MDS Alert

Published on Tue Jul 16, 2013 PDF

Despite simple ‘copy edits,’ clarifications do little to clarify.

Among the most controversial and confusing changes contained in the Centers for Medicare & Medicaid Services’ (CMS’) May 2013 MDS 3.0 updates were the edits to G0110 Activities of Daily Living (ADL) Assistance. Although the actual edits won’t necessarily confuse you, the implied overhaul to the item’s “Rule of 3” will throw you for a loop.

First, CMS edited the last bullet under the third Rule of 3 to match the item set:

“When there are three or more episodes of a combination of full staff performance, weight-bearing assistance, and/or non-weight-bearing assistance — code limited assistance (2).”

Similarly, CMS edited the last bullet under Instructions for Rule of 3 and the ninth box down on the algorithm to match the item set and manual text, stated Ann Spenard,  MSN, RN, CWCC, vice president of consulting services for Wethersfield, CT-based Qualidigm, in a recent CMS presentation.

Spenard also points out that CMS updated the sixth box down on the algorithm to include the full definition of “extensive assistance:”

“Did resident require full staff performance at least 3 times but not every time or weight bearing assistance 3 or more times?”

CMS Clarifies Rule of 3 — Or Did It?

CMS’ revision to the ADL algorithm on page G-6 was merely a “copy edit” for consistency throughout the chapter, explained MDS instructor Judy Wilhide Brandt in an article for Washington, D.C.-based Leading Age, an association of non-profit organizations advocating for the elderly.

Problem: But prior to the May 2013 updates, CMS had released an email to the state RAI managers in March that practically redefined the Rule of 3 for ADL coding in Section G0110, Brandt pointed out. In the email, CMS provided the following instructions:

• If an ADL occurs at the same level three or more times, assign that code. (Example: If the resident received total assist once, extensive assist twice, limited assist twice, and supervision three times, you would code “1- Supervision.”)
• If an ADL occurs three or more times at multiple levels, code the most dependent. (Example: If the resident received limited assist three times, supervision three times, and independent three times, you would code this as “2- Limited Assist.”)
• If an ADL does not occur at the same level for three or more times, follow the guidance on G-4 (at the bottom) and G-5 (at the top).

Beware of the Underlying Confusion

“CMS officials are very clear that this interpretation is not a policy change, saying repeatedly that it has always been this way,” Brandt said. “When deciding how to code G0110 Self Performance, we are not to start at the top of the algorithm, where it says: ‘Start here.’” Instead, you need to start in the box on the right-hand side, where the first line there says:

“When an activity occurs 3 times at any 1 given level, code that level.”

“This is the basis for the discrepancy in interpretation,” Brandt lamented. “If this represents a change in how you have historically coded this section, you are not alone.”

Beware: “Following this guidance will, all things being equal, cause ADL scores to drop,” Brandt noted. “But this may be mitigated somewhat by bed-side interviews and assessment to determine when a higher level actually happened three times.”