Memory Care: Best Practice Documentation

1. SOC Homebound Status: a. If Mini-Cog score is 0-3, SELECT nervous system involvement under “Body Structure Impairment.” (See 4b note regarding consideration of reversible deliriums.) b. If Mini-Cog score is 0-2, SELECT Mental Function Impairment (Movement related, Sensory, Mental, Voice and Speech) under “Body Function Impairment.” (Note: Be as specific as possible; also, there can be multiple body function impairments related to the nervous system structural impairment.) c. Do not forget to assess for other Body Structure/Function impairments that may be independent of cognitive impairment. 2. Pain: If Mini-Cog score is 0-2, PAID-AD scale should be used to measure pain. If patient has impaired executive function, they are not likely able to adequately recall and quantify pain over a 24 hour period. Use of this tool helps to support skill and medical necessity. a. Document in “O” (Observation) section of nursing note or in “A” (Assessment) section of therapy note OR free-texted in physical assessment section under “other”. b. Keep in mind: in conditions such as Parkinson’s Disease where visuospatial awareness/perceptual awareness skill deficits are highly common in disease process (even in patients with seemingly WNL memory and problem solving): these deficits impact a patient’s ability to adequately quantify pain, even if cognition seems completely normal. c. “Vision” deficits in Parkinson’s sometimes mask deficits in visuospatial/perceptual awareness. Example: If a patient is wanting to sit in a trash bin vs chair, consider possible impairment of relationship between self and environment. 3. M1700: If Mini-Cog Score is 0-2, M1700 score should likely be 2,3,4, but should be individually assessed. a. Remember that a score of “4” refers to cognitive function that is totally dependent due to disturbances such as constant disorientation OR coma OR persistent vegetative state OR delirium. Consider: Does this patient have the ability to improve their cognitive function and functional scores, considering the disease process? Is patient disoriented to their own deficits, i.e. time, situations, CGs, current environment? Will the patient continue to need constant supervision ongoing due to their cognitive status/diagnosis? b. Consider reversible deliriums, i.e, post-op confusion due to anesthesia and opioid pain meds. This should be noted in the assessment portion of the EMR, and would not “count against” the audit score. However, if it is not clearly noted, the clinician may benefit from education here. The point is for all of us to get in the habit of doing a “5 (more or less) Why” process. Why is the Mini-Cog score less than 4? Our POC can then reflect appropriate interventions. 4. PHQ-2 Depression Screening: If Mini-Cog Score is 0-3, answer to question “Is the patient physically and cognitively able to be screened for depression using PHQ-2” is likely to be “No.” Consider executive function impairments and ability to adequately recall and quantify responses to screening questions of PHQ-2 “Over the last two weeks, how often have you been bothered by any of the following problems?” If the patient cannot remember 3 words in 3 minutes, how can they accurately recall the last 2 weeks to report on the PHQ-2? 5. Add-On Evaluations: If Mini-Cog score is 3 or less, physician should be contacted with results of Mini-Cog and request for referral to OT or ST. 6. Cognitive Staging: If Mini-Cog score is 3 or less, patient should be staged with CATG, ALLEN, RTI, GDS or other standardized tool. Stage should be based upon results of two different assessment tools. a. Mini-cog score of 3 indicates possible mild cognitive impairment. Further assessment needed. Recommend assessment with the MoCA, which has higher sensitivity and specificity for MCI. b. Add Snapshot note to reflect stage and which tool was used. 7. Memory Care Pathways: Should be used by both NURSING and THERAPY. a. TAKE CREDIT if you have to modify how you teach your patient Consider: use of spaced retrieval, how you approach patient, need for CG education regarding dementia medication/disease process. Example: Do you need to joke with patient first or pretend that you just so happened to run into them and they just so happen to be your favorite person in the world, before you can walk them? This is all part of a memory care approach!!! b. SLPs-Remember that “executive function” pathways may be selected only for Mild Cognitive Impairment, or Allen Level 5/GDS 2 or 3. Use of executive function implies cognitive rehabilitation, which Medicare and other payors consider to be unproven . 8. Diagnosis: Document dementia related dx: Carefully probe family/facility/MD if specific diagnosis has ever been documented or investigated. Symptom codes may be used. See coding information below. 9. HH Utilization: Be sure that nursing and therapy visit numbers are appropriate based on C/F scores, PLOF, and medical record. Consider staggering disciplines as appropriate to optimize utilization but also allow success of meeting each discipline’s goals – who really needs to be in there first? Should all disciplines be in simultaneously?

In patients with cognitive impairment, these codes are acceptable to support medical necessity.

1. Verify through discipline-specific Local Coverage Determination as applicable available at cms.gov 2. Supporting documentation required for all (H and P, etc. for diagnoses; collaboration with physician for symptom codes)

F01.xx Vascular dementia (Code 169.31 first, followed by F01.5+) F02.xx Dementia in other diseases classified elsewhere. Must code underlying pathology first, i.e. Alzheimers, Creutzfeldt-Jakob disease, DLB, Dementia with Parkinsonism F03.xx Dementia unspecified F03.90 Unspecified dementia without behavioral disturbances F03.91 Unspecified dementia with behavioral disturbances. G30.x Alzheimer’s disease G31.x G31.1 Senile degeneration, non-alcohol related G31.0 Picks disease G31.2 Degeneration of N.S. due to alcohol G31.83 DLB G31.84 MCI R41.0 Confusion (with no current diagnosis) R41.3 Memory loss (with no current diagnosis) R41.81 Cognitive decline (with no current diagnosis) R41.84 Other specified cognitive deficit, i.e., R41.848 Attention and concentration deficit R41.841 Cognitive communication deficit R41.842 Visuospatial deficit R41.843 Psychomotor deficit R41.844 Frontal lobe and executive function deficit

Only code a specific pathology, i.e., Alzheimer’s, Vascular, Lewy Body, etc., with supporting documentation from physician included in EMR. Symptom codes, such as R41.84, can be used with supporting therapist assessment documentation. As always, coordinate with referring physician.

These are guidelines only. Specific questions should be directed to your PRQI or BD.