Test Your Knowledge Questions:

1) A resident had a fall at home that resulted in an acetabular fracture but did not receive surgery. The provider’s progress notes indicated, “Unspecified fall, initial encounter” (W19.XXXA), as the primary medical diagnosis. Should this diagnosis be used? 

2) A resident who was in a facility in 2017 and returned as a new admission this year. It was noted that her last name was misspelled on all of the assessments from 2017. Can these assessments be modified? 

3) Can a person who is not a nurse be the MDS coordinator with an RN overseeing them? Considerations: Non-nurse no license, Non-nurse therapist, or Non-nurse Respiratory therapist.

4) If a resident falls while on LOA, comes back to the facility, and complains of pain with an acute fracture noted, is the facility responsible to code fall with major injury in-house?

5) Are the Casper reports available on iQIES?  

6) A Medicare resident discharged home. The resident had a fall once home, went to the ED, and was readmitted to the same facility. When the resident left, a DCRNA was scheduled (planned), and a PPS Part A end-of-stay assessment was scheduled but not started. Would this now be treated as a new Admission with an Entry Admission/5 Day Assessment? 

7) Are there is any regulation that prevents therapists to enter rehab information in Section O? 

8) A resident with an ongoing pressure ulcer was FIRST coded by a wound nurse as "Unstageable- Slough and/or Eschar." The most recent documentation that occurred prior to the look-back time period (quite a few months after it was first identified) documents "STAGE 4." How should this continue to be coded?

9)  If a resident is totally incontinent (check and change in bed): For GG0130C, Toileting Hygiene, would the resident be coded as Dependent, or 09? 

10) Our software auto-populates I0020B and I8000A with the same ICD-10 code. Is this an RAI User’s Manual requirement? 

11) A resident was admitted with a PEG tube about a year ago. They were hospitalized and had the PEG tube replaced. The resident returned to the facility under Medicare. Would the new PEG tube be considered and would the resident qualify to utilize the 100 days? 

12) Is the Baseline care plan done only on the very first admission to the facility or is it to be completed on reentry as well? 

13) The look-back period for Section GG is 3 days. Is Section GG completed on the ARD date? This would not include the whole 3-day look-back period. Would this be correct?

14) Should Thoracentesis, colonoscopy, and/or paracentesis be coded in Section J as Major Surgery?   

15) A facility received a letter from CMS stating the 80% threshold on the MDS reporting requirements for FY 2022 was not achieved. When reviewing the PPS-DC assessments for that time period, well over 20% of the assessments, Self-Care DC Performance, Eating, Oral Hygiene, and Toileting Hygiene were coded; the remaining four activities were dashed. For Mobility DC Performance, Rolling Left and Right were often dashed as well. Could this be the source of the problem? 

16)  Is the medication Unisom considered a hypnotic for the MDS in Section N? 

17) There are no shower stalls but rather 'shower rooms' in the facility. Each resident is wheeled into the shower room for their weekly shower, remaining in the shower chair during the course of the activity. Would tub/shower transfer be coded as Dependent, as the resident did not participate in the transfer into the shower room or would it be coded as 09 not applicable or 10 not attempted due to environment? 

18) Is there a requirement that other departments (Activities, Dietary, Social Services, etc.) complete their sections on MDS? Or can the MDS Coordinator complete all the sections? 

19) A resident was thought to have Medicare Part A and an Admission/5-Day assessment was completed and submitted. Later found out the resident was actually Managed Care. The Admission/5-Day needs to be inactivated and an admission completed. How is this corrected? 

20) A resident was in an SNF with a qualifying hospital stay over a month ago. The resident was discharged home a week ago. The resident is returning to the SNF for skilled services. Does the resident require a new qualifying hospital stay (QHS) to use the remaining Medicare benefits?

21) A Quarterly assessment was missed a few months ago for a resident who has now been discharged. How can this be corrected?