Kasey Stevens | Quality Insights: Alrighty. Good afternoon, and welcome to our series of webinars focused on bringing you information about COVID-19 related topics.
Kasey Stevens | Quality Insights: My name is Casey Stevens. And I'm a communication specialist here at quality insight, to day. We are going to be focusing on the minimum data set. Changes are coming sections GGH. And I.
Kasey Stevens | Quality Insights: Everyone has entered the meeting on mute. But we will have discussion following the presentation. If you have any questions or comments, please submit them, either using the chat or the QA. Tool in your Zoom menu. You can also raise your hand to request to be unmuted, to ask your question aloud. We invite you to join us every Wednesday, 2 Pm. For more of our weekly webinars. Next week we'll be discussing the Mds. Changes and highlight sections, JKL. And M. And now I'd like to introduce our guest today. Deborah Wright.
Kasey Stevens | Quality Insights: Deborah is a quality improvement specialist at quality insights. She joined our team after being in the long term care industry for more than 30 years. She's a wealth of experience and long term care and nursing management, ranging from certified nurse assistant to Vice President of healthcare operations. She's most passionate when she's working with the Mds. Process and quality improvement. Deb thanks for joining us today.
Debra Wright: Thanks, Casey. So I am gonna stop my video here and share my screen.
Debra Wright: Alright.
Debra Wright: So like Casey said, we're gonna talk. Section G is not in the on the new Federal Mds. I just have a couple of things I want to touch base with that, and then we'll go into Section GGH. And I.
So just a recap from all the other
Debra Wright: weeks that we've done. Here are the links to the Mds forms and the Rei manual. The Rei manual is still in draft form, but the forms are finalized. And here's also a link to Cms's official Youtube channel, where they have a variety of different trainings. But here are some examples of training sites that they have for the Mds.
Debra Wright: Some overall changes to the Rei Manual. They made a lot of. The the language is now neutrogen gender neutral. There's minor updates to wording to enhance better understanding. They've improved some clarity. All the references to keys have been changed to I keys, and they made revisions pertaining to the legal proxy, information for family members and significant others.
Debra Wright: There's been revisions. To the chapter guidance for chapters 1, 2, and 4. We're not reviewing those. But just so you're aware that those changes have been made. And then here's a list of the data elements that are either new or revised in the guidance for Chapter 3.
Debra Wright: So getting into where we left off. So. Section G, this is just an Fyi section G is not on the new Federal
Debra Wright: Mds, that's going into effect October first, however, depending on your state. There are some sections that still will be required on the Osa. So it's again removed from the federally required Mds. And most of the items have either been retired or moved into Section Gg.
Debra Wright: so Gigi, our favorite section, functional abilities and goals. The intent of this section is to include items about the residents, functional abilities and goals. It focuses on their prior level of function, their function at admission for their baseline and then their function for their discharge performance.
Debra Wright: We're gonna identify discharge goals. We're gonna look at the performance throughout a residence, stay their mobility devices in their range of motion. That's all been pulled in from Section G, and then the functional status is assessed, based on the need for the assistance when pro, when performing that self care and mobility activities.
Debra Wright: So what data elements have been moved from G and incorporated into Gg, we're gonna be looking at the Adl assistance
Debra Wright: bathing balance during transfers and walking and their rehab potential.
Debra Wright: Section G, data elements that were added to Gg also include the functional limitation and range of motion mobility devices, personal hygiene bathing. This is where they've taken that tub shower transfer aspect and moved it into section Gg, and depending on the type of assessment, the data elements are gonna differ. So whether we're doing an admission gig, a discharge, or an Oprah or an Ipa assessment.
Debra Wright: So prior functioning, just a little clarification in this overall, this section hasn't changed too much.
It is still only completed on the Pps. 5 day. The clarification that they had was mainly related to steps in that the stair activity indicates that a resident went up and down this there stairs by any safe means.
Debra Wright: So if they are using an assistive device or any kind of equipment, whether it's a walk or a cane, even a stared lift. How did they get up and down those steps? With, and what level of assistance they did clarify, though, that going up and down a ramp, if if you've installed a ramp
Debra Wright: that that does not count as going up and down steps.
Debra Wright: limitation and range of motion. It's the exact same that we had in Section G. They just moved it into Gg. Upper and lower extremities that they defined it. That's a limited ability to move a joint that interferes with daily functioning, particularly with activities of daily living or places the resident at risk, and they gave lots of coding tips and examples are in the Rai manual
Debra Wright: mobility devices. Again, this is exactly what we had in G. They just moved it into gg.
Debra Wright: so the look back period. So
Debra Wright: took me a little bit to to pull this all together. But basically what they're saying is, we now have 3 different sections for the Gg. We have our Pps admission, we have obra assessments and we have discharge assessments where we're going to be doing. Gg, so a standalone 5 day medicare part a admission. We're gonna be looking at the first 3 days of the part, a stay
Debra Wright: and over admission. So they're not on Medicare part A, and it's just a a regular obra admission assessment that never was really, truly clarified in the what we're doing now, but they've clarified it now that it is the first 3 days of the stay, starting with the entry date. So if we're combining it with the 5 day. The look back period is still the first 3 days.
Debra Wright: technically, which probably a lot of facilities were not doing is if it was a standalone over admission. We we should have been looking at the ard back 2 days because it was an obra assessment.
Debra Wright: But now they've now clarified that so it's all the same, and if it's a stand alone, Medicare, part A, or if it's an over admission, we're looking at that first 3 days of the stay for our look back. Period.
Debra Wright: If it's an IPA assessment, we're looking at the A. RD. And 2 previous days. if it's a part, a discharge just like before we're looking at the end of the Medicare stay in 2 previous days.
Debra Wright: and if it's an obra discharge or an obra than the admission we are looking at either the discharge date or the ard date plus 2 previous days.
Debra Wright: So this is just some screenshots to show that there's 3 different sections. Now for self care, for admission, self care for discharge, and self-care for an obra or an interim. Mds.
Debra Wright: And the same thing for the mobility. We have the mobility. 3. Day admission, mobility, 3 day discharge and mobility for an Oprah or an interim. Mds.
Debra Wright: So for the admission functional assessment, they gave a little bit of a clarification with this in that the admission assessment should be completed
Debra Wright: for the benefit services in order to reflect the residents. True admission baseline function. So what is their baseline function when they came into the facility? So that's why we're looking at the first 3 days, whether it's a Medicare Pps or an over admission. What was their baseline when they came in to the facility, and they they further identified and and defined that prior to benefit of services means prior to provision of any care that we, as the facility would
Debra Wright: be resulting in their independent coding. So we want to be able to to treat them and give them the services that they need, and still identify what their baseline function is
Debra Wright: for the discharge we are going to code with each admission assessment when there's a start of A. PPS. Stay.
Debra Wright: discharge goals are not required when it's a standalone over assessment. So we're only doing that discharge goal with the Pps stay because for the sniff
Debra Wright: quality reporting program, a minimum of one self care or mobility goal must be coded now as a facility, you can choose to complete more than one self care or mobility, discharge goal. But you must have at least one, and obviously the more that you identify, and the more you're working with the Resident, the more it reflects their true status and helps individualize their care and their care, planning.
Debra Wright: So just to go through the coding instructions. For the most part this has not changed. They've added a couple of clarifications, but that hasn't changed. So just to review the coding because it is so much different than Section G, we're gonna Code 6 independent. If the Resident completes the activity by themselves, with no assistance from a helper.
Debra Wright: We're gonna Code 5 setup or cleanup assistance if the helper provides
Debra Wright: that setup or cleanup. But the Resident completes the activity. So the the helper and the staff only assist prior to or following the activity, but not during the activity. So if we're providing them with their hygiene items, or we're opening a food container, or we're giving them their assistive device. But once we do all that, they're able to do the activity, then we would code 5 for that setup.
Debra Wright: We'll code for for supervision or touch touch touching assistance. If the helper provides verbal queues or touching studying contact guard assistance as the resident completes the activity. This assistance can be in a number of different forms, it can be intermittently or throughout. The entire activity could be verbal queues. General supervision.
Debra Wright: We're also gonna code supervision. If the Resident requires only verbal queues to complete the activity safely. So if they're doing the entire activity. But throughout the activity. We're supervising them. And we're giving them verbal cues. Then we're gonna want to code 4 for that.
Debra Wright: We're gonna code 3 for partial or moderate assistance. If the helper does less than half the effort, and we're gonna code 2. If the helper does more than half the effort
Debra Wright: and then dependent. This is one that I think a lot of people tend to code incorrectly or miss the opportunity to code. This is when the helper does all of the effort.
Debra Wright: or
Debra Wright: even if the the Resident assist with the activity, it takes 2 helpers to to complete the activity. So if they are transferring, and there's 2 helpers on each side of the Resident to do that transfer, then we're coding dependent, even though the Resident did transfer from bed to chair by themselves. But if we were there with them and helping them, then we would code
Debra Wright: 2. We would code one for dependent, because there were 2 helpers with them.
Debra Wright: And then these codes haven't changed any will. Code 7. If the Resident refused Code 9, if the the activity wasn't acquable for them. we would code 10 if we didn't attempt due to environmental limitations, and we would code 88 if we didn't attempt due to medical condition or safety concerns.
And then here's just the decision tree to walk you through which level of assistance
Debra Wright: and what we're gonna do now for the rest of Section Gg, we we could talk about section Gg all day.
Debra Wright: But so for this short period that we have today, I'm only gonna talk about the coding tips that were added to Section G other than that. Everything that was in Section G prior is still there. We're just adding some additional coding tips. And that's what we're gonna review today.
Debra Wright: So for eating under self care. They added that eating is to assess the residents ability to use suitable utensils, to bring the food or liquid to their mouth and swallow the food, or once the the meal is placed in their food before the Resident is placed before the Resident. So that was the coding tip for eating, for oral hygiene, they added clarification. If the resident is.
Debra Wright: we would still code oral hygiene, based on the amount of assistance that it required the helper to clean the residents, gums.
Debra Wright: toileting hygiene they included, performing perineal, hygiene, managing their clothing, be such as before and after voiding or having a bow movement and adjusting the clothes relevant to the the individual resident
Debra Wright: shower and bathing self. They added that this could be from any location, whether you they were getting a bed bath whether we were assisting them to a tub bench.
Debra Wright: And we would code 5 if we did the setup or cleanup assistance. If the Resident completed the bathing task after we reach, retrieve the supplies, and provided the necessary setup for them.
Debra Wright: Dressing. If a resident requires assistance, with dressing, including assistance from buttons, fasteners fastening a Bra code based on the type and amount of assistance required to complete the entire dressing activity. So they just clarified that there a little bit
Debra Wright: personal hygiene. They added. The personal hygiene involves the ability to maintain personal hygiene, including combing their hair, shaving, makeup, washing, and drying their face and hands, but it does not include
Debra Wright: bath showers and oral hygiene. So it's all those other things, and personal hygiene would not be included in a standalone pps, but all the other all the other types
under mobility.
Debra Wright: they added, rolling left to right. If the Resident doesn't sleep in bed, they clarified that that we should assess bed mobility activities, using the alternate furniture. And what's which? The resident sleep? So maybe rolling left and right, is shifting their weight, left to right, as they're in their their recliner chair, or whatever they're using to sleep in
Debra Wright: lying to sitting on the the side of the bed. Remember before part of the definition was, the residents. Feet had to touch the floor in order to perform that task. They've taken that piece out of it. So it's still lying to sitting on the side of the bed, but they removed the residents touching the fleet. Feet part
Debra Wright: sit to stand. This, the activity includes the Resident coming to a full standing position from any sitting surface, and they they added clarification that if the full body lips, such as a hoy ear lift. Mechanical lift is used to assist in transferring a resident for a bed to chair transfer. We would code that this activity did not occur.
Debra Wright: share to bed.
Debra Wright: to chair, transfer, transfer. They clarified this at the transfer can be a stand pivot, squat, pivot, or a slide board transfer, so we would start the assessment with the residents sitting at the edge of the bed, or their alternative sleeping surfaces and ends with the residents sitting in a chair or wheelchair
Debra Wright: they further clarified it that when possible, the transfer should be assessed. An environmental situation in which, taking more than a few steps, would not be necessary to complete the transfer. So you wanna have whatever wherever they are, transferring whatever chair they're transferring to from bed. You wanna have that chair as close to the bed as possible.
Debra Wright: Toilet transfer includes the residents, ability to get on and off the toilet, with or without a raised toilet seat or a bedside. Komodo, whatever they're using for their their toileting. That's that's what we would look at
Debra Wright: and we're looking at the the process. We're looking at the hygiene clothing management and transferring on and off of bedpan are not considered part of a toilet transfer, so we can use the toilet we can use the bedside commode. We can have a raise toilet seat, but the bedpan
Debra Wright: is not considered part of this.
Debra Wright: and then we would code 5 if the Resident requires a helper to position set up on the bedside, commode before and after. In those activities. If they do not require assistance during the toilet transfer, we would Code 5 for setup and cleanup assistance
Debra Wright: tub shower transfer involves the ability to get in and out of the tub or shower. We're not gonna include the washing, rinsing, drying, or any other bathing activities. In this item, we're just focusing on the transfer. And if the Resident does not get in out of the tub or the shower, then we would code. The appropriate activity did not occur. Either refuse, not applicable, or did it for their safety interventions
Debra Wright: car transfer. They clarified that this does not include getting to or from the vehicle doesn't include opening and closing the door and doesn't include fastening or unfastening the seat belt. It's basically just the transfer from their their wheelchair or walking to the vehicle and actually getting in the vehicle.
Debra Wright: If the resident remains in a wheelchair and does not transfer in and out of a car or a van seat, then we would code the activity as as activity not attempted, whichever one the appropriate one is for them
Debra Wright: walking. Starts once. Once the Resident is in a standing position. So we're not gonna include that from the sit to the stand cause we've already addressed that this is just the actual physical movement of walking. So a walking activity cannot be completed without some level. The resident participation
Debra Wright: And the helper cannot complete a walking activity for a resident. Not really sure
Debra Wright: what that means. I can visualize it, but we they further clarified it so they must have had some questions. With that
during a walking activity a resident must.
Debra Wright: may may be able to take a a a break, so if they need to sit and rest, then we would consider the activity that it didn't happen.
Debra Wright: or they couldn't complete it. But they are able to take a brief standing rest. So if they get so far because they're doing the 150 feet, and after 75 feet they just are like they have to take a little breath. That's okay. But if they actually have to sit to rest, to finish the activity, then we would code the appropriate, unable to complete activity code.
Debra Wright: They further stated that we can use our clinical judgment to determine how the the resident assessment of walking is conducting. We can do a combination of multiple walking activities, to determine the type and amount of assistance needed for each individual activity.
Debra Wright: And this is just says the same thing.
Debra Wright: one step, 4 steps, 12 steps. Completing the stair activities indicates that a resident goes up and down the stairs by any safe means, with or without any assistive device. So they just made this match what they were saying. In the prior functioning example and clarification that whatever whatever device they need to get up and down the steps in a safe manner. We can count that as we're looking at the level of assistance.
Getting to and from the stairs is not included when coding the curb or step activities
Debra Wright: ascending and descending the stairs does not have to occur sequentially or during one session. If the assessment of going up the stairs and then down the stairs occurs sequentially. The Resident may take a standing or seated rest break between ascending and descending the 4 steps or 12 steps.
Debra Wright: A resident who uses a wheelchair may be assessed going up and down the steps in a wheelchair, and we would just code based on the type and amount of assistance required from the helper.
Debra Wright: and if at the time of the assessment, the Resident is unable to complete the activity because of a physician prescribed restriction. For instance, the no stair climbing for 2 weeks, but could perform this activity prior to the current illness, then we would code 88, not attempted, due to medical conditions. And I think what they were getting at with this is, if they
Debra Wright: didn't have to do steps when they were discharged, we would code. This is not acapable. So this is where they're trying to determine. Do they have to do steps? And they just can't because of medical condition, or do they not need to have to do steps
Debra Wright: picking up an object? They further add more to coding tips for this one, that the activity includes the resident bending or stooping from a standing position to pick up a small object from the floor, so, picking up the object must be assessed while the Resident is in a standing position. If the Resident is not able to stand. The activity did not occur in the appropriate activity not attempted code would be used.
Debra Wright: If a resident is in the standing position and unable to pick up the small object from the floor and requires assistance we would code based on how much assistance we gave them.
Debra Wright: to pick up the the object they can use assistive devices. So if they're in a standing position, and they have a reacher, and they use that reacher and they're able to pick up the object. Then, again, we would just code based on the assistance that was provided.
Debra Wright: all the wheelchair items under mobility. The if the Resident uses a wheelchair for self mobilization prior to admission to the facility we would code yes, to open up the rest of the wheelchair items, so the admission assessment could indicate that the Resident does not use a wheelchair, but subsequent assessments could indicate that they used a wheelchair. So if we're doing that admission assessment and they didn't use a wheelchair before they're saying we should. Code.
Debra Wright: no, but then, if they become wheel chair bound, and they're using a wheelchair for the mobility. Then the subsequent assessments. We would start coding the wheelchair.
Debra Wright: So that was an awful lot for Section G, and I feel like, if you are new to the Mds. It could be very confusing. Those were just the changes that were added. In this version of the Rai.
Debra Wright: So section H. Not much changes here. Bladder and bow. Here's the intent.
Debra Wright: the coding tips. They further clarified that the one time, Catherine, for urine specimens which we knew we couldn't code. They've also added that one time catherizations for the post void residuals. We should not be coding those as one time catherizations. They also added a definition for stress incontinence.
and then active diagnosis.
Debra Wright: Not much has changed here as well. Here's the intent
Debra Wright: coding instructions. Haven't changed. They, when the one coding instruction that, they added, is one in a queue condition is the primary reason for the residents. Sniff, stay, it can be coded at I 0 0 20 B. However.
Debra Wright: in a lot of times it's more common that a resident presents to the sniff for care related to an after fact of a disease, condition, or injury. So a lot of times that subsequent account or sequela codes would be what's used. So maybe they are just coming in for uti because their weekend, and then they're gonna go back home. But maybe it's a uti and dementia and and post cba.
That's that's what it means. Like, figure out, what is the what's the the biggest reason for why they are coming to the facility or at the facility.
Debra Wright: And then they added the example we've all been, you know, hearing and talking about the schizophrenia and those audits that are coming. So the example that, they added is this resident was admitted without a diagnosis of schizophrenia.
Debra Wright: After admission the Resident is prescribed. An anti-psychotic medication for schizophrenia by the primary care physician.
Debra Wright: however, the residents, medical record includes no documentation of a detailed evaluation by an appropriate practitioner of the residents. Mental physical psychosocial and functional status and persistent behaviors for 6 months prior to the start of the anti psychotic medication in accordance with the professional standards. So that's an awful lot of detail that has to be met for that diagnosis of schizophrenia now
Debra Wright: so coding schizophrenia at I 6,000 would not be coded.
Debra Wright: and the rationale is because, although the Resident has that physician diagnosis and is receiving that anti psychotic medication, we, it would not be appropriate to Code because of the lack of documentation of that detailed evaluation in accordance with the professional standards. It lacks the residents, mental, physical, psychosocial, functional status.
Debra Wright: and the persistent behaviors for the time period required of that 6 months prior to the start of the anti psychotic medication.
Debra Wright: And here are just the same resources from the beginning of the slide for the Rei Manual. The the Mds forms in the Youtube channel.
Debra Wright: So at this time, if if there's any, not any questions, I will turn it back over to Casey.
Kasey Stevens | Quality Insights: Awesome. Thank you so much, Deb. In a moment we'll begin the QA. Portion of the webinar. If you have a question or comment. Please submit them, either using the chat or the QA. Tool in your Zoom menu.
Kasey Stevens | Quality Insights: You can also raise your hand and request to be unmuted to ask your question aloud. I'd like to again invite everyone to next week's webinar, which will discuss Mds changes in sections JKL. And M.
Kasey Stevens | Quality Insights: That Webinar will be next Wednesday at 2 Pm. And I'll drop a link to register for that in the chat.
Kasey Stevens | Quality Insights: We also invite you to bring your questions to our virtual live chat. Every Tuesday and Thursday at noon. Debra right will be there to answer your questions about topics such as quality, improvement, initiatives, infection control and Mds coding. You can find the links to those live chat in our webinars in the Newsletter we send out each Friday, called the last minute lowdown.
Kasey Stevens | Quality Insights: And if you'd like to receive that newsletter, and don't think you're on your on the mailing list, you can send me an email at Keith stevens@qualityinsights.org. I'll also put that in the chat, and I'll make sure you get you on the mailing list.
Kasey Stevens | Quality Insights: Alrighty. Let's check out. See if there any questions here for Deb. We've got a first one for an end of a Pps assessment. Do I need an Osa.
Debra Wright: So if it first of all, West Virginia has not made a decision yet for their Osa. So my answer is not going to be pertinent to West Virginia. So for Pennsylvania, Pennsylvania is doing the Osa.
Debra Wright: And if you're a facility that is duly certified in Medicare and Medicaid for every Obra and Pps assessment, except with this charge and entry. Mdss. Yes, we will need to do an Osa.
Kasey Stevens | Quality Insights: Another question here. If a resident is admin with a diagnosis of schizophrenia, and on long term anti psychotics. How would we know the behaviors and the 6 months receiving the medication start? Is that up to the physician to document?
Debra Wright: Okay? So I'm gonna do a disclaimer that I am not an expert in this this particular area, however based. Just looking at the definition, I would say that if they have significant behaviors for the past 6 months, there is going to be some kind of physician documentation, whether it's from the Pcp. Or A psychologist that's following in them that you should be able to have that proof of the documentation to
Debra Wright: to identify that 6 month proceeding.
Kasey Stevens | Quality Insights: Fantastic. Thank you, Deb. I'll see any other questions roll in here for a moment.
Kasey Stevens | Quality Insights: Friday. It looks like that's it for questions. Before we sign off. We'd like to ask everyone here today to please answer short evaluation of today's webinar. The evaluation is anonymous and will show us a pop up as the webinar ends. You have a couple of minutes to fill that out. We greatly appreciate it. Deb again. Thanks for joining us today, and thank all of you for joining us. We hope we that we can see you again next week.
Debra Wright: Thank you.