Questions and answers from the American Association of Nurse Assessment Coordinators (AANAC). (AANAC's PPS Review).

Is it possible that the new Quality Measures (QMs) from the Centers for Medicare and Medicaid Services (CMS) are asking too much of long-term care facilities? Recently, a NAC posed the question this way:

Q: The recent implementation of the Quality Measures Pilot Project and the publication of MDS information focus more attention on resident pain than ever before. The objective now is for a facility to aim for 0%. I am at a loss as to how to deal with this on the MDS since most of our short-term residents are here because they have some problem that causes pain. What do you suggest?

A: The key to managing the QM is to control the pain. It is unrelieved pain that becomes a problem. The QM triggers if the resident has moderate pain at least daily, or horrible/excruciating pain even once. It is not unreasonable to expect facilities to control such pain in their residents. Also, the MDS item doesn't ask you what kind of pain the resident would have had if pain management had not been effective, but rather is seeking information only about pain the resident has actually experienced.

Remember the basic rules of pain management: Thoroughly assess the location and characteristics of the pain; identify factors that reduce or exacerbate it; always believe what the resident says about her/his pain; monitor nonverbal, as well as verbal, indications; use a standardized scale of o to 10 to assess the degree of pain; medicate for pain before the pain becomes severe (and don't forget nonpharmaceutical interventions); and always monitor effectiveness of the pain medication and change the treatment plan if it isn't working.

If a pain-management program is working, then moderate pain daily and horrible/excruciating pain are not issues and, therefore, not coded on the MDS.

There will always be an occasional resident whose pain is not under control. Or, if you admit a lot of hospice residents, pain probably will not be easily controlled for some of them. That is to be expected. In these cases, the facility's efforts should be reflected in nurses' notes, physicians' orders, interdisciplinary team meetings and care plans.

More questions:

Q: Have I missed a new regulation? The RAI Manual says that "injections" include subcutaneous, intramuscular or intradermal injections, but I am hearing that subcutaneous injections are not induded. What did I miss?

A: Subcutaneous injections were deleted from the list of direct skilled services with the PPS Interim Final Rule issued May 12, 1998. Thus, they no longer constitute a skilled service under Medicare Part A when given on a daily basis. However, when coding Section 03 of the MDS, the RAI Manual instructions still apply; i.e., intramuscular, intradermal and subcutaneous injections are counted when determining the number of days in the observation period that the resident received injections.

Q: We have a resident with cancer of the spine. She is a paraplegic and will need radiation five days a week. She will have to go by ambulance to and from the hospital since she cannot use wheelchair transportation. What is the facility's responsibility in this matter, i.e., who is responsible for the cost of the radiation treatments, and who is responsible for the ambulance rides?

A: For a Part A resident, radiation therapy with specific service codes is excluded from consolidated billing when furnished by a Medicare-participating hospital or critical-access hospital. This means that the facility is not responsible for including them on the SNF UB-92 claim form to bill Medicare Part A. The radiation therapy provider can bill Medicare Part B directly. Transmittal A-00-88 contains the list of excluded HCPCS codes, and you can find the updated information at www.hcfa.gov/medlearn/refsnf.htm.

Regarding ambulance transportation via gurney, if it is medically necessary because the resident is physically unable to travel any other way, then the ambulance trips associated with the excluded radiation therapy are also excluded from consolidated billing.

Q: A resident's five-day MDS has been completed. He has been refusing to attend therapy, but still qualifies for Medicare A for his new PEG tube. PT ends on day 13 and I initiate an OMRA, with day 23 as ARD. Will that OMRA provide payment from day 15 to day 22 (assuming that the five-day would provide payment up through day 14)?

A: Remember that you must meet all of the requirements for all of the PPS assessments. You can combine the 14-day assessment (which sets payment for days 15 to 30) and the OMRA as long as their ARD windows overlap. In other words, the ARD for your 14-day assessment must be set between day 11 and 19. Your OMRA ARD must be set for day 8, 9 or 10 after all therapy ends, i.e., day 21, 22 or 23. Since there is no overlap in the assessment windows for the two assessments, you cannot combine the assessments. So you must complete the 14-day assessment with an ARD of day 1 through 19 to set payment for day 15 through 30.

When you complete your OMRA on day 23, as you have planned, the new RUG level takes effect on the ARD of that off-cycle assessment. However, you can combine the OMRA with the 30-day assessment, since the assessment window--days 21 to 34--overlaps with the OMRA's assessment window (day 21, 22 or 23). The billing office would need to be informed that the OMRA is replacing the 30-day assessment so it will know to use the HIPPS modifier 28.

With thanks to Rena R. Shephard, RN, BA, FACDONA, AANAC president and president of RRS Healthcare Consulting Services, San Diego, California.