MDS Alert

Published on Fri Jun 26, 2009 PDF

Master this short list to keep your RUG-III scores on the up and up.

Is your team aware of services and conditions that you shouldn't capture when they occurred before admission? If not, the SNF could be in for some payment recoupments down the line.

For example, you can only count days of physician visits (P7) or order changes (P8) that occurred since admission to the SNF. But don't code a day of standard admission orders or return admission orders, states the RAI User's Manual. You can, however count as a day of order changes, "orders written on the day of admission as a result of an unexpected change/deterioration in condition or injury," the manual allows.

One more: Code only abnormal labs (P9) since admission, advises Marilyn Mines, RN, RAC-CT, BC, manager of clinical services for FR&R Healthcare Consulting in Deerfield, Ill. P9 isn't a RUG driver, but abnormal labs can help support medical complexity or acuity.

Of course, you can't capture rehab therapy, respiratory therapy or restorative nursing before admission to the SNF.

Remember: "In coding the PPS assessment, you can't count [rehab] therapies provided after readmission unless the therapist does another evaluation," says Elisa Bovee, MS, OTR/L, director of education and training at Harmony Healthcare in Topsfield, Mass. That holds true even if the resident was in the SNF only a short time and received rehab before being readmitted to the hospital,Bovee points out.

You should check or code a physician-documented diagnosis in Section I if it affects the resident's current ADL status, mood, behavior, medical treatment, nursing monitoring or risk of death, etc., according to the RAI User's Manual. And you can code a diagnosis or condition that occurred before admission if the SNF team is doing something about the problem, advises Cindy MacQuarrie, RN, MN, managing consultant for BKD LLP in Kansas City, Mo. Thus, "if there are no assessments or interventions related to the diagnosis, you shouldn't code it in Section I," MacQuarrie adds.

Examples: Suppose the resident has a long-standing diagnosis, such as congestive heart failure, on the hospital diagnosis list or in the hospital medical record documentation.

Yet, he hasn't received any treatment for the condition for some time, and the condition isn't impacting the person's ADLs, etc., says MacQuarrie. "Then the team shouldn't code it."

Beware: Consultant Jane Belt, MS, GCNS-BC, RAC-MT, sometimes see dehydration status post coded on the MDS based on the hospital discharge summary or diagnosis list. And "that means it isn't a current diagnosis," says Belt, a consultant with Plante & Moran Clinical Group in Columbus, Ohio.

"Staff will argue that a resident is at risk for dehydration, so they should code it in Section I," adds Darlene Greenhill, a nursing home consultant in Atlanta. "But the RAI Manual talks about coding active diagnoses. And all residents -- some more than others -- are at risk for dehydration where [monitoring and other strategies] are part of general nursing care."

On the other hand, if the resident had a dehydration diagnosis in the hospital, and the SNF team is still evaluating the person to make sure he maintains adequate hydration, then it's appropriate to code that diagnosis, says MacQuarrie.

The same holds true for pneumonia."If the care team is still assessing the resident's respiratory status following a hospital-treated pneumonia, and the resident is getting antibiotics for pneumonia, then you'd code the pneumonia," MacQuarrie says.

Keep in mind: Section I2 is really looking for an "active, acute condition," advises Rena Shephard, MHA, RN, RAC-MT, C-NE, president & CEO of RRS Healthcare Consulting Services in San Diego. Thus, once the resident completes treatment "and the nursing staff isn't even monitoring [the person's] respiratory status any more than they monitor anyone else, you wouldn't code pneumonia anymore," she adds.