Harmony Healthcare Blog

ADL Coding: The Rule of Three

Posted by The Harmony Team on Thu, Nov 16, 2017


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

We spend a great deal of time educating the industry on the accurate coding of Activities of Daily Living of the four late loss ADLs which include: 

  • Bed Mobility
  • Transfers
  • Eating
  • Toileting 
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Topics: ADL Coding

ADL Coding: Outcomes and Improvement

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Fri, May 06, 2016

In our blog post ADL Coding: Where Does the Confusion Begin? we reviewed ADL Coding and the two assist levels seemingly with the most confusion on coding: Limited Assistance and Extensive Assistance.  Today, we are going to take this conversation to a stratospheric level of critical thinking.  

The Federal Government is hot to trot on defining and depicting patient outcomes with a direct impact on SNF payment as a result of improvement. The essential question that every facility should be asking: 

Is the MDS an Effective Tool to Measure Improvement?

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Topics: ADL Coding, Activities of Daily Living

ADL Coding: Where Does the Confusion Begin?

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Wed, May 04, 2016

ADL (Activities of Daily Living) Coding is always a beneficial topic of discussion given the blow incorrect coding can have on reimbursement and quality of care.  Typically, this miscoding starts with a misunderstanding of the definitions on the amount of assistance provided by the caregiver.  Thus, it is imperative that facility staff (inclusive of the nurse assistants, therapists and nurses) fully understands the intent of each level of assist provided on the MDS.  It is extremely common for patients to be erroneously coded into the wrong category.  Of interest, the two levels seemingly with the most confusion are Limited Assistance and Extensive Assistance.

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Topics: ADL Coding, Activities for Daily Living

Chronic Disease Management in the Skilled Nursing Facility Population

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Tue, Aug 26, 2014

While there is a great deal of focus on the management of post acute patients in the SNF population, many of whom will return to the community, management of long term care patients is equally essential to the provision of services along the continuum of care.  According to CMS regulations, long term care patients have a right to function at their highest practicable level, including the delivery of services to slow the progression of decline, as long as these services meet the definition of skilled criteria.

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Topics: ADL Coding, Skilled Therapy

ADL Skills: Addressing Posture and Positioning in the SNF

Posted by The Harmony Team on Fri, Oct 28, 2011

Poor sitting posture is a common problem in long-term care and has an effect on function and performance of ADL skills. Skilled Nursing Facilities strive for a restraint free environment, no recorded falls and eliminating the occurrence of skin breakdown at the facility level.  Committee meetings, QA teams and active walking rounds are a part of the daily operations in the SNF aimed at minimizing and eliminating the above listed clinical barriers to function.

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Topics: SNF, ADL, ADL Coding

ARD: Impact on Rehabilitation Plus Categories

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Fri, Jun 18, 2010
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Topics: ADL Coding, ARD

ADL Coding-Positioning and Seating

Posted by Kris Mastrangelo, OTR/L, LNHA, MBA on Wed, Jun 02, 2010

Positioning and Seating
Poor sitting posture is a common problem in long-term care and has an effect on function and performance of ADL skills.  The resident's ability to function in their environment is improved through good body alignment.  The primary goals of a positioning program includes improving body alignment, preventing or mitigating of the effects of pressure on existing pressure ulcers and improvement in ADL participation.  It is as important for caregivers to understand the unique situation of the identified patient at risk and document using and ADL flow sheet.  For example, one patient may tolerate sitting for 2 hours without skin compromise while another should be limited to 45 minutes out of bed. 
There are many factors to take into consideration when addressing positioning needs:
Is there abnormal tone contributing to poor posture and can it be normalized through treatment?
Is there muscle weakness contributing to poor posture and body alignment and can it be improved through treatment?
Can the patient get stronger?
Are there contractures contributing to positioning problems?
Can the contractures be reduced?
Is there any skin breakdown?
Is there adequate support of the extremities in the current seating system?
Does the patient have pain?
Does the patient have circulatory compromise?
Does the patient's position in the seating system vary throughout the course of the day or during specific tasks?
Evaluation and treatment of the above concerns are areas of specialty for a therapist versus the nurse or CNA.  This intervention meets the skilled criteria by definition and qualifies for coverage regardless of the patient's ability to demonstrate functional improvement.

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Topics: Medicare Part A, ADL Coding, Medicare Reimbursement

Managing Medicare Length of Stay

Posted by The Harmony Team on Wed, May 26, 2010

Case management by the rehab staff is one of the primary factors effecting Medicare length of stay.  Generally, when a patient is admitted for short term rehab their underlying medical conditions stabilizes before they have reached their functional potential.  Therefore, although Harmony always teaches that nursing anchors all Medicare Part A skilled admissions, there are instances when the Rehab Department is the driving force behind the patients discharge plan. 
Medicare supports providing rehab services to help the patient achieve their prior level of function.  This should be thoroughly investigated and considered when discussing the patient's potential discharge and Medicare length of stay.  The following is a brief list of questions to consider before taking a patient off therapy:
Is the patient going home with an assistive device they did not previously use?  Does the patient have the potential to progress to a less restrictive device?
Are we asking caregivers to assist the patient with any of their ADL or IADL tasks that the patient was able to do before?  Does the patient have the potential to do these tasks on their own with further training?
If the patient is returning to an assisted living facility, did the patient utilize all of their services before or will they be using services that they previously did not?  Do they have the potential to resume their prior routine?
Even though the patient has assistance available (ALF, spouse, etc.) do they want to rely on their caregiver or are there activities the patient would like to be able to do on their own?
Does the patient enjoy making their bed every morning?
Would the patient prefer if other people did not wash their undergarments?
Does the patient like to make their own afternoon tea?
If yes is the answer to any of these questions it is clinically appropriate to investigate continuing the therapy program and further progress the patient to their highest functional ability.  It is important to update the therapy plan of care to include new goals specific to these higher functioning tasks and ensure that it documented that these goals directly relate to the patient's prior level of function and appropriate Medicare length of say. 

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Topics: Length of Stay, ADL Coding, Rehab Case Management

Nursing Documentation-ADL Coding

Posted by The Harmony Team on Wed, May 26, 2010

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.  

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Topics: ADL Coding

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