Questions & answers from the American Association of Nurse Assessment Coordinators (AANAC).
A: Here's a summary:
* W1 -- All assessments and all discharge and reentry tracking forms (optional until May 2007)
* W2 -- All assessments of all types and all discharge tracking forms with ARD or discharge date from October 1 through June 30
* W3 -- All assessments of all types and all discharge tracking forms
Section W must be filled out according to the requirements published in the RAI User's Manual. Even though you might have more than one assessment showing the same vaccination for a resident, the system is set up to count it only once. Download the form and the manual instructions at www.cms.hhs.gov/quality/mds20.
Q: If PT evaluated a patient and the orders were to receive PT for 10-12 days, and OT was ordered for 7-10 days, what would be the number of days in T1c? And how would you count the minutes? For example, if it's 12 days, I know I will project PT minutes until day 12, but how about OT? Will I project the number of minutes until day 12 or only for 10 days?
A: You project the number of days through day 15 on which the resident will receive at least one discipline of therapy. So the projection would be for 12 days (since PT will see him/her for about 12 days in the first 15 days of the Medicare stay). For the minutes, you would need to estimate the total number of therapy minutes through day 15, which would include the PT services up to 12 days and the OT services up to 10 days. Keep in mind that the projections include days and minutes already delivered and recorded in Section P.
Q: When obtaining the new QI/QM reports in the CASPER system, is it necessary to change the time span covered by the report every time the reports are run? If so, what is the suggested time period to include in the reports? Is it better if it is monthly, quarterly, semiannually, etc.?
A: Because MDSs are completed on many residents only quarterly, when you run the reports every month very few new assessments are in the database. That's because relatively few nonadmission OBRA-required assessments (which are the assessments utilized for most of these reports) are completed in one month. For the same reason, it is recommended that the report cover a six-month period rather than three months or one month, although many providers prefer reports that cover a three-month period. The reports default to the most recent six-month period. If you want the report to cover some other period, you must change the dates.
Q: Regarding an excoriated area: I coded it as an abrasion, but another MDS nurse wanted it coded as a stage II pressure ulcer. The documentation in the chart says the resident has a red excoriated area on the right buttock.
A: The answer depends on the cause of the open area. If pressure was involved in development of the open area, it would be coded in M1 and M2 as a pressure ulcer; since it is open, it would be a stage II if it met the definition of a stage II ulcer. However, if pressure was not a contributing factor, the area would not be staged and would not appear in M1 or M2. Instead, it would be coded in M4a.
Q: When someone does not meet skilled need anymore, do we give an ABN or an expedited review? I know if she uses all her days you do not have to give her anything.
A: The Generic notice must be given to each resident who is ending a course of Medicare coverage in a SNF (unless discontinuation of services is by the resident's choice, benefits are exhausted, resident dies, or resident is transferred to a hospital). If the beneficiary notifies the QIO that she wants that decision reviewed, the QIO will notify the SNF, and the Detailed Explanation form must be given that same day.
If the resident is on Part A and is being discharged from the facility, the Generic notice must be given to provide the beneficiary the opportunity to dispute the date of discontinuation of Medicare services. If the resident were remaining in the facility, a denial letter or ABN also would be required to offer the opportunity to request a demand bill to determine who would be liable to pay for the continued stay.
Q: A Medicare patient was admitted 8/15/05. He was discharged to the acute hospital 8/22 with the code 8, discharged prior to completing initial assessment. The patient came back from the acute hospital 8/29, and he was discharged home 9/3, again with the code 8. Regarding the AB1 date on the second discharge prior to completing the initial assessment, if I keep the Date of Entry as 8/15/05 (since it says not to include readmission from the hospital), it looks like the patient has been at the facility for more than 14 days and no comprehensive assessment was done. I know I will get an error if I submit this. What am I doing wrong?
A: According to the RAI User's Manual, "If the resident is unstable and has several return visits to the hospital before the Admission assessment is completed, the facility should continue to submit discharges prior to completion of the initial assessment (AA8a = 8) until the resident is in the facility long enough to complete the comprehensive Admission assessment. The same date of entry (AB1) should be used for all these discharges" (p. 2-24, paragraph 5).
It also states (in boldface in the manual), "For MDS purposes, the date of entry is the date the resident first entered the facility for care, regardless of how the facility chooses to 'open' or 'close' its medical records during the course of the stay." On page 3-13 you can find the definition of "Date the Stay Began": "The initial date of admission to the nursing facility. This date will not change on subsequent assessments until the resident is discharged with a return not anticipated. If the resident is discharged as a return not anticipated and returns at a later date, the resident will be considered a new admission and a new date of entry will be entered on the assessment." You are within the guidelines as specified above. You shouldn't worry about AB1 = 8/15 being more than 14 days since you have a DC = 8.
With thanks to Rena Shephard, MHA, RN, FACDONA, AANAC founding Chair and clinical editor, and President of RRS Healthcare Consulting Services, San Diego.