MDS 3.0 Updates 2018 Cassie Crafton R.N., CDP, RAC-CT - Arkansas Health Care Association
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MDS 3.0 Updates 2018 Cassie Crafton R.N., CDP, RAC-CT
Objectives
• Understand new MDS 3.0 items in Sections GG, I, J, M, N and
O that will be effective October 1st, 2018
• Know which MDS 3.0 items that will be removed and language
changes
• Understand and interpret Quality Measures, Quality Reporting
Program (QRP), and Value-based Purchasing (VBP)
• Review Five Star Reports and Nursing Home Compare
Clarifications with Resident Interviews
Timing of Interviews
• Section C (BIMS)- to be conducted preferably on the ARD or
the day before
• Section D (PHQ-9)- to be conducted preferably on the ARD or
the day before
• Section F (Activities/Preferences)- during the 7 day look back
period
• Section J (Pain)- to be conducted anytime during the 5 day
lookback period preferably on the ARD or the day before
Clarifications with Resident Interviews
• Staff interview should not be completed in place of resident
interview IF the resident interview could have been completed
• B0700 should NOT be coded as “Rarely/Never Understood” if
any of the resident interviews were completed
PPS Changes • Section GG changes • Admission and Discharge Assessments • Language Changes
PPS: Admission Assessment • Admission: The 5 - Day PPS assessment (A0310B = 01) is the first Medicare - required assessment to be completed when the resident is admitted for a SNF Part A stay • This functional assessment must be completed within the first 3 days (3 calendar days) of the Medicare Part A stay, starting with the date in A2400B. Start of Most Recent Medicare Stay, and the following 2 days, ending at 11:59 p.m. on Day 3
PPS: Discharge Assessment
• The Part A PPS Discharge Assessment is required to be
completed when the resident’s Medicare Part A Stay ends (as
documented in A2400C. End of Most Recent Medicare Stay),
either:
– As a standalone assessment when the resident’s Medicare Part A
stay ends, but the resident remains in the facility, or
– May be combined with an Omnibus Budget Reconciliation Act of
1987 (OBRA) Discharge if the Medicare Part A stay ends on the
day of, or 1 day before the resident’s Discharge Date (A2000)
Coding Tips
• Admission Performance and Discharge Goals are coded on
every Admission Assessment (Start of Part A PPS Stay)
regardless of length of stay and planned or unplanned
discharge
• If the resident has an incomplete stay:
– Complete admission performance and goals
– Discharge self-care and mobility performance items are not
required
Section GG- Intent • Functional status is assessed based on the need for assistance when performing self - care and mobility activities • Residents in SNFs have self - care and mobility limitations and are at risk for further functional decline and complications because of limited mobility
New Items Section GG
• GG 0100 Prior Functioning: Everyday Activities
• Intent: To identify resident’s functional status prior to current
illnessSection GG Prior Functioning
• Self Care: Code the resident’s need for assistance with bathing,
dressing, using the toilet, or eating prior to the current illness,
exacerbation, or injury
• Indoor Mobility (Ambulation): Code the resident’s need for
assistance with walking from room to room (with or without a
device such as cane, crutch, or walker) prior to the current illness,
exacerbation, or injury
• Stairs: Code the resident’s need for assistance with internal or
external stairs (with or without a device such as cane, crutch, or
walker) prior to the current illness, exacerbation, or injury
• Functional Cognition: Code the resident’s need for assistance with
planning regular tasks, such as shopping or remembering to take
medication prior to the current illness, exacerbation, or injurySection GG: Prior Functioning
• Coding Instructions:
– Code 3, Independent- no assistance, with/without assistive
devices
– Code 2, Needed Some Help- needed partial assistance
– Code 1, Dependent- helper completed activity; includes
needing 2 person assist
– Code 8, Unknown
– Code 9, Not Applicable- were not applicable to the
resident’s prior to current illnessSection GG
• New Item Added: G110- Prior Device Used
– Check all that applyGG0110 Prior Device Used
• Clarifications
– Walker: any type of walker (pickup walker, hem-
walker, rolling walkers, platform walkers.
– Mechanical Lift: sit-to-stand, stand assist, full body
lifts (e.g., Hoyer)Section GG • New items GG0130 Self-Care 4 new items
Section GG: New items GG0170 • Mobility 7 new items
Section GG: GG0170 Mobility
Section GG: GG 0170 Mobility
Section GG • Coding of GG0130 and GG0170 • 4 “Not attempted” codes items • 10- Not attempted due to environmental limitations ( NEW)
Section GG: Coding Instructions • Admission Performance- code based on the first 3 days of Medicare Part A stay • Discharge Performance- code based on last 3 days of Medicare Part A stay • Coding is based on “usual performance” will require clinical judgement • If activity occurs multiple times (e.g., eating, toileting, dressing, bed mobility activities, bed/chair transfers, do not code most dependent, do not code most independent • Some items may only be assessed once, code that status
Changes to Section GG
• Coding and item definitions clarified and aligned:
– “Contact guard” added to definition of code 04,
Supervision or touching assistance
– Eating (Item GG0130A) definition clarified to include the
ability to bring food and liquid to the mouth and swallow
food once the meal is placed before the resident
– Oral hygiene (Item GG0130B) revised to: …The ability to
insert and remove dentures into and from the mouth and
manage denture soaking and rinsing with use of
equipmentChanges to Section GG:
• MDS item definitions clarified and aligned:
– Toileting hygiene (GG0130C) revised to: … adjust clothes
before and after voiding or having a bowel movement
– Sit to stand (GG0170D): revised to include wheelchair …
from sitting in a chair, wheelchair, or on the side of the bed
– Wheelchair/scooter à wheelchair and/or scooterSteps for Assessment Section GG
• Assess the resident’s self care and mobility performance
based on direct observation; the resident’s self-report; and
reports from clinicians, care staff, or family reports,
documented in the resident’s medical record during the 3-day
assessment period
• Residents should be allowed to perform activities as
independently as possible, as long as they are safe
• If helper assistance is required because a resident’s
performance is unsafe or of poor quality, score according to
amount of assistance provided
• For Section GG, a “helper” is defined as facility staff who are
direct employees and facility - contracted employees (e.g.,
rehabilitation staff, nursing agency staff)Steps for Assessment Section GG
• Activities may be completed with or without assistive
device(s). Use of assistive device(s) to complete an activity
should not affect coding of the activity.
• If the resident’s self-care and mobility performance varies
during the assessment period, record the resident’s usual
ability to perform each activity.
-Do not record the resident’s most independent performance
-Do not record the resident’s most dependent performance
• Refer to facility, Federal, and State policies and procedures to
determine which SNF staff members may complete an
assessment. Resident assessments are to be done in
compliance with facility, Federal, and State requirements.Activity Not Attempted
CodesCoding scenario
Answer: • Code 02: Substantial or Maximal Assist • CMS states that when coding bladder and bowel take the lower score. Since the helper had to provide more than HALF of the task then the correct coding would be 02.
Coding: Shower/Bathing
ANSWER • CODE: 04 Supervision or touching assistance • CMS states that transfers on or off tub bench is NOT part of the Shower/bathing assessment
Coding: Upper Body
Answer: • Code: 02 Substantial or maximal assist • CMS states that Helper is doing more than HALF of the effort
Lower Body Dressing
Answer: • Code 03 Partial/Moderate Assistance • CMS states prothesis is considered to be part of clothing. Helper is completing less than HALF of the effort
Footwear
Answer: • Code 04: Supervision or Touching Assistance • CMS states due to occasional loss of balance a helper provides touching assistance while bending over.
Discharge Goals
Discharge Coding Tips
• Use the six-point scale or ‘activity was not attempted” codes
to code the resident’s Discharge Goal(s). Use of codes 07, 09,
10, or 88 is permissible to code discharge goal(s).
• For the SNF QRP, a minimum of one self-care or mobility goal
must be coded. However, facilities may choose to complete
more than one self-care or mobility discharge goal.
• Use of a dash ( – ) is permissible for any remaining self - care
or mobility goals that were not coded.
• Using the dash in this allowed instance after the coding of at
least one goal does not affect Annual Payment Update (APU)
determination.Discharge Coding Tips
• Licensed qualified clinicians can establish a resident’s
Discharge Goal(s) at the time of admission based on:
– Resident’s prior medical condition(s)
• Prior and current self care and mobility status
• Discussions with resident and family concerning discharge goals
– Professional’s standard of practice
– Expected treatments
– Resident motivation to improve
– Anticipated length of stay
– Resident’s planned discharge setting/home
• Goals should established as part of the resident’s care planDischarge: Roll
Answer: • Code: 01 Dependent • Resident required Two Helpers to compete task
Car Transfers
Answer: • Code 04 Supervision or Touching Assistance • Guidance states that opening and closing doors and seatbelts are not a part of assessment.
Section GG: Summary
5-Day Assessment Column
1 5-day Assessment Column 2
• All items in column 1 • Must have at least one
must be completed discharge goal completed
(may be in GG0130 or
• Base coding on first 3 GG0170)
days of Med A stay • May use 1 of the 4 “not
• No dashes attempted” as goals
• Dash goals not
• Choose any number completed
from the 1-6 scale OR • Goals may indicate an
• 1 of the 4 “not improvement, maintain,
attempted” codes or possible declineSection GG: Summary
SNF PPS Discharge
Assessment Use of Dashes
• All items in Column 3 • Section GG is the
must be completed number 1 reason for
2% penalty
• Base coding on last 3
days of Med A stay • Confusion on coding
rules
• No dashes • Use of dashes
• Chose any number • Only items used for
from the 1-6 scale or QRP QM calculation
• 1 of the 4 “not are subject to the 2%
attempted codes penalty if dashedSection I: New item I0020 • Resident’s primary medical condition • Provides check boxes for 14 different items
Section I: New item I0020 • Select the condition that represents the primary condition that resulted in resident’s admission to the nursing facility • If number 14 selected, enter an appropriate ICD-10- CM code in I0020 • If any condition 1-13 selected, then item I0020 is left blank • Includes the primary medical condition in Section I, Active Diagnoses
Section I
• Code 01, Stroke, if the resident’s primary medical condition
category is due to stroke. Example include ischemic stroke,
subarachnoid hemorrhage, cerebral vascular accident, and
other cerebrovascular disease
• Code 02, Non-Traumatic Brain Dysfunction, if the resident’s
primary medical condition category is non-traumatic brain
dysfunction. Examples include Alzheimer’s disease, dementia
with or without behavioral disturbance, malignant neoplasm
of brain, and anoxic brain damage
• Code 03, Traumatic Brain Dysfunction, if the resident’s
primary medical condition category is traumatic brain
dysfunction. Examples include traumatic brain injury, severe
concussion, and cerebral laceration and contusionSection I
• Code 04, Non-Traumatic Spinal Cord Dysfunction, if the
resident’s primary medical condition category is non-traumatic
spinal cord injury. Examples include spondylosis with myelopathy,
transverse myelitis, spinal cord lesion due to spinal stenosis, and
spinal cord lesion due to dissection of aorta
• Code 05, Traumatic Spinal Cord Dysfunction, if the resident’s
primary medical condition category is due to traumatic spinal cord
dysfunction. Examples include paraplegia and quadriplegia
following trauma
• Code 06, Progressive Neurological Conditions, if the resident’s
primary medical condition category is a progressive neurological
condition. Examples include multiple sclerosis and Parkinson’s
diseaseSection I
• Code 07, Other Neurological Conditions, if the resident’s
primary medical condition category is other neurological
condition. Examples include cerebral palsy, polyneuropathy,
and myasthenia gravis
• Code 08, Amputation, if the resident’s primary medical
condition category is an amputation. An example is acquired
absence of limb
• Code 09, Hip and Knee Replacement, if the resident’s primary
medical condition is due to a hip or knee replacement. An
example is total knee replacement. If hip replacement is
secondary to hip fracture, code as fracture.Section I
• Code 10, Fractures and Other Multiple Trauma, if the
resident’s primary medical condition category is fractures and
other multiple trauma. Examples include hip fracture, pelvic
fracture, and fracture of tibia and fibula
• Code 11, Other Orthopedic Conditions, if the resident’s
primary medical condition category is other orthopedic
condition. An example is unspecified disorders of joint
• Code 12, Debility, Cardiorespiratory Conditions, if resident’s
primary medical condition category is debility or a
cardiorespiratory condition. Examples include COPD, asthma,
and other malaise and fatigueSection I
• Code 13, Medically Complex Conditions, if the resident’s
primary medical condition category is a medically complex
condition. Examples include diabetes, pneumonia, chronic
kidney disease, open wounds, pressure ulcer/injury, infection,
and disorders of fluid, electrolyte, and acid-base balance
• Code 14, Other Medical Condition, if the resident’s primary
medical condition category is not one of the listed categories.
Enter the ICD-10 code, including the decimal, in I0020A. If item
I0020 is coded 1-13, do not complete I0020ASection J: New item J2000 Prior Surgery
• Indicate if the resident has had a major surgery in the 100 days
prior to admissionSection J: J2000
• Examples
– Admitted to SNF after hip replacement surgery 5 days
prior. Code 1, Yes, meets criteria
– Cyst removal in outpatient One month prior to
admission. Code 0, No, does not meet “major
surgery criteria
– Gall bladder surgery performed 6 months prior to
admission. Code 0, No, does not meet criteria due to
greater than 100 days agoSection K
• Change in Coding Instructions related to K0510 and K0710
• CMS no longer requires completion of Column 1 for K0510C or
K0510D. Some states may still require. Arkansas will notSection K
• Change in coding instructions to K0710
– CMS no longer requires completion of Column 1 K0710 A and B.
Some states may still require. (Arkansas does not)Section M: Intent • The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. • It is important to recognize and evaluate each resident’s risk factors and to identify and evaluate all areas at risk of constant pressure.
Section M: Intent • A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Be certain to include in the assessment process a holistic approach. • It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound.
Section M: Intent
• CMS adheres to the following guidelines:
– Stage 1 pressure injuries and deep tissue injuries
(DTIs) are termed “pressure injuries” because they
are closed wounds
– Stage 2, 3, or 4 pressure ulcers, or unstageable ulcers
due to slough or eschar, are termed “pressure ulcers”
because they are usually open wounds
– Unstageable ulcers/injuries due to non - removable
dressing/device are termed “pressure ulcers/injuries”
because they may be open or closed woundsSection M: Definitions
• New: The term “device” was added to items: M0300E–
M0300E2Section M: Definitions
• New:
– Removed the term “suspected deep tissue injury
in evolution” and replaced with “deep tissue
injury” to items M0300G and M0300G1Section M: Definitions
• Pressure Ulcer/Injury Risk Factor
– Examples of risk factors include immobility and decreased
functional ability; co-morbid conditions such as end-stage
renal disease, thyroid disease, or diabetes; drugs such as
steroids; impaired diffuse or localized blood flow; resident
refusal of care and treatment; cognitive impairment;
exposure of skin to urinary and fecal incontinence;
microclimate, malnutrition, and hydration deficits; and a
healed ulcerSection M: Definitions
• Pressure Ulcer/Injury
– A pressure ulcer/injury is localized injury to the
skin and/or underlying tissue, usually over a
bony prominence, as a result of intense and/or
prolonged pressure, or pressure in combination
with shear. The pressure ulcer/injury can present
as intact skin or an open ulcer and may be
painful.Section M: Deletions
• Items Retiring October 1, 2018
– M0300B3 Date of Oldest Stage 2 Pressure Ulcer
– M0610 Dimensions of Unhealed Stage 3 or 4 Pressure
Ulcers or Eschar
– M0700 Most Severe Tissue Type for Any Pressure Ulcer
– M0800 Worsening in Pressure Ulcer Since Prior
Assessment (Omnibus Budget Reconciliation Act (OBRA) or
Scheduled PPS) or Last Admission/Entry or Reentry
– M0900 Healed Pressure UlcersSection M: Coding
• Steps for completing M0300A–G
1. Determine Deepest Anatomical Stage
2. Identify Unstageable Pressure Ulcers/Injuries
3. Determine “Present on Admission”
On the Admission Assessment, “on admission” means as
close to the actual time of admission as possible
On each assessment determine the number of pressure
ulcers/injuries present and determine the number of these that were
present on admission
Manual instruction 9 under Step 3: If a pressure ulcer was
numerically staged, then became unstageable, and is subsequently
debrided sufficiently to be numerically staged, compare its numerical
stage before and after it was unstageable. If the numerical stage has
increased, code this pressure ulcer as not present on admission.Coding Scenario 1
• A resident develops a Stage 2 pressure ulcer while
at the nursing facility. The resident is hospitalized
due to pneumonia for 8 days and returns with a
Stage 3 pressure ulcer in the same location. How
would you code M0300C1 and M0300C2 on the
5Day PPS assessment?Answer: • Stage 3 • Present on admission
Coding Scenario 2
• A resident is admitted to a nursing facility with a short
leg cast to the right lower extremity. He has no visible
wounds on admission but arrives with documentation
that a pressure ulcer exists under the cast. Two weeks
after admission to the nursing facility, the cast is
removed by the physician. Following the removal of the
cast, the right heel is observed and assessed as a Stage 3
pressure ulcer, which remains until the subsequent
assessment.
• How would you code M0300C1 on the subsequent
assessment?Answer • Stage 3 • Present on admission
Coding Scenario 3 • Mr. H was admitted with a known pressure ulcer/injury due to a non-removable dressing. Ten days after admission, the surgeon removes the dressing, and a Stage 2 pressure ulcer is identified. Two weeks later the pressure ulcer is determined to be a full thickness ulcer and is at that point Stage 3. It remains Stage 3 at the time of the next assessment. • How would you code M0300C1?
Answer • Stage 3 • Not present upon admission
Section M: Summary
• Wording revisions due to Ulcer vs Injury
– Injury is used for closed wounds (Stage 1, Deep Tissue Injury)
– Ulcer is used for open wounds (Stage 2-4, Unstageable due to
slough/eschar
• Significant Change in Definition related to “Present on
Admission”
– If the pressure ulcer/injury was present on admission/entry or
reentry and becomes unstageable due to slough or eschar, during
the resident’s stay, the pressure ulcer/injury is coded at M0300F
and should not be coded as “present on admission”Section M: Summary
• If two pressure ulcer/injuries occur on the same bony
prominence and are separated, at least superficially, by skin,
then count them as two separate pressure ulcer/injuries.
Stage and measure each pressure ulcer/injury separately.
• M1040D-open lesions that develop as part of a disease or
condition and are not coded elsewhere on the MDS, such as
wounds, boils, cysts, and vesicles, should be coded in this
item.
• M1040G-do not code cuts/lacerations or abrasions here.
Although not recorded on the MDS, these skin conditions
should be considered in the plan of careSection M: Summary • Deleted Items: – M0610 (Wound Measurements) – M0700 (Most Severe Tissue Type Present) – M0800 (New or Worsened Pressure Ulcer) – M0900 (Healed Pressure Ulcers)
Section N
• Three New items added
• New QRP QM (drug regimen review)
• Drug Regimen Review
– Upon admission medications reviewed
– Significant clinical issues reported to provider
(physician or NP) and follow up
orders/recommendations implemented by midnight
of the following day
– Upon discharge any clinically significant issues were
reported to provider and orders/recommendations
implemented by midnight the next daySection N: N2001 and N2003 • To be completed on 5 day PPS assessment • Two questions related to resident admission (drug regimen review)
Section N: N2001 and N2003 • Coding N2001 0- No, no issue found (Go to Section O) 1- Yes, Issue found (continue to N2003) 9- NA, Resident not taking medications (skip to O) • Coding N2003 (Only completed if answered YES to N2001) 0- No 1- yes
Section N- N2005 • Covers entire stay- from Admission throughout stay • If N2003 us coded as “No”, then N2005 must also be “No”
Drug Regimen Review
• If the physician prescribes an action that will take longer than
midnight of the next calendar day to complete, then code 1,
YES, should still be entered, if by midnight of the next calendar
day, the clinician has taken the appropriate steps to comply
with the recommended action.
• Example of a physician-recommended action that would take
longer than midnight of the next calendar day to complete.
– The physician writes an order instructing the clinician to monitor
the medication issue over the next three days and call if the
problem persists.Drug Regimen Review
• Includes all medications
– Prescribed and over the counter medications
– Administered by an route (including oral, topical, inhalant,
injection, sublingual, parenteral, and by infusion
– Includes total parenteral nutrition (TPN) and oxygen
• A clinical significant medication issue is a potential or actual
issue that, in the clinician’s professional judgement, warrants:
– Physician (or physician-designee) communication and
– Completion of prescribed/recommended action by midnight of
the next calendar dayDrug Regimen Review • Clinically Significant Issues – Medication prescribed despite medication allergies – Adverse reactions to medications – Duplicate therapy – Wrong patient, drug, dose, route, and time errors – Omissions – Drug interactions – Ineffective drug therapy – Nonadherence to drug therapy
Drug Regimen Review
• Who can perform the Drug Regimen Review?
– CMS does not provide guidance on who can or cannot code the DRR
items
– Each facility determines their own policies and procedures for
completing the assessments
– Each facility provides patient care according to their unique
characteristics and standards
– Not strictly a pharmacy function
• Communication Methods
– In person
– Telephone, voicemail
– Electronic means
– Fax
– Any means that appropriately conveys messages of patient statusDrug Regimen Review
• Drug Regimen Review performed:
– Upon admission or as close to Admission as
possible (per CMS)
– Should be completed within first 24 hours
– Drug Regimen Review is ongoing throughout stay
• Each new drug order
• Each revision or change in drug order
• Change in clinical statusDrug Regimen Review
• Medication Reconciliation
– Compare admission orders with medications received
in hospital, prior to hospitalizations
– Review Diagnosis and Allergies
– Review Labs and ongoing lab monitoring (coumadin,
etc.)Drug Regimen Review
• Operational Changes
– Develop and review current processes
– Involve consultant pharmacist
– Need to educate nursing staff on drug regimen
review and requirements
– Educate providers on new regulations and
requirements
– Documentation:
• Nurse document DRR upon admission (review,
physician notification, and recommendation)Section O
• Chemotherapy Clarification
– Hormonal and other agents administered to prevent
the recurrence or slow the growth of cancer should
NOT be coded in this item, as they are not considered
chemotherapy for the purpose of coding the MDS
– Examples: Tamoxifen, Evista, Fareston, Arimidex,
Aromasin, Femara, Lupron, Eligard, Lupron Depot,
ViadurSection O
• Clarifications for O0100F and O0200G
– O0100F now defined as an invasive mechanical ventilator
(ventilator or respirator)
– O0100G now named a non-invasive mechanical ventilator
(BiPAP/CPAP)
• Pneumococcal
– Removed old CDC diagram
– Follow guidance at :
• https://www.cdc.gov/vaccines/vpd/pneumo/downloads/
pneumo-vaccine-timing.pdfCare Area Assessments • Opioids have been added to the care areas – Delirium – Visual Function – Communication – Activities of Daily Living – Incontinence – Mood State – Falls – Dental Care – Pressure Ulcer/Injury
Care Area Assessments
• Updates to CAAs
– Behavioral Review of Indicators updated with
inclusion of Section E items
• Potential Indicators of Psychosis
• Behavioral Symptoms
– Alarm use has been added as a factor to can cause or
exacerbate behaviorSummary
• Resident Interviews
– Updated to day of ARD or day before
• Section GG
– Updated items
– Addition of prior functioning
– Self care
– Mobility
• Section I
– New item I0020 (Primary Medical Condition)
• Section J
– Prior SurgerySummary
• Section K
– K0510C (Mechanically altered diet)
– K0510D (Therapeutic Diet)
– K0710A (Proportion of total calories)
– K0710B (Average fluid intake)
• Section M
– Language changes
– Deleted items (M0300B3, M0610A-C, M0700, M0800A-F,
M0900A-D)
– Clarification “present upon admission”Summary
• Section N
– Drug Regimen Review
• Medication Review
• Medication Follow-up
• Medication Intervention
• Section O
– Chemotherapy medication clarification
– Invasive mechanical ventilator separated from non invasive
mechanical ventilator
• Updates to Care Area Assessments worksheets
– Opioids added to care areasQuestions or Comments?
Thank You.
Cassie Crafton RN, CDP, RAC-CTYou can also read
