AANAC'S pps review: questions & answers from the American Association of Nurse Assessment Coordinators (AANAC).

Q: Here's the scenario:

* Discharged from SNF Medicare: 06/27/06

* Admitted Back to Acute Care: 08/18/06

* Admitted to SNF Medicare: 09/23/06

I calculate that as not having a 60-day break and, therefore, the resident can't be covered on Part A. Is that correct?

A: This is a 52-day break in skilled level of care, so the resident does not qualify for a new benefit period. However, if your resident had another 3-day qualifying stay and has Medicare A days available from the original benefit period, he can be covered now. You would pick up the Medicare A day count where you left off in June and would start the PPS cycle again at day 1. If the resident exhausted his 100 days in June, then he would not have any Medicare days available and could not receive coverage at this time.

Q: We do not have our flu vaccine yet. Which response do I check--"unable to obtain" or "not offering at this time"? We do know when it is coming.

A: This is the official answer from the QTSO (the folks who maintain the database for CMS) Web site, available at https://www.qtso.com/mdsfaq.html#w3b:

W2b

Q: If the facility knows that their supply of flu vaccine won't be available by the ARD date, how should item W2b be coded?

A: Before choosing a response, determine whether the vaccine is unavailable because of a declared vaccine shortage (as described in the RAI manual) or because the vaccine supply is expected to be delivered after the ARD.

If the resident was offered the vaccine by the ARD but the vaccine is unavailable at the facility due to a declared vaccine shortage (as described in the RAI manual), then code response 6, "Inability to obtain vaccine."

If the resident was not offered the vaccine by the ARD because the vaccine is unavailable due to a declared vaccine shortage (as described in the RAI manual), then code response 6, "Inability to obtain vaccine."

If the resident was offered the vaccine by the ARD, and the facility knows it will receive its supply of vaccine after the ARD, a response of "unable to determine" (a dash) is allowable.

Some software systems require a double dash rather than a single dash. If your software won't take either, contact your software vendor for assistance. The data specifications provided by CMS allow the "unable to determine" code in this field, and the software should provide it.

Q: When are the Advance Beneficiary Notices (ABNs) issued?

A: ABNs are an option instead of the traditional denial letters. CMS intends for them to replace the denial letters eventually. Like denial letters, they are issued when a resident is denied coverage on admission and when a resident is coming off skilled coverage and will be remaining in the facility. The ABN/denial letter is required only when the denial is issued because the resident does not meet either level of care or medical necessity criteria. It is not required when denial is for technical reasons, such as lack of 3-day stay or benefits exhausted (although advance notice about these situations is highly recommended--see the optional Notice of Exclusion from Medicare Benefits [NEMB] form at the Web address below).

You can find everything you ever wanted to know about all of these forms at www.cms.hhs.gov/BNI/01_overview.asp#TopOfPage.

Q: Regarding coding pain: The RAI User's Manual says to code for the presence or absence of pain regardless of pain management efforts, i.e., breakthrough pain. So if pain meds are effective, are we supposed to code "0," no pain?

A: Right. If a resident is on a pain management program and has not experienced any pain at all during the 7-day observation window, you would code "no pain" on the MDS. If, however, the resident was on a Duragesic patch and had breakthrough pain during the observation period, then you would code the presence of pain on the MDS. So, the real question is: Did the resident experience any pain during the 7-day look-back window?

With thanks to Diane Carter, RN, MSN, CS, President and CEO of the American Association of Nurse Assessment Coordinators (AANAC).

About AANAC

Q: What is AANAC and how do I get my questions answered on the Resident Assessment Instrument/Minimum Data Set (RAI/MDS)?

A: The American Association of Nurse Assessment Coordinators is a nonprofit association of your peers, including all members of the interdisciplinary team dedicated to networking, education, and advocacy on behalf of all clinicians involved in the RAI/MDS process. From our online discussion group each week, we select the best questions and answers our members have raised. The questions and answers are reviewed by a national advisory board of experts in this field, and they are subsequently published in NAC News, AANAC's weekly online newsletter. In addition to our weekly questions and answers, the newsletter contains a variety of timely and accurate information on this process. AANAC also offers certification and other educational information services for clinicians committed to accurate and timely completion of the MDS. For further information on AANAC, call [phone] or visit www.aanac.org.