Ensuring the Accuracy of the MDS

The Minimum Data Set (MDS) as a part of the Resident Assessment Instrument (RAI) was developed by the Health Care Financing Administration to assist Medicare/Medicaid certified nursing homes in developing a comprehensive care plan for each resident. The Institute of Medicine report in 1986 identified uniform resident assessment as essential to improvement in the quality of care delivered to residents and reform of the survey process. Facilities have had varying success in using the RAI system to develop effective care plans. State surveyors use information found in the RAI and the care plan to evaluate a facility's compliance with Federal regulations. Unfortunately, staff of many facilities have viewed this requirement as "government paper work" and have not integrated the MDS process into the care systems in their facilities.

Beginning July 1, 1998, the Health Care Finance Administration started to use a prospective payment system (PPS) for Medicare beneficiaries in Skilled Nursing Facilities (SNF). The prospective payment system was developed using one hundred and eight items from the MDS to calculate a Resource Utilization Group (RUG) for each resident. The grouping calculated for each resident determines the reimbursement the facility will receive for the resident's Medicare stay.

This change in the reimbursement system for Skilled Nursing Facilities has significantly enhanced the role of the Registered Nurse (RN). Federal regulations require that a registered nurse "conduct or coordinate" the assessment. Registered nurses have a critical role in assuring that the facility receives the appropriate reimbursement for the care of each Medicare beneficiary as well as coordinating the care and services provided. This enhanced role will be a challenge. It is essential that registered nurses develop systems which ensure that each assessment is completed accurately and within the time frames required by the Medicare reimbursement system.

Development of a System to Manage the MDS Process

It is very important that all staff who are involved in the completion of the MDS use the operational definitions found in the Long Term Care Resident Assessment User's Manual Version 2.0. Failure to use the operational definitions may cause an incorrect calculation of the Resource Utilization Group for that resident. Errors could lead to underpayment or overpayment for the care delivered.

Using a systems approach can assist health care professionals responsible for completing the MDS in assuring accuracy of the data. Assuring accuracy is essential to ensure that appropriate care and services are provided to each resident as well as the receipt of appropriate reimbursement by the facility.

Each facility should develop a specific training and competency program which must be completed before a health care professional participates in a resident assessment. All health care professionals responsible for completing all or part of the MDS must read the user's manual. Opportunity should be provided for asking questions. If there are issues raised which are not addressed in the MDS Manual, the state RAI coordinator should be contacted. A list of state RAI coordinators with their phone numbers can be found in Appendix A of the RAI manual.

The next step in developing competency in completing the MDS should include the opportunity for new employees to assess a resident and compare that assessment with one completed in the same time frame by an experienced registered nurse. The findings from the two assessments should be compared. When there are differences in coding, there should be a discussion of the operational definitions found in the manual. Again, if there are unresolved issues, the state RAI coordinator can be contacted for further information. It is the responsibility of the facility to ensure that all health care professionals complete the assessments of residents accurately.

Training sessions for health care professionals are provided periodically by state survey agencies. Other training opportunities are provided by professional organizations and educational institutions. The Health Care Financing Administration provides updated information concerning the MDS and the Prospective Payment System on the Internet. The following websites are useful resources:

PPS Website

www.hcfa.gov/medicare/snfpps.htm

MDS Website

www.hcfa.gov/medicare/hsqb/mds20/default.htm

It is essential that the operational definitions found in the MDS Manual be used to code the MDS. Assessments have traditionally been based on one direct observation by the assessor. Many MDS items require the gathering of information over a 24 hour period for one or more days, dependent on the assessment period determined by the RAI coordinator. All staff who observe, care for, and interact with a resident can provide information critical to the accurate completion of the MDS.

The Registered Nurse responsible for performing or coordinating the assessment for a resident has the responsibility for identifying the time period in which the assessment information will be collected. This date is recorded at Section A3a. This date sets the last day staff can collect information for a specific assessment. Events or changes which occur after that date cannot be included in the assessment. The Medicare system provides a range of dates in which each assessment must be completed. The Registered Nurse must work in concert with the business office in ensuring that assessments required for the Medicare payment system are completed according to the Medicare schedule and at the same time ensure that all required clinical assessments are completed according the regulations found in the Code of Federal Regulations at 42 CFR 483.20. Some software vendors included a scheduling program in their software. Most facilities will use a tickler file or similar system to identify the dates Medicare and Clinical assessments are due.

Role of the Registered Nurse in Prospective Payment

Registered nurses have an important role in ensuring that residents in Skilled Nursing Facilities receive the maximum benefit from their Medicare stay. Registered nurses are responsible for assessment and reassessment of residents to ensure that appropriate care planning is performed and appropriate services are delivered to each resident. In addition to ensuring quality care for residents, registered nurses are responsible for ensuring that the resident's assessment reflects the resident's condition and the services provided so that the facility received the appropriate reimbursement for each resident whose stay was reimbursed by Medicare Part A.

PPS for Skilled Nursing Facilities has significantly enhanced the role of the RN. Federal regulations require that a registered nurse "conduct or coordinate" the assessment. This enhanced role will be a challenge. It is essential that registered nurses develop systems which ensure that each section of the assessment is completed accurately and within the time frames required by the Medicare reimbursement system.

Sections G, P and T

All sections of the MDS are important. However, there are four sections which appear to be problematic for many facilities: Section G1- Assessment of Activities of Daily Living; Section P1 - Special Treatments, Procedures and Programs; Section P3 - Nursing Rehabilitation/Restorative Care; and Section T1b, c, d - Ordered Therapies.

Section G - Physical Functioning and Structural Problems

The definitions in the RAI manual state that the resident is to be assessed over a 24 hour period. For the Medicare 5 day assessment and readmission assessment, the assessment reference period can be the first to eighth day of admission or readmission. For other Medicare assessments, the period will be within seven days of the assessment reference date. Residents who are very dependent in their ADL's can be assessed in a shorter time frame than those residents whose ADL performance varies from day to day or who are relatively independent. One important concept of the MDS coding system is that the resident is assessed at their most dependent. A resident who normally was able to propel a wheel chair without assistance asked staff to push them back to their room from the dining because she was short of breath. If this activity occurred only one time in the assessment period, the coding for locomotion off the unit for self performance would be G1f(A) = 0 - independent, but the coding for G1f(B) = 2 - one person physical assist.

Staff on all three shifts should provide information to the Registered Nurse concerning the resident's functioning on their particular shift. Residents are often more dependent late in the day and during the night than during day time hours. Providing nurse aides with a simple form to complete each shift indicating the level of assistance the resident received during the assessment period would significantly improve the accurate coding of items in this section.

Coding Section G accurately requires that the registered nurse understand the operational definitions and apply them correctly. The following is a review of the definitions used to complete Section G. Additional explanatory information is provided in italics and the use of bold print within the MDS definitions.

ADL Coding Definitions

ADL Self- Performance

Code for the resident's performance over all shifts during the assessment period-Not including setup.

Code 0 - Independent - No help or staff oversight - or - help/oversight provided only 1 or 2 times during the last 7 days.

To accurately assess that an individual met the definition for independent in an activity of daily living, the full assessment period may need to be utilized.NOTE: Medicare 5 day and Medicare Readmission assessments may not cover a 7 day period. The assessment period is between the day of admission and the assessment reference date set by the RAI Coordinator.

Code 1 - Supervision - Oversight, encouragement, or cuing provided 3 or more times during the last seven days -or-Supervision (3 or more times) plus physical assistance provided only 1 or 2 times during the last 7 days.

Again with more independent residents, it maybe advisable to assess over the full five to seven day assessment period to determine the actual amount of assistance they may need. Remember that residents perform activities of daily living multiple times over a 24 hour period.

Code 2 - limited Assistance - Resident highly involved in activity: required physical help in guided maneuvering of limbs, or other non-weight-bearing assistance 3+ times - or - more help provided only 1 or 2 times during the last 7 days.

Note that the term non-weight-bearing assistance is used. Residents may receive non-weight-bearing assistance one or two times in an assessment period to be coded as independent or needing supervision. Limited assistance introduces weight-bearing assistance. Nurse aides need to understand the difference between non-weight bearing support and weight-bearing support in order to provide accurate information to the registered nurse.

Code 3 - Extensive assistance - While the resident performed part of the activity over the assessment period, help of the following type(s) was provided 3 or more times:

Full staff performance means that staff performed all aspects of the activity for the resident. Activities of daily living include multiple tasks. Registered nurses need to carefully read the definition for the activity.

Code 4 - Total Dependence - Full staff performance of the activity during the entire assessment period.

Few residents are completely dependent on staff for performance of an activity. The resident must be incapable of participating in any aspect of the activity. If the resident performs one aspect of an activity one time during the assessment period, a coding of 4 -Total Dependence is inaccurate.

Code 8 - Activity did not occur during the entire assessment period.

A resident who is bedfast and did not leave the bed during the assessment period would be coded on the MDS as a 4 for self performance for transfer.

ADL Support

Code for most support provided over all shifts during the assessment period; code regardless of resident's self-performance classification.

Code 0 - No setup or physical help from staff

The resident was able to perform the activity completely independently without physical assistance or cuing by staff.

Code 1 - Setup help only.

A resident is able to ambulate and transfer if staff place a walker beside the resident's bed in a specific position. Resident is able to be independent in bed mobility if staff raise the siderails so the resident can use the rails to change their position in bed.

Code 2 - One-person physical assist.

Code 3- Two or more persons physical assist.

Code 8 - Activity did not occur during the entire 7-day period.

Sections P and T

The items in Section P record special treatments and procedures which the resident received both in and out of the facility. Part a of Section P is used to identify treatments and programs which the resident received in the previous 14 days. The assessment reference date determines the look back time frame.

The items listed under treatments (P1a. Special Care - TREATMENTS) can occur in and out of the facility. Transfer information provided by a hospital or another inpatient facility is critical for accurate completion of this section for 5 day /readmission Medicare assessments, 14 day Medicare assessments and Initial Comprehensive Assessments. This section allows facilities to identify resource intensive services provided to residents while in the facility. Residents who received the specialized treatments listed in this section while in a hospital are often admitted to a SNF for continued monitoring of the clinical condition which precipitated the need for the treatments and the effect of the treatments. The 14 day look back allows facilities to identify treatments which require monitoring for a period of time. An example would be a resident who received chemotherapy while in the hospital and was transferred to a SNF for skilled observation and treatment of symptoms related to the resident's response to the chemotherapy.

The programs listed under P1a Programs are limited to those programs provided within the facility. Therefore, only those programs offered from the day of admission are recorded in this section.

Section P1b. Therapy assessment evaluations are often completed by the therapists providing the services. Time spent by the therapist performing the initial therapy evaluation cannot be included in the days and minutes recorded in this section. In some facilities a therapist will evaluate each resident admitted for Medicare Part A services for the need for therapy. In other facilities, this evaluation will be delegated to the registered nurse coordinating the resident's assessment. Timely evaluations and initiation of appropriate therapies must be coordinated so that therapies can be recorded during the Medicare assessment periods. If therapies are not initiated in a timely manner, another assessment may need to be conducted to capture the information needed to reflect the therapies being provided. In October 1998, the Health Care Financing Administration issued additional guidance for completing Sections P and T on their PPS website.

Nursing Rehabilitation Services are included in the RUG-III calculation. Registered nurses should evaluate each resident for the need for nursing restorative care (rehabilitation). This care must be delivered by nursing staff (including nurse aides) and supervised by a registered nurse. This is an area which is often overlooked by registered nurses coordinating the MDS. The failure to include rehabilitation/restorative services may have a negative impact on the reimbursement received by the facility.

Sections T1b, T1c, and T1d are completed with 5 day Medicare Assessments and Medicare Readmission Assessments. This section includes the amount of therapy provided since admission or readmission and therapy expected to be provided during the resident's first 14 days of stay. Many facilities have the mistaken idea that there is an advantage to delay completion of the 5 day Medicare or Readmission Assessment until at least five full days of therapy have been delivered. The number of days of therapy and minutes of therapy recorded in this section includes the therapy recorded in Section P as well as the days and minutes of therapy expected to be delivered. Therefore, using grace days will not change the RUG-III calculation. Registered nurses must work in collaboration with therapists in identifying residents who could benefit from therapies. The resident's ability to tolerate therapy, should also be evaluated. Residents who are unable to tolerate therapies at admission may need to be re-evaluated later in their stay. As an advocate for residents, registered nurses should ensure that each resident receives appropriate therapies during their Medicare stay.