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MDS 3.0 Changes Effective October 1, 2018

MDS 3.0 Changes Effective October 1, 2018. Sue Pinette RN, RAC-CT September 2018. MDS 3.0 Changes Effective 10/1/18. Centers for Medicare & Medicaid Services’ Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual October 2018

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MDS 3.0 Changes Effective October 1, 2018

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  1. MDS 3.0 ChangesEffective October 1, 2018 Sue Pinette RN, RAC-CT September 2018

  2. MDS 3.0 Changes Effective 10/1/18 Centers for Medicare & Medicaid Services’ Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual October 2018 Changes for Long-Term Care (RUG III) and PPS (RUG IV) The only change in Chapter 2 of RAI Manual is the updating of a link of pages 2-4: https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Post-Acute-Care-QualityInitiatives/IMPACT-Act-of-2014/IMPACT-Act-of-2014-DataStandardization-and-Cross-Setting-Measures.html Maine Department of Health and Human Services

  3. MDS 3.0 Changes Effective 10/1/18 Section A: No changes Section B B0700, page B-7: 4. Consult with the primary nurse assistants (over all shifts), if available,and the resident’s family, and speech-language pathologist. Coding Tips and Special Populations • This item cannot be coded as Rarely/Never Understood if the resident completed any of the resident interviews, as the interviews are conducted during the look-back period for this item and should be factored in when determining the residents’ ability to make self understood during the entire 7-day look-back period. • While B0700 and the resident interview items are not directly dependent upon one another, inconsistencies in coding among these items should be evaluated. Maine Department of Health and Human Services

  4. MDS 3.0 Changes Effective 10/1/18 Section C Steps for Assessment • Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards. 2. Determine if the resident is rarely/never understood verbally, in writing, or using another method. Coding Instructions Code 0, no: if the interview should not be conducted because the resident is rarely/never understood; cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available. Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Maine Department of Health and Human Services

  5. MDS 3.0 Changes Effective 10/1/18 Coding Tips • Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. • If the resident interview was not conducted within the look-back period (preferably the day before or the day of the ARD), item C0100 must be coded 1, Yes, and the standard “no information” code (a dash “-”) entered in the resident interview items. • Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted, but was not done. Maine Department of Health and Human Services

  6. MDS 3.0 Changes Effective 10/1/18 Section D Steps for Assessment • Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards. 2. Determineif the resident is rarely/never understood verbally, in writing, or using another method. Coding Instructions Code 0, no: if the interview should not be conducted because the resident is rarely/never understood; cannot respond verbally, in writing, or using another method; or an interpreter is needed, but not available. Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood verbally, in writing, or using another method, and if an interpreter is needed, one is available. Maine Department of Health and Human Services

  7. MDS 3.0 Changes Effective 10/1/18 Section D Coding Tips • Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. • If the resident interview was not conducted within the look-back period (preferably the day before or the day of)the ARD, item D0100 must be coded 1, Yes, and the standard “no information” code (a dash “-”) entered in the resident interview items. • Do not complete the Staff Assessment for Resident Mood items (D0500) if the resident interview should have been conducted, but was not done. Maine Department of Health and Human Services

  8. MDS 3.0 Changes Effective 10/1/18 Section E: No changes Section F Steps for Assessment • Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards. 2. Determine if the resident is rarely/never understood verbally, in writing, or using another method. If the resident is rarely or never understood, attempt to conduct the interview with a family member or significant other. 3. If resident is rarely/never understood and a family member or significant other is not available, skip to item F0800, Staff Assessment of Daily and Activity Preferences. Code 0 = no Code 1 = yes Maine Department of Health and Human Services

  9. MDS 3.0 Changes Effective 10/1/18 Section GG Intent: This section includes items about functional abilities and goals. It includes items focused on prior function, admission performance, discharge goals, and discharge performance. Functional status is assessed based on the need for assistance when performing self-care and mobility activities. Maine Department of Health and Human Services

  10. MDS 3.0 Changes Effective 10/1/18 For the purposes of completing Section GG, a “helper” is defined as facility staff who are direct employees or facility-contracted employees (e.g., rehabilitation staff, nursing agency staff). When helper assistance is required because a resident’s performance is unsafe or of poor quality, consider only facility staff when scoring according to the amount of assistance provided. Maine Department of Health and Human Services

  11. MDS 3.0 Changes Effective 10/1/18 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. • For the 5-Day PPS assessment, code the resident’s functional status based on a clinical assessment of the resident’s performance that occurs soon after the resident’s admission. This functional assessment must be completed within the first three 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 two days, ending at 11:59 PM on day three. The assessment should occur, when possible, prior to the resident benefitting from treatment interventions in order to determine the resident’s true admission baseline status. Even if treatment started on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment. Maine Department of Health and Human Services

  12. MDS 3.0 Changes Effective 10/1/18 For the discharge assessment (i.e., standalone Part A PPS or combined OBRA/Part A PPS), code the resident’s discharge functional status, based on a clinical assessment of the resident’s performance that occurs as close to the time of the resident’s discharge from Medicare Part A as possible. This functional assessment must be completed within the last three calendar days of the resident’s Medicare Part A stay, which includes the day of discharge from Medicare Part A and the two days prior to the day of discharge from Medicare Part A. Maine Department of Health and Human Services

  13. MDS 3.0 Changes Effective 10/1/18 Definition: Usual Performance A resident’s functional status can be impacted by the environment or situations encountered at the facility. Observing the resident’s interactions with others in different locations and circumstances is important for a comprehensive understanding of the resident’s functional status. If the resident’s functional status varies, record the resident’s usual ability to perform each activity. Do not record the resident’s best performance and do not record the resident’s worst performance, but rather record the resident’s usual performance. 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. Maine Department of Health and Human Services

  14. MDS 3.0 Changes Effective 10/1/18 At admission, when coding the resident’s usual performance, “effort” refers to the type and amount of assistance the helper provides in order for the activity to be completed. The 6-point rating scale definitions include the following types of assistance: setup/cleanup, touching assistance, verbal cueing, and lifting assistance. On discharge, use the same 6-point scale or “activity was not attempted” codes that are used for the admission assessment to identify the resident’s usual performance on the discharge assessment. Maine Department of Health and Human Services

  15. MDS 3.0 Changes Effective 10/1/18 Coding a dash (“-”) in these items indicates “No information.” CMS expects dash use for SNF QRP items to be a rare occurrence. Use of dashes for these items may result in a 2% reduction in the annual payment update. If the reason the item was not assessed was that the resident refused (code 07), the item is not applicable (code 09), or the activity was not attempted due to medical condition or safety concerns (code 88), use these codes instead of a dash (“-”). Maine Department of Health and Human Services

  16. MDS 3.0 Changes Effective 10/1/18 Coding Reminders Documentation in the medical record is used to support assessment coding of Section GG. Data entered should be consistent with the clinical assessment documentation in the resident’s medical record. (RAI Manual, page GG-7) Maine Department of Health and Human Services

  17. MDS 3.0 Changes Effective 10/1/18 Coding for GG0100 for admission and discharge assessments Maine Department of Health and Human Services

  18. MDS 3.0 Changes Effective 10/1/18 Maine Department of Health and Human Services

  19. MDS 3.0 Changes Effective 10/1/18 Maine Department of Health and Human Services

  20. MDS 3.0 Changes Effective 10/1/18 Coding for GG0130 and GG0170 for admission and discharge assessments Maine Department of Health and Human Services

  21. MDS 3.0 Changes Effective 10/1/18 Maine Department of Health and Human Services

  22. MDS 3.0 Changes Effective 10/1/18 Maine Department of Health and Human Services

  23. MDS 3.0 Changes Effective 10/1/18 Maine Department of Health and Human Services

  24. MDS 3.0 Changes Effective 10/1/18 Assess the resident’s self-care performance status based on: • Direct observation • The resident’s self-report • Reports from qualified clinicians, family and/or care staff Observations and reports must be documented in the resident’s medical record during the three-day admission assessment period, starting with the date in A2400B, Start of most recent Medicare stay. Maine Department of Health and Human Services

  25. MDS 3.0 Changes Effective 10/1/18 Section GG0130 – Self-Care:

  26. MDS 3.0 Changes Effective 10/1/18 Section GG0130 – Self Care: Discharge

  27. MDS 3.0 Changes Effective 10/1/18 Section GG0170 – Mobility:

  28. MDS 3.0 Changes Effective 10/1/18 Section GG0170 – Mobility (cont.)

  29. MDS 3.0 Changes Effective 10/1/18 Section GG0170 – Mobility Discharge Performance (cont.)

  30. MDS 3.0 Changes Effective 10/1/18 Section GG0170 – Mobility Discharge Performance (cont.)

  31. MDS 3.0 Changes Effective 10/1/18 Section GG: Summary The items in Section GG are used to calculate the SNF QRP Function quality measure. Section GG focuses on prior function, admission performance, discharge goals, and discharge performance. Functional status is assessed based on the need for assistance when performing self-care and mobility activities. 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.

  32. MDS 3.0 Changes Effective 10/1/18 a. Convert episodes of Total Dependence (4) to Extensive Assistance (3).– if this change makes 3 episodes at Extensive Assistance (3), code as Extensive Assistance (3). Did the resident require a combination of Total Dependence and Extensive Assistance 3 or more times but not 3 times at any one level? (Items3a and& 3b Rule of 3) Did the resident require a combination of Total Dependence, Extensive Assistance, and/or Limited Assistance that total 3 or more times but not 3 times at any one level? (Item 3cb Rule of 3) Maine Department of Health and Human Services

  33. MDS 3.0 Changes Effective 10/1/18 Section I: Active Diagnoses

  34. MDS 3.0 Changes Effective 10/1/18 Item I5100 Quadriplegia Quadriplegia primarily refers to the paralysis of all four limbs, arms and legs, caused by spinal cord injury. Coding I5100 Quadriplegia is limited to spinal cord injuries and must be a primary diagnosis and not the result of another condition. Functional quadriplegia refers to complete immobility due to severe physical disability or frailty. Conditions such as cerebral palsy, stroke, contractures, brain disease, advanced dementia, etc. can also cause functional paralysis that may extend to all limbs hence, the diagnosis functional quadriplegia. Maine Department of Health and Human Services

  35. MDS 3.0 Changes Effective 10/1/18 Section J Steps for Assessment • Interact with the resident using his or her preferred language. Be sure he or she can hear you and/or has access to his or her preferred method for communication. If the resident appears unable to communicate, offer alternatives such as writing, pointing, sign language, or cue cards. 2. Determine if the resident is rarely/never understood verbally, in writing, or using another method. If the resident is rarely/never understood, skip to item J1100, Shortness of Breath Coding Instructions Code 0, no: if the interview should not be conducted because the resident is rarely/never understood; cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available. Code 1, yes: if the interview should be conducted because the resident is at least sometimes understood. Maine Department of Health and Human Services

  36. MDS 3.0 Changes Effective 10/1/18 Section J Coding Tips • Attempt to conduct the interview with ALL residents. This interview is conducted during the look-back period of the Assessment Reference Date (ARD) and is not contingent upon item B0700, Makes Self Understood. • If the resident interview was not conducted within the look-back period (preferably the day before or the day of)the ARD, item J0200 must be coded 1, Yes, and the standard “no information” code (a dash “-”) entered in the resident interview items. • Do not complete the Staff Assessment for Pain items (J0800–J0850) if the resident interview should have been conducted, but was not done. Maine Department of Health and Human Services

  37. MDS 3.0 Changes Effective 10/1/18 J2000: Prior Surgery Generally, major surgery for item J2000 refers to a procedure that meets all the following criteria: 1. The resident was an inpatient in an acute care hospital for at least one day in the 100 days prior to admission to the skilled nursing facility (SNF), 2. The resident had general anesthesia during the procedure, and 3. The surgery carried some degree of risk to the resident’s life or the potential for severe disability.

  38. MDS 3.0 Changes Effective 10/1/18 J2000: Prior Surgery Examples: 1. Surgical removal of a skin tag from her neck a month and a half ago; the procedure was done as an outpatient. 2. Six months ago, a resident was admitted to the hospital for five days following a bowel resection (partial colectomy) for diverticulitis; no other surgeries since that time. 3. The resident was transferred to the facility immediately following a four-day acute care hospital stay related to dehiscence of a surgical wound subsequent to a complicated cholecystectomy for which she received general anesthesia. The attending physician also noted diagnoses of anxiety, diabetes, and morbid obesity in her medical record.

  39. MDS 3.0 Changes Effective 10/1/18 Section K CMS does not require completion of Column 1 for items K0510C and K0510D; however, some states continue to require its completion. It is important to know your state’s requirements for completing these items. Maine will continue to require completion of K0510C and K0510D. CMS does not require completion of Column 1. While Not a Resident for items K0710A and K0710B; however, some states continue to require its completion. It is important to know your state’s requirements for completing these items. Maine will continue to require completion of K0710A and K0710B. Maine Department of Health and Human Services

  40. MDS 3.0 Changes Effective 10/1/18 Maine Department of Health and Human Services

  41. MDS 3.0 Changes Effective 10/1/18 Maine Department of Health and Human Services

  42. MDS 3.0 Changes Effective 10/1/18 Section M There are 50 pages in the change document for Section M. FYI… There were 56 pages in the change document for Section GG. Luckily, the changes are far less complicated! Maine Department of Health and Human Services

  43. MDS 3.0 Changes Effective 10/1/18 CMS has further adopted the Section M guidelines to be more consistent with the National Pressure Ulcer Advisory Panel (NPUAP). Thus, all references to PRESSURE ULCER throughout Section M have been changed to PRESSURE ULCER/INJURY. The following items has been removed from the MDS: • M0300B3. Date of the oldest Stage 2 Pressure Ulcer • M0610. Dimensions of Unhealed Stage 3 or 4 Pressure Ulcer or Unstageable due to Eschar • M0700. Most Severe Tissue Type for Any Pressure Ulcer • M0800. Worsened in Pressure Ulcer Since Prior Assessment • M0900. Healed Pressure ulcers Maine Department of Health and Human Services

  44. MDS 3.0 Changes Effective 10/1/18 Definitions Pressure Ulcer/Injury: (RAI Manual, page M-4) 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. Healed Pressure Ulcer Completely closed, fully epithelialized, covered completely with epithelial tissue, or resurfaced with new skin, even if the area continues to have some surface discoloration. Maine Department of Health and Human Services

  45. MDS 3.0 Changes Effective 10/1/18 M0210. Planning for Care: RAI Manual, page M-5: The comprehensive care plan should be reevaluated to ensure that appropriate preventative measures and pressure ulcer/injury management principles are being adhered to when new pressure ulcers/injuries develop or when existing pressure ulcers/injuries worsen. RAI Manual, page M-6: If two pressure ulcers/injuries occur on the same bony prominence and are separated, at least superficially, by skin, then count them as two separate pressure ulcers/injuries. Stage and measure each pressure ulcer/injury separately. Maine Department of Health and Human Services

  46. MDS 3.0 Changes Effective 10/1/18 M0300 Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage Step 1: Determine Deepest Anatomical Stage Step 2: Identify Unstageable Pressure Ulcers Step 3: Determine “Present on Admission” M0300A: Number of Stage 1 Pressure Injuries M0300B: Stage 2 Pressure Ulcers M0300C: Stage 3 Pressure Ulcers M0300D: Stage 4 Pressure Ulcers M0300E Unstageable Related to Nonremovable Dressing/Device: no changes M0300F Unstageable Related to Slough and/or Eschar: new examples  M0300G Unstageable Related to Deep Tissue Injury: no changes Maine Department of Health and Human Services

  47. MDS 3.0 Changes Effective 10/1/18 Section M These items have been retired M0610: M0700: M0800: M0900:

  48. MDS 3.0 Changes Effective 10/1/18 M1030 Number of Venous and Arterial Ulcers: No changes M1040 Other Ulcers, Wounds and Skin Problems: M1040A, Infection of the foot (e.g., cellulitis, purulent drainage): no changes M1040B, Diabetic foot ulcer(s): no changes M1040C, Other open lesion(s) on the foot: no changes M1040D, Open lesion(s) other than ulcers, rashes, cuts M1040E, Surgical wound(s): no changes M1040F, Burn(s) (second or third degree): no changes M1040G, Skin tear(s) M1040H, Moisture Associated Skin Damage (MASD) M1040Z, None of the above were present Maine Department of Health and Human Services

  49. MDS 3.0 Changes Effective 10/1/18 M1200: Skin and Ulcer/Injury Treatments M1200A, Pressure reducing device for chair: no changes M1200B, Pressure reducing device for bed: no changes M1200C, Turning/repositioning program: no changes M1200D, Nutrition or hydration intervention to manage skin problems: no changes M1200E, Pressure ulcer/injury care: no changes M1200F, Surgical wound care: no changes M1200G, Application of non-surgical dressing, other than to feet. M1200H, Application of ointments/medication: no changes M1200I, Application of dressings to feet: no changes M1200Z, None of the above were provided Maine Department of Health and Human Services

  50. MDS 3.0 Changes Effective 10/1/18 Section N0450 Antipsychotic Medication Review changes N0450A: Code 0, no: if antipsychotics were not received: Skip N0450B, N0450C, N0450D and N0450E. (new skip pattern) N0450D: Code 0, no: if a GDR has not been documented by a physician as clinically contraindicated. Skip N0450E, Date physician documented GDR as clinically contraindicated Maine Department of Health and Human Services

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