The Nov. 7, 2012, minimum data set (MDS) 3.0 Resident Assessment Instrument User’s Manual became effective immediately upon release. The changes impacted 133 pages of the manual and ranged from simple page number changes, corrected typos, and clarifications, to significant regulation updates.

Knowing the highlights and significant changes that impact day-to-day work flow can assist providers in improving MDS coding accuracy and avoid default payments.

Chapter 1 Update:
Care Area Assessments Appendix C Tools Use Optional

The Care Area Assessment (CAA) process involves further investigation of triggered areas to determine whether interventions and care planning are required for a resident. The Centers for Medicare & Medicaid Services (CMS) has clarified that the CAA resources in Appendix C are provided as a courtesy to facilities. These resources include a compilation of checklists and Web links that may be helpful in performing the assessment of a triggered care area. “The use of these resources [is] not mandatory and represent[s] neither an all-inclusive list nor government endorsement” (p. 1-6).
Though, as outlined in chapter 1, use of Appendix C’s CAA tools is not mandatory, in chapter 4 the facility’s interdisciplinary team (IDT) members are instructed to collaborate with the medical director to identify current evidence-based or expert-endorsed resources and standards of practice that they will use for the expanded assessments and analyses that may be needed to adequately address triggered areas. As part of the survey review process, facility staff should be able to provide surveyors with a list of the resources that they use (p. 4-8). The format for documenting the CAAs is not mandated, but the content is. The CAAs documentation should include an analysis of the cause and contributing factors; true nature of the issue or condition; complications affecting care; risk factors; and factors to individualize the care plan, the need for referral, and whether or not to proceed to care planning.

Resident Assessment Instrument Conceptualized

The Resident Assessment Instrument (RAI) involves assessment, decision making, and identification of outcomes, then the development, implementation, and evaluation of the care plan. The previous version of the manual had the “identification of outcomes” placed after the care plan development.
In the RAI process, the language regarding “decision making” has changed from determining the resident’s “problems” to focusing on “clinical issues and needs.” The IDT is to work with the resident (and/or the resident’s family, guardian, or other legally authorized representative) and the resident’s physician to determine the severity, functional impact, and scope of a resident’s clinical issues and needs (instead of their “problems;” p. 1-9).

Resident’s Participation Guides Care Plan Development

Using the RAI process leads to improved outcomes for a resident’s quality of care and “enhanced quality of life.” A resident has experienced goal achievement when the resident actively participates in his or her care and when the care plan reflects appropriate resident-specific interventions that are based on careful consideration of individual problems and causes. Linking input from the resident, resident’s family (and/or guardian or other legally authorized representative), and the IDT leads to improved resident level of functioning or a slower rate of deterioration (p. 1-10).
It is noteworthy that the RAI process is the combination of resident-driven care that links Quality of Care and Quality of Life together.

Chapter 2 Update:
Stand-Alone Unscheduled Assessment, Two-Day Flexibility Period

The two-day flexibility period for opening and setting the Assessment Reference Date (ARD) for stand-alone, unscheduled prospective payment system (PPS) assessments includes the Change of Therapy (COT) Other Medicare Required Assessments (OMRA), a stand-alone End of Therapy OMRA (EOT), and a stand-alone Start of Therapy OMRA (SOT).
Facility staff must set the ARD for a day within the allowable ARD window for that assessment type (such as day seven of the COT rolling window), but may only do so by day two following the day after the window has passed (p. 2-40).

Optional Completion Of The EOT

The EOT is not required unless the resident remains skilled for at least three days after the last day of therapy. If the Resource Utilization Group (RUG) would be higher due to the EOT completion, facility staff may choose to complete it. If so, then the EOT may be combined with the Discharge assessment if those days coincide (p. 2-48).

EOT With Therapy Resumption

In cases where therapy resumes after the EOT OMRA is performed and the resumption-of-therapy date is no more than five consecutive calendar days after the last day of therapy is provided, an EOT with resumption (EOT-R) can be completed. The therapy services must be expected to resume at the same RUG-IV classification level and with the same therapy plan of care that had been in effect prior to the EOT OMRA (p. 2-49).

Combining COT With Scheduled Assessment Optional

If day seven of the COT observation period falls within the ARD window of a scheduled PPS assessment, the skilled nursing facility (SNF) staff may choose to complete the PPS assessment alone by setting the ARD of the scheduled PPS assessment for an allowable day that is on or prior to day seven of the COT observation period.
If the scheduled assessment ARD falls on or before day seven of the rolling COT window, the window is reset (p. 2-51). Use this option when the RUG is estimated to drop.
If it is not, facility staff may choose to combine the COT ARD with the scheduled assessment and receive a higher RUG back to the beginning of the COT window.

Clarification On Resident Interviews

The ability to carry resident interviews from a previous assessment to the current assessment is a continuation of previous updates and a welcome reduction in frequency (p. 2-52). CMS has indicated that when using a prior interview, the person who originally did the interview and attested to its accuracy must attest to its accuracy on the current assessment and enter the date the interview originally was completed as indicated on that prior assessment.

Early PPS Assessments

It is critical to note that when a COT is early, the rolling ARD window is reset with the ARD of the early COT. If facility staff don’t recalculate the rolling seven-day schedule with the early COT, the
next COT ARD will be out of compliance (p. 2-73).

Late PPS Assessments

One of the changes with the most impact is the new guidance on how to apply default days when an assessment is late.  For a scheduled assessment, default is applied for the number of days that an ARD is late rather than back to the beginning of the payment period. This is a very positive change for providers, as they will receive fewer default days under the new rules (pp. 2-73 and 6-53).

Missed PPS Assessment

One of the most painful results of the complicated PPS scheduling is “provider liability” (when the facility cannot be paid for Medicare-provided days). This occurs when facility staff fail to set the ARD timely for either a scheduled or unscheduled PPS assessment and the resident has been discharged or is no longer on Medicare.

If the SNF fails to set the ARD of a scheduled PPS assessment prior to the end of the last day of the ARD window, including grace days, and the resident was already discharged from Medicare Part A when this error is discovered, the provider cannot complete an assessment for SNF PPS purposes and the days cannot be billed to Part A. An existing Omnibus Budget Reconciliation Act of 1987 assessment (except a stand-alone discharge assessment) in the Quality Improvement and Evaluation System Assessment Submission and Processing (QIES ASAP) system may be used to bill for some Part A days when specific circumstances are met. See chapter 6, Section 6.8 for greater detail.
In the case of an unscheduled PPS assessment, if the nursing facility fails to set the ARD for an unscheduled PPS assessment within the defined ARD window for that assessment, and the resident has been discharged from Part A, the assessment is missed and cannot be completed. All days that would have been paid by the missed assessment (had it been completed in timely fashion) are considered provider-liable. However, as with the late unscheduled assessment policy, the provider-liable period only lasts until the point when an intervening assessment controls the payment (p. 2-74).

Chapter 3 Update: Unhealed Pressure Ulcers

Item M0210, Unhealed Pressure Ulcer(s), has a clarifying definition added:
“Scabs and eschar are different both physically and chemically. Eschar is a collection of dead tissue within the wound that is flush with the surface of the wound. A scab is made up of dried blood cells and serum, sits on the top of the skin, and forms over exposed wounds such as wounds with granulating surfaces (like pressure ulcers, lacerations, and evulsions). A scab is evidence of wound healing.” (More on p. M-5.)

Reduce Unnecessary Medications

While assuring that only those medications required to treat the resident’s assessed condition are being used, it is important to assess the need to reduce these medications wherever possible and ensure that the medication is the most effective for the resident’s assessed condition (p. N-4).

Isolation Definition Changed

The concept of “strict isolation” now reads “single-room isolation” in multiple areas in section O. Instructions in item O0100M clarify that staff are to code this only when it includes isolation for active infectious disease and the resident requires transmission-based precautions and single-room isolation (alone in a separate room) because of active infection (for example, symptomatic and/or have a positive test and are in the contagious stage) with highly transmissible or epidemiologically significant pathogens that have been acquired by physical contact or airborne or droplet transmission (p. 0-4).

Definition Of Continence Revised

Continence is “any void into a commode, urinal, or bedpan that occurs voluntarily, or as the result of prompted toileting, assisted toileting, or scheduled toileting.” With the updated definition, coders will focus on the voluntary and intended nature of the void in approved receptacles (Appendix A, p. A-5).
Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of content management for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.