The May 2013 update to the “Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual, Version 3.0” for the minimum data set (MDS) includes some notable changes for nursing home staff to be aware of, and the fiscal year (FY) 2014 prospective payment system (PPS) proposed rule and the upcoming Oct. 1, 2013, MDS technical specifications hint of more changes to come.
More than 225 pages of the manual are affected by the May update. They include many inconsequential changes to wording, punctuation, and capitalization. But there are also a significant number of clarifications that affect facility staff who care for residents and interdisciplinary team members who code the MDS.

Part A Transitions

One welcome update entails a situation in which a resident who was covered by a managed care (Medicare Part C) plan transitions to traditional Medicare Part A. Chapter 2 (page 2-45) of the manual now says that “if a resident goes from Medicare Advantage to Medicare Part A, the Medicare PPS schedule must start over with a five-day PPS assessment, as the resident is now beginning a Medicare Part A stay.”
In this situation, the Medicare beneficiary continues in the same benefit period, but the PPS schedule is restarted with a five-day assessment and staff can begin submitting these assessments to the federal database.

Skin Conditions

Pressure ulcer staging and management of skin condition are a key focus of the May update. More than 50 pages of edits were placed into section M, “Skin Conditions.” The edits begin by saying, “Pressure ulcer staging is an assessment system that provides a description and classification based on anatomic depth of soft tissue damage” (page M-4).
The update puts an increased focus on pressure ulcer management as a “system” and prioritizes identifying the numerical stage of pressure ulcers and showing evidence of improvement and progress toward healing.
“If a pressure ulcer fails to show some evidence toward healing within 14 days, the pressure ulcer (including potential complications) and the patient’s overall clinical condition should be reassessed,” it says (page M-9).
When a pressure ulcer either fails to show improvement or worsens, “the interdisciplinary care plan should be reevaluated to ensure that appropriate preventative measures and pressure ulcer management principles are being adhered to when new pressure ulcers develop or when pressure ulcers worsen” (page M-25).
National experts advise facility staff to utilize quality assurance and performance improvement (QAPI) principles to assess and analyze the development or worsening of pressure ulcers, conducting root cause analysis and developing performance improvement plans (PIPs) to address the issues.

RUG Criteria Changes

Looking forward, both the FY 2014 proposed rule and the posted technical specifications for changes to the MDS item sets are targeted to become effective Oct. 1, 2014. One key change that will impact providers is that the Centers for Medicare & Medicaid Services (CMS) has proposed adding a new item to Section O, O0420. This item asks for the number of distinct calendar days of therapy that was provided in a given week (seven-day period).
This change will impact the Rehabilitation Resource Utilization Group (RUG) categories, as determination of the level will include matching the current RUG criteria with the number of days indicated by this new item on the MDS.
This new item is necessitated by the fact that the current RUG grouper does not capture distinct therapy days. CMS provided the following example:

A resident receives 150 minutes of therapy in the form of physical therapy and occupational therapy on Monday (one session of physical therapy and one session of occupational therapy) and Wednesday (one session of physical therapy and one session of occupational therapy) and speech therapy on Friday. The intent of the Medium Rehab classification criteria is for such a resident not to classify into the Medium Rehab RUG category, since he or she only received therapy on three days (Monday, Wednesday, and Friday) during the seven-day look-back period.
However, the MDS item set only requires the skilled nursing facility (SNF) to record the number of days therapy was received by each therapy discipline during that seven-day look-back period, without distinguishing between distinct calendar days. Thus, in the example above, the SNF would record the following on the MDS: two days of physical therapy, two days of occupational therapy, and one day of speech therapy.
Currently, the RUG grouper adds these days together, allowing the resident described above to be classified into the Medium Rehab category even though the resident did not actually receive five distinct calendar days of therapy.
This resident would not meet the classification criteria for the Medium Rehab category as they were intended to be applied. However, the MDS item set currently does not contain an item that permits SNFs to report the total number of distinct calendar days of therapy provided by all rehabilitation disciplines, allowing some residents to be classified into Rehabilitation RUG categories when they do not actually meet the classification criteria (Davis, 2013).

Policy Manual Changes

With the addition of item O0420 to the MDS item set in October, facility staff will need to tighten up their rehabilitative service scheduling, while keeping in mind regulations in the Medicare Benefit Policy Manual (BPM). The BPM says that staggering the timing of various therapy modalities in an arbitrary fashion throughout the week to meet the requirement for “daily skilled need” does not satisfy the SNF coverage requirement for skilled care (CMS, 2006, chapter 8, section 30.6).
This requirement is only met when there is a valid medical reason why both therapy services cannot be furnished on the same day. The basic issue here is not whether the services are needed, but when they are needed.
Since accuracy of MDS coding is critical to quality measures, five-star ratings, survey management, and Medicare compliance, it is important that staff be well versed in the May “RAI User’s Manual” update changes.
Take note, also, of all the changes that have been preliminarily posted for the MDS item sets for Oct. 1, 2013. The “RAI User’s Manual,” PPS rule, “Medicare Benefit Policy Manual,” MDS Technical Specifications, and other CMS clarifications all need to be pieced together to create a picture of success for facility staff action. Indeed, staff have their work cut out for them.
Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE, is vice president, curriculum development, for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.
2. Centers for Medicare & Medicaid Services (2006), “Medicare Benefit Policy Manual” 
3. Davis, C. (June 5, 2013). Highlights of the SNF PPS rule detailed in May SNF ODF. AANAC LTC Leader, 1–4. Retrieved June 5, 2013