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Test Your Knowledge Answers:

1) That code is an external cause code. SNFs are not required to use those codes and often cause billing issues. Use an actual medical diagnosis instead; this diagnosis is why the resident is requiring care in your nursing home. 

2) Modifications for assessments can only be transmitted within the last 2 years. 

3) The MDS must be coordinated by a registered nurse.  The Care Area Assessments must be completed by a staff member who can assess. Care planning should be initiated by a registered nurse. 

4) Unfortunately, it is. They are still a resident of the facility when on leave. 

5) Yes, it is in iQIES. Top of the page you will see assessments and next to it reports. It's a drop-down box where you can make selections. 

6) The OBRA Discharge with return not anticipated is correct. A0310G1 would be coded as yes it was an interrupted stay and A0310H would be coded as no it is not a Part A PPS Discharge MDS. An entry tracking form and a new Admission MDS would be completed. Do not do a new 5-day PPS MDS since it was an interrupted stay. There may also be an IPA opportunity.

7) MDS does not specify who should complete specific sections. This would be based on facility policy. The only items that are required to be completed by a registered nurse are Z0500, V0200B, and X1100. 

8) When an unstageable ulcer becomes stageable it's no longer unstageable and should be staged. Once staged numerically, it will never be staged at a lower level. A Stage 3 ulcer may become unstageable when slough or eschar prevents you from telling if it has remained a Stage 3 or has worsened and become a Stage 4. Stage 4s however can never become anything else so slough and eschar can't make it unstageable (it is already a Stage 4). Until it heals, it should be recorded on the MDS as a Stage 4.

Per NPIAP guidelines once an Unstageable Pressure Injury can be staged, it must be staged and it will at least be a Stage 3 because slough can't form on epithelial tissue. It will never be less than that stage and needs to be coded on the MDS accordingly.

Stage 4 pressure ulcers can become unstageable due to slough or eschar if the wound bed cannot be visualized to see the stage. The ulcer will never be staged at Stage 3 because wounds are not reverse staged.  But a Stage 4 ulcer that becomes covered with slough or eschar is considered worsened and is coded as unstageable due to slough or eschar.

9) Toilet hygiene includes managing clothing and perineal hygiene. It includes incontinence care.  Pulling down clothing including incontinence briefs, providing hygiene, assisting to put on a clean brief, and adjusting clothing is included even if the resident is in bed when toilet hygiene is completed.

10) The primary diagnosis coded in I0020B also needs to be entered into the section I checkboxes or in I8000. Auto-populated coding must be checked and validated for section I coding. Your software, no matter how well-intentioned, should NOT be making the MDS diagnosis coding decisions. The software does not know which diagnoses are still active. It is our job to make sure that diagnoses are correctly coded on the MDS. You can change or delete incorrect diagnoses entered by your software. The software does not know more than you do about the resident and the physician's documentation of diagnoses. 

11) If the resident was skilled for 100 days, exhausting Medicare benefits, and has never gone 60 consecutive days without a skill, then they would not qualify for a new 100-day benefit period. 

12) The Baseline care plan would need to be completed for every first admission to the facility but also for any re-entry where the Baseline care plan or comprehensive care plan does not exist. 

13) The 3-day window for a 5-day PPS MDS is the first 3 days of the stay. The ARD would usually be outside that window. 

For the OBRA MDSs, it may not be ideal to be 'working on the edge' like that. There is a three-day window. The assessments may want to be completed early in the window so there would be time to collaborate with the other members of the interdisciplinary team who are involved in completing Section GG assessments for the resident.

14) Per the RAI manual to code Major surgery (J2000) it has to meet 2 criteria:

1. The resident was in an acute care hospital for at least one day in the 100 days prior to admission to the SNF

2. The surgery carried some degree of risk to the resident's life or the potential for severe disability

15) It sounds like only the PDPM payment items were focused on without realizing that the PPS Discharge is not used for payment. All GG items must be assessed to complete the SNF QRP measures. 

16) Code according to the pharmacological classification. 

17) The item is not reporting how the resident got to the shower room. The question is asking how the resident transferred into the shower. If a staff member completed the transfer into the shower, it would be dependent.

18) CMS does not mandate which discipline/role should complete each MDS section. It is a facility decision. 

19) You do not want to inactivate your Admission assessment. Print a copy of the combination Admission/5-Day assessment. Then MODIFY the combination MDS to change the coding in A0310B from 01 to 99. The PPS 5-Day for payers other than original Medicare A cannot be transmitted to the federal database, but the OBRA Assessments must be submitted. The printed copy should suffice for billing to the Managed Care plan.   

20) The 30-day transfer window applies to the QHS and any subsequent Medicare Part A-covered SNF stay. You would need to know the last covered day (LCD) and count from there. To be eligible, the current services must be related to a condition treated in the QHS or following SNF stay. 

21) With the resident’s stay ended, there is nothing you would do with this missed MDS at this point. To be proactive, I would review the MDS scheduling process at your facility to determine how this happened and also audit all other current residents for compliance.