Taming the MDS
Well-designed care programs for patients with complex needs can reduce Medicare expenses
The next round of MDS 3.0 changes, which take effect Oct. 1, might not be as sweeping as those from the past few years, but Minimum Data Set experts warn they could still spell trouble for ill-prepared providers.
Like MDS revisions released previously, the coming round of updates will directly impact providers' processes and practices, as well as vendors' computer-based programs and automated MDS tools. Experts say many providers are already falling dangerously behind.
In fact, many providers still are not familiar with changes that took place in the spring, says Leah Klusch, RN, BSN, FACHCA, executive director of The Alliance Training Center Inc.
“Some mistakenly believe they'll have more than enough time to prepare before October 1
rolls around. But there could be big challenges because many people haven't even updated their MDS manuals with the updates that came out in May,” she notes. “If you're not already prepared with the May changes when the Centers for Medicare & Medicaid Services releases the manual revisions in October, you're going to have problems.”
Providers who dig in now and become well-versed in the looming requirements will find it far easier to weather the next MDS update storm. In the process, they'll lower the likelihood of suffering decreased reimbursement, more survey deficiencies and a weakened five-star quality rating.
At first glance, the expected Oct. 1 updates read like a veritable alphabet soup of section changes. Sections A, H, K, M, N, O and Q all are areas to re-examine. Overall, the updates are more clarifications of verbiage and clean-ups of issues that have been questioned by Registered Nurse Assessment Coordinators over time, says Kirby Cunningham, RN, director of Clinical Professional Service for AOD Software.
“With MDS 3.0 settling into a more mature product, the changes are less overwhelming and more specific to recording resident data that is accurate for a given topic or item,” Cunningham observes.
Some of the more substantive changes coming in October involve Sections K and O. 2013 updates to Section K reflect the regulatory focus on quality of life. Specifically, Section K0700 Perfect Intake by Artificial Route is being replaced by K710, which includes seven new item groups. These groups look at the percentage of calories residents received under various circumstances, including via intravenous or tube feeding, along with fluid intake.
“The November 30, 2012, State Operations Manual update at F-322 instructs surveyors to identify circumstances where feeding tube use could have been avoided and when normal eating skills could potentially have been restored. This will be reinforced by the MDS data,” adds Linda Elizaitis, RNC, RAC-CT, BS, president of CMS Compliance Group Inc.
The Quality Indicator Survey Critical Elements for Tube Feeding Pathway can effectively guide providers, including those in non-QIS states. Long-term care providers should re-assess nutrition protocols to make sure they are consistent with regulatory requirements, and that staff understand the coding of the MDS, Elizaitis stresses.
For Section O, providers should be prepared for several new items related to therapy minutes. This includes a new classification of co-treatment minutes for speech, occupational and physical therapy, explains Brian Dimit, director of industry marketing for PointClickCare.
Specifically, Section O changes involve the recording of distinct calendar days to qualify for a rehab medium category. This can be especially tricky if the resident does not have therapy on five distinct days and the issue is raised as to whether skilled care is actually being provided, says Carrie O'Connell, RN, an in-house long-term care specialist for Health Care Software (HCS) Inc.
“This change involves more oversight of the therapy department, and coordination of care when multiple disciplines are providing therapy services,” she says.
Diligently tracking days that therapy is delivered and ensuring there are five distinct days within the look-back period for all residents falling into the rehab medium category is critical, O'Connell stresses: “This is an opportunity to jump-start the PPS morning meeting and refocus the current therapy communication process.”
For added protection, she urges providers to steer clear of cookie-cutter therapy treatment plans and avoid the “medium” category, especially if it was often used previously.
M in the spotlight
Providers also should be familiar with new RAI manual clarifications under Section M regarding the reporting of skin problems.
“CMS is stressing that pressure ulcer management is a process, with a goal of showing evidence of healing and not just a code on a piece of paper. Critical thinking skills will be an integral part of this new process,” says Renee Loenen, MS, RN, RAC-CT, product analyst for HealthMEDX.
Another Section M focal point is that many facilities still have processes that call for only one nurse to complete wound care.
“This can create some inconsistency in the MDS to other documentation,” points out Pat Boyer, MSM, RN, NHA, president of Boyer & Associates LLC.
Section G also warrants attention. Tracking Activities of Daily Living accurately is always a challenge, reminds Joel VanEaton, MDS resources education coordinator, Extended Care Products.
“Recently, a discussion from CMS is that the Rule of Three may undergo some clarification. This may change the way some SNFs score the ADLs,” he says.
Boyer adds that if a resident has been supervised three times and a variety of other codings were involved — total, extensive, limited — staff will now need to code for supervision. Having staff code every time they provide assistance to the resident is a prudent move for accuracy and reimbursement.
“We have already seen less reimbursement due to more A's in RUG levels,” she says. “I think this will further promote that.”
Self-performance items in G0110, which Loenen says are often under-coded, can also leave providers vulnerable. Touch- screen kiosks with embedded training and caregiver videos can help with this, she says, as can hands-on practice of what limited assist looks like compared to extensive assist.
Don't scratch off Section Q, Participation in Assessment and Goal Setting, from the list of potential coding hiccups, either. Although this section already underwent changes in May, more are slated for October.
“This is an area that's ripe for deficiencies during survey since federal regulations, under 483.15 Quality of Life, require that the resident be able to make choices, and under 483.25 Quality of Care, that services are being provided to ensure the highest well-being of the resident,” says Elizaitis.
Section Q also covers discharge planning — a function skewered in a government report earlier this year. The report noted that Medicare paid $5.1 billion for inadequate care and discharge planning in 2009.
“A list of facilities with poor performance in these areas was being submitted to the State Survey and Certification Agencies, so these facilities would be reviewed first for potential enforcement actions,” Elizaitis says. “Under the requirements of Section Q, an interdisciplinary team should be involved in the care planning and discharge processes, along with involvement of the resident and any authorized family members or legal representatives.”
Staff also should stay abreast of MDS changes taking place at the state level. Several states, including Massachusetts, Illinois and Maryland, will be seeing changes. Some relate to Section S, which includes advanced directives, reminds Dimit.
Sources agreed that navigating MDS changes and completing forms accurately largely hinges on providers' access to and implementation of the most current tools and resources, beginning with an updated RAI manual.
Every team member who completes a part of the MDS should receive a copy of the specific changes to their section, according to Loenen. The MDS coordinator should verify that team members understand the changes.
Although Chapter 3 of the RAI manual details individual MDS questions, pay close attention to scheduling information, particularly in Chapters 2 and 6, stresses Josh Shupp, executive vice president of //SOS/ Corporation.
“Use of off-schedule assessments presents a challenge and having a thorough understanding of when and how to use them, how they impact billing and how the overall assessment works is an essential part of proper MDS management,” he says.
Another word of caution: Don't assume that vendors always have the most current versions of the RAI manual in place.
“I've seen some software vendors recently whose embedded RAI manual is not up to date,” says VanEaton.
Awareness of CMS draft postings, located on the CMS Technical Information page, also is invaluable, Shupp emphasizes.
Expertise in the process is so important, “MDS staff cannot be pulled in to fill staff vacancies,” Boyer emphasizes. “Facilities need to have multiple people who can do [it]. The consequence of not completing the MDS accurately and timely is immense.”