Questions & answers from the American Association of Nurse Assessment Coordinators (AANAC).

Q: A resident scores 10 times a 3 (Extensive Assistance)/3 (Assist of 2+ Persons Physical Assist) and 10 times a 2 (Limited Assistance)/2 (1 Person Physical Assistance) on the mobility tasks in section G. Would you code him a 2 or a 3 for Column A, ADL Self-Performance? I know he would be coded a 3 in Column B for staff support since the instructions are to code the highest level of assistance provided, even if it occurred only once. However, I am confused about self-performance if his scores are divided equally during the look-back period.

A: For ADL self-performance, code an item in G1 at the highest level of dependence that occurred 3 or more times. The exception is coding total dependence: To use that code, the staff has to perform all aspects of the activity for the resident during the entire observation period. There is no participation by the resident at all at the dependent level. For the example cited in the question, the resident would be coded 3 (Extensive Assistance)/3 (Assist of 2+ Persons Physical Assist).

Q: I noticed that there was a change to the instructions for item M4c in the RAI User's Manual, effective in April. What changed?

A: The new instructions for M4c, Other Skin Problems or Lesions Present, are: "Code in M4c any open lesions/sores that are not coded elsewhere in Section M. Do not code skin tears or cuts here." The new language eliminated some of the redundancy with M1 and inconsistency with coding of wounds caused by injury.

Q: I keep getting confused on this point. The manual keeps referring to active assistive range of motion (ROM). What if you have a patient that requires passive range of motion (PROM) and has no limits with that? Since it is not active assistive, would that be coded as a functional limitation in ROM? I thought it means that if a patient has ROM with PROM you wouldn't code for decreased ROM. Help, please.

A: Section G4 is measuring Functional Limitations in Range of Motion. A resident who was not able to move his joint--required passive range of motion--would be coded as a limitation in range of motion. Look at the example on the top of page 3-111 (in the RAI User's Manual). In the example, the resident has flaccid hemiparesis. The example codes the resident with Limitation on one side of the body. The intent of the question is not to determine if it is possible to move the joint through the full range of motion; it is to identify limitations that interfere with daily functioning, particularly with activities of daily living, or that place the resident at risk of injury.

Q: I have a Medicare Part A resident who is going to a wound clinic in a hospital. We have received a bill for "OR minor," which was for surgical debridement, lab costs, and clinic charges. Since surgical debridement is beyond our scope of practice in the nursing facility, wouldn't this be able to be billed by the hospital rather than by the nursing facility?

A: What might seem to be obvious isn't always the rule when it comes to consolidated billing. You will need to check the specific HCPCS code for the procedure against the consolidated billing Help File to determine if it is excluded from consolidated billing and therefore billable to Part B by the wound clinic. Go to www.cms.hhs.gov/manuals/pm_trans/R189CP.pdf for the current Help File. Also, codes added for 2004 can be found at www.cms.hhs.gov/medlearn/2004snfannualupdate.asp.

Q: I work at the SNF unit of a hospital, and most of our patients are high level. When PT and OT evaluate these patients, the estimated duration of therapy is usually 5-7 days, and then they're discharged home. Therapy orders are usually written for PT and OT daily for 7 days. Regarding Section T, if the patient is discharged after the 7th day of therapy, should I enter 7 days as the estimated number of days and calculate the minutes based on those 7 days? Or should I calculate the estimated number of days and minutes through day 15 even though I know from the start that this patient will only stay here for 7 days?

A: If you know coming in the door that the resident will be leaving prior to day 15, then you must enter the number of days the resident is expected to be in the facility and receiving the services. The following section of the PPS Final Rule (July 30, 1999, page 41662) is at the center of this answer:

If the physician orders therapy for 10 days, the projected number of days in section T will be 10 rather than 14; likewise, if the physician does not order a limited number of days, the projection will be based on the entire two weeks, assuming the beneficiary's continued stay and receipt of services.

The RAI User's Manual clears up the question of what to do if the resident is expected to stay for at least 15 days but leaves early: "Calculate the expected number of days through day 15, even if the resident is discharged prior to day 15." and "Calculate the expected number of minutes through day 15, even if the resident is discharged prior to day 15. (p. 3-216)."

In that case, you would bill only for the number of days the resident was actually in the facility and receiving the services.

With thanks to Rena R. Shephard, MHA, RN, FACDONA, AANAC Chair, and President of RRS Healthcare Consulting Services, San Diego.