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

Coding for pain can be a conundrum, as the first question demonstrates:

Q: When coding for pain, what point in time are we looking at--any time during the week of observation that the pain assessment is done? If the resident takes a PRN med that controls his pain several times during the week of observation, is he coded as having pain? If the PRN medication is effective, do you answer the pain question after the pain med takes effect or before?

A: What you must look at is the objective presence of pain and its level regardless of pain-management interventions. The assessment covers 24 hours per day, 7 days per week, across all disciplines for the entire observation period. In MDS terms, that translates to this: During the 7-day observation period, if a resident has mild pain 5 days and moderate pain 2 days, the correct coding is "daily moderate pain." If the resident has no pain 5 days and moderate pain 2 days, the correct coding is "moderate pain less than daily."

Current clinical practice recognizes that people should not have to be in enough pain to have to ask for pain medication before interventions are implemented. The goal of pain management should be to provide a consistent level of comfort while maintaining as much function as possible. On the MDS, we are rewarded for our pain-management efforts by coding "no pain" or "mild pain less than daily" when our efforts are successful. We are rewarded professionally by providing compassionate care to our residents.

It isn't always possible to get pain under this kind of control. The medical record, in that case, should reflect all of the continuing efforts to achieve that goal.

Please see the pain resource manual developed by the QIOs for use by nursing homes. You can find it under "Clinical Resources" at www.medquic.org/nursinghomes/index. shtml.

Q: The December 2002 revision of the RAI User's Manual states that skin tears that are over pressure points should be counted on M1 as an ulcer. I have two questions regarding this:

1. Are we to code all skin tears in section M1, or only skin tears that are over pressure points?

2. If we need to code skin tears over pressure points in M1, should we count them as pressure in M2, or can we still code them as skin tear in M4?

A: All skin ulcers, including all skin tears, are to be coded in Ml, which identifies them generically as ulcers. Ml should be coded according to this definition:

A skin ulcer/open lesion can be defined as a local loss of epidermis and variable levels of dermis and subcutaneous tissue, or in the case of Stage I pressure ulcers, persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved. Open lesions/sores are skin ulcers that may develop because of injury, circulatory problems, pressure, or in association with other diseases such as syphilis. Rashes with out open areas, burns, desensitized skin and surgical wounds are not coded here, but are included in Item M4. (December 2002 revision of RAT User's Manual, p. 3-159)

Skin tears meet this definition because they "develop because of injury." If a skin tear is related to pressure, it should also be coded in M2. The skin tear is also coded in M4f to identify the origin of the ulcer as being a skin tear.

Q: Should we only be coding the limitations in range of motion (ROM) that interfere with ADLs? The manual states this, but therapy has a hard time differentiating ROM limitation vs functional limitation. And what if the resident is not cognitively able to perform any ADL tasks--how would we code ROM then?

A: The cause of the interference with daily function is the issue here. As the manual says, code it on the MDS only if the limitation in ROM interferes with daily functioning (particularly with ADLs) or places the resident at risk of injury. If a cognitively impaired resident cannot comb her hair because of a ROM limitation in the shoulder, code it in G4. If she can physically reach all parts of her hair, even though she has a limitation in ROM of the shoulder, but cannot comb her hair because of cognitive impairment, then do not code it in G4.

Q: If a resident is being covered under Medicare A benefits, is it okay for that resident to go out for an afternoon with his family?

A: Yes, a leave of absence (LOA) is fine--even if the resident wants to go out overnight. Please note that while it is fine for the resident to go on a LOA, the facility cannot bill for midnights that the resident is not in the bed; the MDS PPS schedule must be altered to exclude those days, and those days are not charged against the resident's benefit period days.

The explanation below is from the Medicare SNF Manual (Pub 12) Chapter 2, Section 214.7, which can be found at http://cms.hhs.gov/manuals/12_snf/sn201.asp#_1_23:

Do not interpret the "practical matter" criterion so strictly that it results in the automatic denial of coverage for patients who have been meeting all of the SNF level of care requirements but who have occasion to be away from the SNF for a brief period of time. While most beneficiaries requiring an SNF level of care find that they are unable to leave the facility for even the briefest of time, the fact that a patient is granted an outside pass, or short leave of absence, for the purpose of attending a special religious service, holiday meal or family occasion, for going on a ride or for a trial visit home, is not by itself evidence that the individual no longer needs to be in a SNF to receive required skilled care. Very often special arrangements, not feasible on a daily basis, have had to be made to allow for absence from the facility. Where frequent or prolonged periods away from the SNF become possible, however, then questions as to whether the patient's care can, as a practical matter, only be furnishe d on an inpatient basis in an SNF may be raised. Base decisions in these cases on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences.

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