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Test Your Knowledge Answers:

1) MDSs for payers other than Medicare do not impact the Medicare APU. Only 5-day PPS MDSs and Part A PPS Discharge MDSs impact the APU. 

2) No, only code medications are given to relieve pain in Section J. 

3) It is important to document the resident's primary diagnoses and to identify active additional diagnoses to bill claims correctly. Often claims pull ICD-10-CM codes from the diagnosis section of the software. When the codes have not been prioritized, the software seems to randomly choose codes or chooses them by the most recently written whether those diagnoses are active or not. 

4) You do not need to modify previous MDSs once the new number arrives. Document the reason the Medicare number has changed in the medical record in case of future audits. If there is an issue with the claims, talk directly to your MAC to help get the claim(s) processed. 

5) The PPS discharge NPE is required when the Part A stay ends, in this case, 12/31/23. A new 5-day would not be submitted to CMS for a non-Part A payer, what is required by the insurance company depends on your facility contract. Yes, a Part A PPS Discharge for 12/31/2023. If UHC requires a 5-day you will need to complete a new 5-day, but it CAN NOT be transmitted) with an ARD within the first 8 days of the Medicare Advantage stay.

6) The waivers have ended, so a 3-day qualifying hospital stay is required before a resident can access the Medicare Benefit and be covered on Medicare A. 

7) This is an example from the RAI, page GG-23.

Eating: The dietary aide opens all of Resident S's cartons and containers on their food tray before leaving the room. There are no safety concerns regarding Resident S's ability to eat. Resident S eats the food themself, bringing the food to their mouth using appropriate utensils and swallowing the food safely.

Coding: GG0130A would be coded 05, Setup or clean-up assistance.

Rationale: The helper provided setup assistance prior to the eating activity. 

8) Yes, the Quarterly can be combined with the OBRA Discharge if the ARD can be set in the appropriate window for each assessment. 

9) ARDs can not be backdated. The administrator does not seem to understand the RAI rules/regulations. Backdating an MDS ARD when the allowable window has passed would render the assessment invalid. See chapter 2, page 2-9:

"Assessment Reference Date (ARD) refers to the specific endpoint for the observation (or "look-back") periods in the MDS assessment process. The facility is required to set the ARD on the MDS Item Set or in the facility software within the required time frame of the assessment type being completed. This concept of setting the ARD is used for all assessment types (OBRA and PPS) and varies by assessment type and facility determination. Most of the MDS 3.0 items have a 7-day look-back period. If a resident has an ARD of July 1, 2011, then all pertinent information starting at 12:00 a.m. on June 25th and ending on July 1st at 11:59 p.m. should be included for MDS 3.0 coding.

From the State Operations Manual, Appendix PP:

§483.20(j) Penalty for Falsification.

§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-

(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or

(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.

§483.20(j)(2) Clinical disagreement does not constitute a material and false statement." 

10) If there is documentation that the resident used the oxygen during the look-back, it can be coded. Not having an order could be a survey issue, however. 

11) Per the updated RAI User's Manual instructions, a Kennedy Terminal Ulcer is not a pressure ulcer so would not meet the criteria requiring a SCSA. 

12) For height, measure from the top of the head to the lowest part of the body remaining after amputation. For weight, some scales can be used to weigh residents who cannot stand (remember to subtract the wheelchair from the reading if you are using a wheelchair scale.) Full-body mechanical lifts often have scales that can be used as well. 

13) No, the SCSA would not need to be completed. When a resident dies or discharges before the assessment completion deadline, the assessment is not required. You can close the assessment as incomplete. It is recommended that the medical record be documented stating the resident died before completion of the SCSA for hospice. 

14) The software is correct and if coded correctly the resident qualifies for SCH. Having said that, you want to verify the diagnoses are correct and that others understand why the resident has difficulty breathing. Although most people with difficulty breathing while laying flat have COPD, we see it with CHF, pneumonia, respiratory failure, etc., and if the resident has a diagnosis of asthma that puts them into SCH as well.

This is from page 6-36 of the RAI and is the qualifier for Special Care High.

I6200, J1100C Chronic obstructive pulmonary disease and shortness of breath when lying flat.

Also, this is the coding guidance in section I, page I-11.

I6200, asthma, chronic obstructive pulmonary disease (COPD), or chronic lung disease (e.g., chronic bronchitis and restrictive lung diseases, such as asbestosis)

So, yes, the combination of I6200 being checked and J1100C being checked, will classify into Special Care High.

15) We are NOT allowed to transmit PPS MDSs for Medicare Advantage plans or other insurance plans other than Traditional Medicare A. See RAI User's Manual, Chapter 5, page 5-1:

5.1 Transmitting MDS Data

All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). Required MDS records are those assessments and tracking records that are mandated under OBRA and SNF PPS.

Assessments that are completed for purposes other than OBRA or SNF PPS reasons are not to be submitted to iQIES, examples include, but are not limited to, private insurance and Medicare Advantage Plans (i.e., Medicare Part C). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications available on the CMS MDS 3.0 website.

16) The NPE will need to be completed.  Whether or not to complete a SCSA would depend on whether the resident meets the RAI requirements. 

The Part A PPS Discharge MDS (NPE) is required when Medicare skilled coverage ends unless the resident dies while on Medicare coverage. Assess for a clinically significant change in condition. No other MDS is required when Medicare coverage ends.

17) The Baseline Care Plan is required for all admissions to the SNF, within the first 48 hours, regardless of payor source. If a resident has an active comprehensive care plan in place, then a Baseline would not be needed if the resident re-admits. If a resident only has a Baseline in place and re-admits, the Baseline should be reviewed/revised as needed. 

18) No, there is not a required notice when benefits are exhausted. CMS has stated that the SNF ABN can be used as a courtesy notice. A facility can create a courtesy notice instead.

The SNF ABN instructions, located on the SNF ABN webpage, state the following:

• The SNFABN can be used as a voluntary notice and replaces the Notice of Exclusion from Medicare Benefits – Skilled Nursing Facility (NEMB-SNF). There are no specific requirements for notice completion when the SNFABN is issued voluntarily, and alternatively, SNFs may develop their own written notice for care that is never covered. When the SNFABN is being issued as a voluntary notice, the beneficiary doesn’t need to select an option box or provide a signature.

• SNFs are not required to give written notice prior to providing care that Medicare never covers, such as care that is statutorily excluded or care that fails to meet a benefit requirement; however, as a courtesy to the beneficiary and to forewarn him/her of impending financial obligation, SNFs are encouraged to give notice.

19) The questions must be asked during the 7-day observation period, but the resident must answer based on the past 5 days from when the questions were asked.

CMS provided the following guidance in the SNF QRP Provider Training Q&A document:

Question #85: Why would an assessor do a pain assessment for the MDS on the day of admission?

A: The pain assessment should be conducted during the 7-day look-back period depending on when the interdisciplinary team sets the Assessment Reference Date (ARD). If the ARD is set early in the resident stay (e.g., day 1 or 2), the resident would reflect on their pain in the past 5 days, just as if the ARD were later in their stay in the facility.

Question #93: What is the look-back period for the Pain Assessment Interview items J0510, J0520, and J0530? A: The Pain Assessment Interview, which includes items J0510–J0530, asks the resident to recall pain in the past 5 days. Staff should conduct the pain assessment during the 7-day look-back period. The residents’ response should be based on their pain recall in the past 5 days.