Long-Term Care Survey Alert
What Kind of Support Documentation Do You Need for This Service Coded on the MDS?
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Question: When we have a resident who receives IV fluids to prevent dehydration in the nursing facility, what kind of support documentation do we need to code the service on the MDS? Answer: "CMS states that the IV fluids have to be for hydration or nutrition," says Patricia Boyer, MSM, RN, NHA, president of Boyer & Associates LLC in Brookfield, Wis. Thus she usually instructs people "to document lab studies or I&O records that support that." When you're preventing dehydration, the resident may not yet show instability, she notes. Thus, the documentation would have to identify the risk factors requiring the hydration, Boyer adds. Also, the physician order should specify the indication for the IV fluids, says Marilyn Mines, RN, RAC-CT, BC, director of clinical services for FR&R Healthcare Consulting in Deerfield, Ill. Question: What support documentation would a nursing facility need to code IV fluids provided in the hospital or emergency department? Answer: Consultant Jennifer Pettis, RN, WCC, RAC-MT, says she'd "expect to see a flow sheet showing the IV fluids were administered and/or documentation in the medical record by the clinician noting how much fluid the patient received"-- and why the IV fluids were ordered, which should be related to treatment of a nutritional and/or hydration need. "The ED might have that information in the transfer summary," adds Pettis, program development manager and regional consultant for Harmony Healthcare International in Topsfield, Mass. "Additionally, it must be clear in the documentation that the IV fluids were not administered as a routine part of an operative or diagnostic procedure or recovery room stay," says Pettis. Editor's note: The above information was provided prior to the spring 2011 RAI User's Manual update, which hadn't been released at press time.
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