If there’s one overwhelming challenge in a long-term care setting, it’s how to code the Activities of Daily Living (ADLs).

Reasons for this include that there are so many employees who contribute to the documentation, and  the terminology can be confusing. Another big misstep is that staff members underestimate how much they assist the patient. 

There are eleven ADLs that are listed on the Minimum Data Set or MDS. They are bed mobility, transfers, walk in room, walk in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene and bathing. Four of these are considered “late loss ADLs” meaning that people retain their functional ability in these four areas the longest. The four late loss ADLs are bed mobility, transfers, eating and toilet use.  A resident may lose the ability to dress himself or walk, but may still have the ability to turn in bed, get out of a chair, feed himself and/or assist with using the toilet.

Why care about ADL coding?

Well, it directly impacts Quality Measurements, how your facility is ranked and the big one, how much reimbursement you receive. The four late loss ADLs are heavily weighted and play an important role with the 5-Star Quality Measure scoring and the RUG level used for Medicare and Case Mix payment. 

The Quality Measurements are dynamic and fluid, and can change the 5-Star ranking during the year, whereas there is less opportunity for the staffing and survey “star” rankings to change. If a nursing home has had an unfavorable survey, it can take years to improve the survey star ranking. But a high QM score can raise the overall star level of a nursing home and is based on more recent information. Residents will stay the same, improve or show a gradual decline with the late loss ADLs. Some residents may have a significant decline, but generally this is not the majority of residents. Yet, if your ADL coding is not accurate it could appear that many of your residents are showing significant declines quarter to quarter.

In addition to your ADL scores, administrators have to look at their RUG levels. Some RUG levels require a certain ADL Index score to qualify into that RUG grouping. If a resident requires very minimal assistance then they will not group into the level despite having the clinical condition. For example, a resident may have received IV fluids for hydration, which is a qualifier for Special Care. The minimum ADL Index score to qualify for Special Care is a 2.

More independent residents are reimbursed at a lower level than those that require more nursing help. The basic urban rate for the Special Care RUG of HB1 is $332.42/day and for the custodial level of PA1 is $184.64/day, a difference of $147.78/day. If the ADL coding had been underscored then this is a costly error.

So, how do we ensure accurate coding of the ADLs? The first important component is that “It takes a village” to ensure accurate ADL coding. One staff member cannot accomplish this process on his or her own. With so many shifts, there could be close to hundred or more employees contribute to providing ADL care.  The following tips can help to promote accurate ADL coding.

1.)  Use an ADL chart to document the care provided on each shift and monitor for compliance with documentation. Electronic documentation systems can revolutionize coding. Remember, the ADL Index may be lower if charting is not taking place.  Develop a method of checking that all documentation has taken place. This might be a review at the end of each shift and if areas are blank, the nursing assistant can complete it before they their shift.  Another method is a check in the morning for the previous three shifts.  The staff member will most likely remember the care provided the previous day and can complete a late entry. 

2.)  Help employees understand the self-performance levels.  Self-performance refers to the resident’s performance and can range from independent to supervision to extensive to dependent or the activity did not take place. Terms such as “extensive assist” or “weight bearing assistance” can be tough to interpret.  A nursing assistant may not realize that putting on Mrs. Jones’ sweater constitutes extensive assistance.  A great method of instruction involves working 1:1 with the nursing assistant. Ask them what they did for Mrs. Jones and then ask them how they would code it. If the code is not an accurate reflection of the care, then “on the spot” training can be done. There cannot be enough nursing assistant training on this issue.

3.) Don’t be humble. The ADL Index score is a combination of self-performance and support.  Support refers to whether the staff member provided any set up or the care involved one or more staff members.  A common area that gets undercoded is bed mobility. In many nursing homes, the nursing assistants pair up on the night shift to provide care. A resident who may only need supervision or the support of one person during the day may need two people at night. There are many reasons for this change in the support level.  The staff may want to reposition the resident without awakening her, so two staff members may be needed to safely reposition the resident.  Many residents may need a pain pill or sleeping aid at bedtime to facilitate sleep and this can impact their need for extra assistance. If two staff were needed to provide the care, then we should be taking credit for it.  Sometimes just taking credit for two staff can change the ADL Index and the reimbursement level. For example, Mr. Peterson needs limited to extensive assistance with the three of the four late loss ADLs. The night nursing assistant has only been coding one person support for bed mobility. The difference between coding one person & two persons can result in a lower RUG level. An RUA (ultra rehab intensity & needing assistance with one staff member) reimburses at the basic urban rate of $467.23/day, but an RUB (ultra rehab intensity & needing assistance with two staff people) reimburses at $558.79/day, a difference of $91.56/day. In many cases, not taking credit for two person help at night with bed mobility has led to the lower ADL Index and the nursing home was not reimbursed for the care that was actually provided.

4.) Monitor ADL coding before the Assessment Reference Date (ARD). Consider an internal audit. By being pro-active and reviewing the ADL coding before the ARD, inaccurate coding can be corrected and the correct coding will be reflected on the MDS. Medicare residents are reviewed frequently with the PPS schedule and new COT monitoring process. In addition to looking at the rehab minutes and clinical conditions, savvy MDS Coordinators will also be looking at the ADL coding. Our long-term residents can be reviewed 2-3 weeks before the next MDS is due. This helps ensure the ADL coding is accurate. In addition, this process assists in determining if the ADLs have changed and if there is a need for rehab services.

5.)  Provide on-going education & training. There are eleven different ADL categories, five different self performance levels and four different support levels.  With three different shifts of staff members caring for the residents there is bound to be on-going education needs. It is recommended that ADL education take place at least quarterly and preferably monthly to keep all staff up to date.

6.) Game on!  Education can lose its effectiveness if it is presented in the exact same format month after month. Consider providing training via a crossword puzzle, “on the spot” quizzing with a small prize (a fun size piece of candy, sticker, etc) if the staff member gives the correct answer, creating a “Jeopardy!” style in-service, having small “huddles” at the nursing stations to focus on a particular area of coding, placing a “Tip” sheet highlighting a different ADL each month in the employee break or rest room &/or creating a “skit” that be humorous but also teaches at the same time.

7.)  Find your champions. One staff member cannot address all the education needs in a nursing home.  Many times the expert educators work mainly during the day. If an evening or night shift staff member has a question, there may not be someone to answer it. Consider having “champion” nursing assistants that understand ADL coding and can answer questions for their peers during the shift. Staff nurses should be familiar with ADL coding definitions and can assist with educating nursing assistants if they note coding that doesn’t seem to reflect the care the resident needs.

ADL coding is a complex process that can be overwhelming if only one or two people are responsible for ensuring the accuracy of the documentation. Accurate ADL coding will result in better Quality Measures, can improve the 5 Star ranking & provides reimbursement for the care that is actually delivered. A comprehensive program utilizing the talents of many people can make it successful. 

Mary-Beth Newell is the vice president of Clinical Reimbursement at Post Acute Consulting.