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Test Your Knowledge Answers:

1) Only a physician or physician extender (nurse practitioner, physician assistant, or clinical nurse specialist) working with the resident can diagnose. A physician should not be queried and asked to add a diagnosis we believe is appropriate—queries should be non-leading. For example, you could document the findings of the nutritional assessment and ask the physician if he/she would like to add a diagnosis to the medical record based on the nutritional assessment. 

2) Yes, I2300 can be coded based only on the diagnosis from the hospital. See page I-13 of the RAI User’s Manual: "If the diagnosis of UTI was made prior to the resident’s admission, entry, or reentry into the facility, it is not necessary to obtain or evaluate the evidence-based criteria used to make the diagnosis in the prior setting. A documented physician diagnosis of UTI prior to admission is acceptable. This information may be included in the hospital transfer summary or other paperwork."

3) Diagnoses in I8000 do not need to be sequenced. 

4) The answer is maybe. Usually, Medicare coverage ends when hospice services begin—both are Medicare Part A services. It is possible to dually cover a resident on Medicare and hospice if the Medicare skilled coverage is totally unrelated to the terminal condition. It is unusual to be able to dually cover a resident on Medicare and hospice at the same time. 

Please also see the Medicare Benefit Policy Manual, chapter 8:

Hospices contract with SNFs for services related to the beneficiary’s terminal condition. These bills are not processed by the A/B MAC (A) or (HHH). However, there will be situations where a beneficiary is admitted as a hospice patient, but later requires daily skilled care unrelated to the terminal condition. If the beneficiary was initially admitted as a hospice patient prior to the date sanctions were imposed, and meets the requirements for Part A coverage; sanctions will not be applicable. Benefits will be paid under SNF PPS from the first date the beneficiary qualifies for Medicare Part A for care unrelated to the terminal condition. The facility must complete the Medicare-required assessments from the start of care for the unrelated condition.

5) You do not need to complete an SCSA for this situation as the resident died before the assessment completion deadline, assuming the enrollment in hospice was less than 14 days prior. You will need a death in facility tracker for the death date. 

Note: The RAI User’s Manual, pages 2-16 through 2-18, provides ARD window and completion deadlines for OBRA assessments. An SCSA must have an ARD set and the assessment completed within 14 days of the determination that an SCSA occurred. For a resident enrolling in hospice, the date of enrollment is the determination date. 

6) No, when a resident dies while on Medicare coverage, only tge death in facility tracking form is needed.  Do not do the Part A PPS Discharge in this case.  This is the only time a Part A PPS Discharge MDS is not needed when Medicare coverage ends. 

7) Melatonin is a supplement and is not considered a Hypnotic according to its drug class. 

8) If the surgery was major surgery and occurred while an inpatient at an acute care hospital or Critical Access Hospital (CAH) within 30 days of the Medicare start date, it should be coded even though the resident was admitted to another post-acute provider between hospital discharge and SNF admission. 

9) If the resident was out at the hospital over 3 consecutive midnights, this is NOT an interrupted stay even though one night was an observation stay.  A Part A PPS Discharge with the OBRA discharge and a new 5-day PPS MDS should be completed on this return.  We count interrupted stays by non-covered days.  Your resident was gone for 3 non-covered days. 

10) The mood interview must be asked as written. The questions cannot be changed, the interviewer cannot try to lead the resident to a different response. Document exactly what the resident answers. Your documentation in the medical record will support the care planning for the resident's mood issues.