying flat for a COPD resident, what if the resident has a cognitive impairment and is not able to answer the question related to SOB while lying flat?

    The nurse would assess the resident
    to identify any difficulty.

    (From the RAI Users' Manual J-22) Interview the resident about shortness of breath. Many residents, including those with mild to moderate dementia, may be able to provide feedback about their own symptoms.
    • If the resident is not experiencing shortness of breath or trouble breathing during the interview, ask the resident if shortness of breath occurs when he or she engages in certain activities.
    • Review the medical record for staff documentation of the presence of shortness of breath or trouble breathing. Interview staff on all shifts, and family/significant other regarding resident history of shortness of breath, allergies or other environmental triggers of shortness of breath.
    • Observe the resident for shortness of breath or trouble breathing. Signs of shortness of breath include: increased respiratory rate, pursed lip breathing, a prolonged expiratory phase, audible respirations and gasping for air at rest, interrupted speech pattern (only able to say a few words before taking a breath) and use of shoulder and other accessory muscles to breathe.
    • If shortness of breath or trouble breathing is observed, note whether it occurs with certain positions or activities.
  1. NTA—Respiratory Arrest—What scenario would this be used considering this is most likely resolved if they are in the SNF?

    If the resident had respiratory arrest during the qualifying stay or during the SNF inpatient stay.  This is spelled out in the CMS PDPM mapping.

Harmony Healthcare International (HHI) is available to assist with any questions or concerns that you may have.  You can contact us by clicking here.  Looking to train your staff?  Join us in person at one of our our upcoming Competency/Certification Courses.  Click here to see the dates and locations. 

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Tags: PDPM

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