MDS 3.0 Updates 2018

Cassie Crafton R.N., CDP, RAC-CT Objectives

• Understand new MDS 3.0 items in Sections GG, I, J, M, N and O that will be effective October 1st, 2018

• Know which MDS 3.0 items that will be removed and language changes Clarifications with Resident Interviews

Timing of Interviews • Section C (BIMS)- to be conducted preferably on the ARD or the day before • Section D (PHQ-9)- to be conducted preferably on the ARD or the day before • Section F (Activities/Preferences)- during the 7 day look back period • Section J (Pain)- to be conducted anytime during the 5 day lookback period preferably on the ARD or the day before Clarifications with Resident Interviews

• Staff interview should not be completed in place of resident interview IF the resident interview could have been completed

• B0700 should NOT be coded as “Rarely/Never Understood” if any of the resident interviews were completed PPS Changes

• Section GG changes

• Admission and Discharge Assessments

• Language Changes Coding Tips

• Admission Performance and Discharge Goals are coded on every Admission Assessment (Start of Part A PPS Stay) regardless of length of stay and planned or unplanned discharge • If the resident has an incomplete stay: – Complete admission performance and goals – Discharge self-care and mobility performance items are not required Section GG- Intent • Functional status is assessed based on the need for assistance when performing self - care and mobility activities

• Residents in SNFs have self - care and mobility limitations and are at risk for further functional decline and complications because of limited mobility New Items Section GG

• GG 0100 Prior Functioning: Everyday Activities • Intent: To identify resident’s functional status prior to current illness Section GG Prior Functioning • Self Care: Code the resident’s need for assistance with bathing, dressing, using the toilet, or eating prior to the current illness, exacerbation, or injury • Indoor Mobility (Ambulation): Code the resident’s need for assistance with walking from room to room (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury • Stairs: Code the resident’s need for assistance with internal or external stairs (with or without a device such as cane, crutch, or walker) prior to the current illness, exacerbation, or injury • Functional Cognition: Code the resident’s need for assistance with planning regular tasks, such as shopping or remembering to take medication prior to the current illness, exacerbation, or injury Section GG: Prior Functioning • Coding Instructions: – Code 3, Independent- no assistance, with/without assistive devices – Code 2, Needed Some Help- needed partial assistance – Code 1, Dependent- helper completed activity; includes needing 2 person assist – Code 8, Unknown – Code 9, Not Applicable- were not applicable to the resident’s prior to current illness Section GG

• New Item Added: G110- Prior Device Used – Check all that apply Section GG

• New items GG0130 Self-Care 4 new items Section GG: New items GG0170

• Mobility 7 new items Section GG: GG0170 Mobility Section GG: GG 0170 Mobility Section GG • Coding of GG0130 and GG0170 • 4 “Not attempted” codes items • 10- Not attempted due to environmental limitations ( NEW) Section GG: Coding Instructions • Admission Performance- code based on the first 3 days of Medicare Part A stay • Discharge Performance- code based on last 3 days of Medicare Part A stay • Coding is based on “usual performance” will require clinical judgement • If activity occurs multiple times (e.g., eating, toileting, dressing, bed mobility activities, bed/chair transfers, do not code most dependent, do not code most independent • Some items may only be assessed once, code that status Steps for Assessment Section GG • Activities may be completed with or without assistive device(s). Use of assistive device(s) to complete an activity should not affect coding of the activity. • If the resident’s self-care and mobility performance varies during the assessment period, record the resident’s usual ability to perform each activity. -Do not record the resident’s most independent performance -Do not record the resident’s most dependent performance • Refer to facility, Federal, and State policies and procedures to determine which SNF staff members may complete an assessment. Resident assessments are to be done in compliance with facility, Federal, and State requirements. Discharge Goals Discharge Coding Tips • Use the six-point scale or ‘activity was not attempted” codes to code the resident’s Discharge Goal(s). Use of codes 07, 09, 10, or 88 is permissible to code discharge goal(s). • For the SNF QRP, a minimum of one self-care or mobility goal must be coded. However, facilities may choose to complete more than one self-care or mobility discharge goal. • Use of a dash ( – ) is permissible for any remaining self - care or mobility goals that were not coded. • Using the dash in this allowed instance after the coding of at least one goal does not affect Annual Payment Update (APU) determination. Discharge Coding Tips • Licensed qualified clinicians can establish a resident’s Discharge Goal(s) at the time of admission based on: – Resident’s prior medical condition(s) • Prior and current self care and mobility status • Discussions with resident and family concerning discharge goals – Professional’s standard of practice – Expected treatments – Resident motivation to improve – Anticipated length of stay – Resident’s planned discharge setting/home • Goals should established as part of the resident’s care plan Section GG: Summary

5-Day Assessment Column 1 5-day Assessment Column 2 • All items in column 1 • Must have at least one must be completed discharge goal completed • Base coding on first 3 (may be in GG0130 or days of Med A stay GG0170) • No dashes • May use 1 of the 4 “not attempted” as goals • Choose any number from the 1-6 scale OR • Dash goals not • 1 of the 4 “not completed attempted” codes • Goals may indicate an improvement, maintain, or possible decline Section GG: Summary

SNF PPS Discharge Assessment Use of Dashes • All items in Column 3 • Section GG is the must be completed number 1 reason for • Base coding on last 3 2% penalty days of Med A stay • Confusion on coding • No dashes rules • Chose any number • Use of dashes from the 1-6 scale or • Only items used for • 1 of the 4 “not QRP QM calculation attempted codes are subject to the 2% penalty if dashed Section I: New item I0020

• Resident’s primary medical condition • Provides check boxes for 14 different items Section I: New item I0020 • Select the condition that represents the primary condition that resulted in resident’s admission to the nursing facility • If number 14 selected, enter an appropriate ICD-10- CM code in I0020 • If any condition 1-13 selected, then item I0020 is left blank • Includes the primary medical condition in Section I, Active Diagnoses Section I • Code 01, Stroke, if the resident’s primary medical condition category is due to stroke. Example include ischemic stroke, subarachnoid hemorrhage, cerebral vascular accident, and other cerebrovascular disease • Code 02, Non-Traumatic Brain Dysfunction, if the resident’s primary medical condition category is non-traumatic brain dysfunction. Examples include Alzheimer’s disease, dementia with or without behavioral disturbance, malignant neoplasm of brain, and anoxic brain damage • Code 03, Traumatic Brain Dysfunction, if the resident’s primary medical condition category is traumatic brain dysfunction. Examples include traumatic brain injury, severe concussion, and cerebral laceration and contusion Section I

• Code 04, Non-Traumatic Spinal Cord Dysfunction, if the resident’s primary medical condition category is non-traumatic spinal cord injury. Examples include spondylosis with myelopathy, transverse myelitis, spinal cord lesion due to spinal stenosis, and spinal cord lesion due to dissection of aorta • Code 05, Traumatic Spinal Cord Dysfunction, if the resident’s primary medical condition category is due to traumatic spinal cord dysfunction. Examples include paraplegia and quadriplegia following trauma • Code 06, Progressive Neurological Conditions, if the resident’s primary medical condition category is a progressive neurological condition. Examples include multiple sclerosis and Parkinson’s disease Section I

• Code 07, Other Neurological Conditions, if the resident’s primary medical condition category is other neurological condition. Examples include cerebral palsy, polyneuropathy, and myasthenia gravis • Code 08, Amputation, if the resident’s primary medical condition category is an amputation. An example is acquired absence of limb • Code 09, Hip and Knee Replacement, if the resident’s primary medical condition is due to a hip or knee replacement. An example is total knee replacement. If hip replacement is secondary to hip fracture, code as fracture. Section I

• Code 10, Fractures and Other Multiple Trauma, if the resident’s primary medical condition category is fractures and other multiple trauma. Examples include hip fracture, pelvic fracture, and fracture of tibia and fibula • Code 11, Other Orthopedic Conditions, if the resident’s primary medical condition category is other orthopedic condition. An example is unspecified disorders of joint • Code 12, Debility, Cardiorespiratory Conditions, if resident’s primary medical condition category is debility or a cardiorespiratory condition. Examples include COPD, asthma, and other malaise and fatigue Section I

• Code 13, Medically Complex Conditions, if the resident’s primary medical condition category is a medically complex condition. Examples include diabetes, pneumonia, chronic kidney disease, open wounds, pressure ulcer/injury, infection, and disorders of fluid, electrolyte, and acid-base balance • Code 14, Other Medical Condition, if the resident’s primary medical condition category is not one of the listed categories. Enter the ICD-10 code, including the decimal, in I0020A. If item I0020 is coded 1-13, do not complete I0020A Section J: New item J2000 Prior Surgery

• Indicate if the resident has had a major surgery in the 100 days prior to admission Section J: J2000 • Examples – Admitted to SNF after hip replacement surgery 5 days prior. Code 1, Yes, meets criteria – Cyst removal in outpatient One month prior to admission. Code 0, No, does not meet “major surgery criteria – Gall bladder surgery performed 6 months prior to admission. Code 0, No, does not meet criteria due to greater than 100 days ago Section K

• Change in Coding Instructions related to K0510 and K0710 • CMS no longer requires completion of Column 1 for K0510C or K0510D. Some states may still require. Arkansas will not Section K

• Change in coding instructions to K0710 – CMS no longer requires completion of Column 1 K0710 A and B. Some states may still require. (Arkansas does not) Section M: Intent • A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program. Be certain to include in the assessment process a holistic approach. • It is imperative to determine the etiology of all wounds and lesions, as this will determine and direct the proper treatment and management of the wound. Section M: Intent • CMS adheres to the following guidelines: – Stage 1 pressure injuries and deep tissue injuries (DTIs) are termed “pressure injuries” because they are closed wounds – Stage 2, 3, or 4 pressure ulcers, or unstageable ulcers due to slough or eschar, are termed “pressure ulcers” because they are usually open wounds – Unstageable ulcers/injuries due to non - removable dressing/device are termed “pressure ulcers/injuries” because they may be open or closed wounds Section M: Definitions

• New: The term “device” was added to items: M0300E– M0300E2 Section M: Definitions • New: – Removed the term “suspected deep tissue injury in evolution” and replaced with “deep tissue injury” to items M0300G and M0300G1 Section M: Coding • Steps for completing M0300A–G 1. Determine Deepest Anatomical Stage 2. Identify Unstageable Pressure Ulcers/Injuries 3. Determine “Present on Admission” On the Admission Assessment, “on admission” means as close to the actual time of admission as possible On each assessment determine the number of pressure ulcers/injuries present and determine the number of these that were present on admission Manual instruction 9 under Step 3: If a pressure ulcer was numerically staged, then became unstageable, and is subsequently debrided sufficiently to be numerically staged, compare its numerical stage before and after it was unstageable. If the numerical stage has increased, code this pressure ulcer as not present on admission. Section M: Summary

• Wording revisions due to Ulcer vs Injury – Injury is used for closed wounds (Stage 1, Deep Tissue Injury) – Ulcer is used for open wounds (Stage 2-4, Unstageable due to slough/eschar • Significant Change in Definition related to “Present on Admission” – If the pressure ulcer/injury was present on admission/entry or reentry and becomes unstageable due to slough or eschar, during the resident’s stay, the pressure ulcer/injury is coded at M0300F and should not be coded as “present on admission” Section M: Summary • Deleted Items: – M0610 (Wound Measurements)

– M0700 (Most Severe Tissue Type Present)

– M0800 (New or Worsened Pressure Ulcer)

– M0900 (Healed Pressure Ulcers) Section N

• Three New items added • New QRP QM (drug regimen review) • Drug Regimen Review – Upon admission medications reviewed – Significant clinical issues reported to provider (physician or NP) and follow up orders/recommendations implemented by midnight of the following day – Upon discharge any clinically significant issues were reported to provider and orders/recommendations implemented by midnight the next day Section N: N2001 and N2003 • To be completed on 5 day PPS assessment • Two questions related to resident admission (drug regimen review) Section N: N2001 and N2003 • Coding N2001 0- No, no issue found (Go to Section O) 1- Yes, Issue found (continue to N2003) 9- NA, Resident not taking medications (skip to O)

• Coding N2003 (Only completed if answered YES to N2001) 0- No 1- yes Section N- N2005 • Covers entire stay- from Admission throughout stay • If N2003 us coded as “No”, then N2005 must also be “No” Drug Regimen Review

• If the physician prescribes an action that will take longer than midnight of the next calendar day to complete, then code 1, YES, should still be entered, if by midnight of the next calendar day, the clinician has taken the appropriate steps to comply with the recommended action. • Example of a physician-recommended action that would take longer than midnight of the next calendar day to complete. – The physician writes an order instructing the clinician to monitor the medication issue over the next three days and call if the problem persists. Drug Regimen Review

• Includes all medications – Prescribed and over the counter medications – Administered by an route (including oral, topical, inhalant, injection, sublingual, parenteral, and by infusion – Includes total parenteral nutrition (TPN) and oxygen • A clinical significant medication issue is a potential or actual issue that, in the clinician’s professional judgement, warrants: – Physician (or physician-designee) communication and – Completion of prescribed/recommended action by midnight of the next calendar day Drug Regimen Review • Clinically Significant Issues – Medication prescribed despite medication allergies – Adverse reactions to medications – Duplicate therapy – Wrong patient, drug, dose, route, and time errors – Omissions – Drug interactions – Ineffective drug therapy – Nonadherence to drug therapy Drug Regimen Review • Drug Regimen Review performed: – Upon admission or as close to Admission as possible (per CMS) – Should be completed within first 24 hours – Drug Regimen Review is ongoing throughout stay • Each new drug order • Each revision or change in drug order • Change in clinical status Drug Regimen Review • Medication Reconciliation – Compare admission orders with medications received in hospital, prior to hospitalizations

– Review Diagnosis and Allergies

– Review Labs and ongoing lab monitoring (coumadin, etc.) Drug Regimen Review • Operational Changes – Develop and review current processes – Involve consultant pharmacist – Need to educate nursing staff on drug regimen review and requirements – Educate providers on new regulations and requirements – Documentation: • Nurse document DRR upon admission (review, physician notification, and recommendation) Section O • Chemotherapy Clarification – Hormonal and other agents administered to prevent the recurrence or slow the growth of cancer should NOT be coded in this item, as they are not considered chemotherapy for the purpose of coding the MDS – Examples: Tamoxifen, Evista, Fareston, Arimidex, Aromasin, Femara, Lupron, Eligard, Lupron Depot, Viadur Section O • Clarifications for O0100F and O0200G – O0100F now defined as an invasive mechanical ventilator (ventilator or respirator) – O0100G now named a non-invasive mechanical ventilator (BiPAP/CPAP)

• Pneumococcal – Removed old CDC diagram

– Follow guidance at : • https://www.cdc.gov/vaccines/vpd/pneumo/downloads/ pneumo-vaccine-timing.pdf

Care Area Assessments • Opioids have been added to the care areas – Delirium – Visual Function – Communication – Activities of Daily Living – Incontinence – Mood State – Falls – Dental Care – Pressure Ulcer/Injury Care Area Assessments • Updates to CAAs – Behavioral Review of Indicators updated with inclusion of Section E items • Potential Indicators of Psychosis • Behavioral Symptoms – Alarm use has been added as a factor to can cause or exacerbate behavior SNF Quality Reporting Program (QRP)

• IMPACT (Improving Medicare Post-Acute Care Transformation) Act of 2014 required standardization of data collection in post- acute settings – Skilled Nursing Facilities – Inpatient Rehabilitation Facilities – Home Health Agencies – Long-term Care Hospitals • CMS in response began SNF Quality Reporting Program – SNFs may receive a 2% reduction to annual payment update if they do not submit required information – Measures cannot be calculated if MDS item set is missing (dashed) or PPS Discharge assessment not completed SNF QRP • FY 2018 QRP Measures: – Long Stay Falls with Major Injury – Residents with Pressure Ulcers that are new or worsened – Admission and Discharge Functional assessment • FY 2020 QRP Measures: – Drug Regimen Review – Changes in skin integrity post-acute care pressure ulcer/injury – Change in Self-Care Score for Medicare patients – Change in Mobility score for Medicare patients – Discharge self-care score for Medicare patients – Discharge Mobility score for Medicare patients SNF QRP Functional Assessment

• The percentage of patients with complete or incomplete Medicare stay with Admission and discharge functional assessment and care plan that addresses function • Numerator: – Residents with complete Medicare A stays • Complete at least one self-care or mobility item on 5 day • Complete discharge functional assessment data on discharge – Residents with incomplete Medicare A stays • Complete admission functional assessment data and a discharge goal for at least one self-care or mobility item on 5 day • Denominator: Number of Medicare PPS stays with a Medicare Part A stay End date during the measure target period FY 2020 SNF QRP • Data collection begins October 1st 2018 – Drug Regimen Review – Changes in skin integrity post-acute care pressure ulcer/injury – Change in Self-Care Score for Medicare patients – Change in Mobility score for Medicare patients – Discharge self-care score for Medicare patients – Discharge Mobility score for Medicare patients • Changes in MDS items to use for these measures – Section GG, Section M, Section N Summary

• Resident Interviews – Updated to day of ARD or day before • Section GG – Updated items – Addition of prior functioning – Self care – Mobility • Section I – New item I0020 (Primary Medical Condition) • Section J – Prior Surgery Summary

• Section K – K0510C (Mechanically altered diet) – K0510D (Therapeutic Diet) – K0710A (Proportion of total calories) – K0710B (Average fluid intake) • Section M – Language changes – Deleted items (M0300B3, M0610A-C, M0700, M0800A-F, M0900A-D) – Clarification “present upon admission” Summary

• Section N – Drug Regimen Review • Medication Review • Medication Follow-up • Medication Intervention • Section O – Chemotherapy medication clarification – Invasive mechanical ventilator separated from non invasive mechanical ventilator • Updates to Care Area Assessments worksheets – Opioids added to care areas Questions or Comments?

Thank You. Cassie Crafton RN, CDP, RAC-CT