MDS 1.19.1 Draft updates Quick Reference

 

Section A (Identification Information)

The current RAI User’s Manual v1.18.11 (pages A-45 – A47 in chapter 3) includes specific instructions and examples for how to code MDS item A2121 (Provision of Current Reconciled Medication List to Subsequent Provider at Discharge) on a standalone Medicare Part A PPS Discharge assessment when (1) the resident stays on the same unit with the same interdisciplinary team, or (2) the resident moves to a different unit and/or receives care from a different IDT.

In the draft RAI User’s Manual v1.19.1, CMS deleted both the instructions and the two corresponding examples for how to code A2121 when the resident stays in the facility after the end of Part A skilled services. AAPACN plans to seek clarification from CMS on how to code the provision of a reconciled medication list to the subsequent provider at discharge in this circumstance.

Section C (Cognitive Patterns)

In the draft RAI User’s Manual v1.19.1 (page C-17 in chapter 3), CMS added the following tip for coding MDS item C0500 (BIMS Summary Score) when the Brief Interview for Mental Status (BIMS) in items C0200 – C0400 is dashed (i.e., not assessed):

If all of the BIMS items are coded with a dash, then C0500 (BIMS Summary Score) must also be coded with a dash.

This new coding tip aligns with—and reaffirms—option c in the current instructions (also on page C-17) for when to use code 99 (unable to complete interview) in C0500:

Code 99 (unable to complete interview):
 
a) If the resident chooses not to participate in the BIMS,
b) If four or more items were coded 0 because the resident chose not to answer or gave a nonsensical response, or
c) If any but not all of the BIMS items are coded with a dash (—).  
Note: A 0 score does not mean the BIMS was incomplete. For the BIMS to be incomplete, a resident must choose not to answer or must give completely unrelated, nonsensical responses to four or more items. If one or more of the 0s in C0200–C0300 are due to incorrect answers, the interview should continue.

Section GG (Functional Abilities)

With the removal of column 2 (Discharge Goals) from MDS items GG0130 (Self-Care) and GG0170 (Mobility) in the finalized MDS item sets, CMS also has adjusted the title of the section and deleted the associated coding guidance and examples from chapter 3 in the draft RAI User’s Manual v1.19.1. In addition, the agency made the following changes in section GG:

* Corrected and updated the example for coding 02 (substantial/maximal assistance) in item GG0130I (Personal Hygiene). This revision better illustrates how the resident meets the definition for substantial/maximal assistance (“If the helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort [page GG-17].”). The draft revised example (page GG-32) is compared to the current example below:

Draft v1.19.1 Revised GG0130I Coding ExampleCurrent v1.18.11 GG0130I Coding Example
Resident J completed all hygiene tasks independently two out of six times during the observation period. The other four times they were unable to complete brushing and styling their hair and washing and drying their face because of elbow pain after initiating the tasks, so a staff member completed these tasks.  

Coding: GG0130I would be coded 02 (substantial/maximal assistance).

Rationale: Although Resident J was able to complete their personal hygiene tasks independently on two of the six occasions the activity occurred, a staff member had to complete their personal hygiene tasks after the resident initiated them on four of the six occasions. Because the staff had to complete Resident J’s personal hygiene tasks on four of the six occasions the activity occurred during the observation period, the staff provided more than half the effort to complete the personal hygiene tasks.
Resident J is unable to brush and style their hair or wash and dry their face due to elbow pain. A certified nursing assistant completes these tasks for them.  

Coding: GG0130I would be coded 02 (substantial/moderate assistance).  

Rationale: Resident J was unable to complete their personal hygiene and required a certified nursing assistant to complete their personal hygiene tasks during the assessment period. The certified nursing assistant provided more than half the effort to complete the personal hygiene tasks.  

* Updated the coding tips for GG0170M (1 Step (Curb)), GG0170N (4 Steps), and GG0170O (12 Steps). The one revised coding tip and two new coding tips address the difference between how to handle a physician-prescribed restriction of no stair climbing vs. a physician-prescribed bedrest, as well as the use of rest breaks once a stair activity has started. The following excerpts (pages GG-61 – GG-62) show these draft revised coding tips compared to the comparable current coding tip:

Draft v1.19.1 Revised Coding Tips for Stair ActivitiesCurrent v1.18.11 GG0130I Coding Tips for Stair Activities
If, at the time of the assessment, a resident is unable to complete the activity because of a physician-prescribed restriction of no stair climbing, they may be able to complete the stair activities safely by some other means (e.g., stair lift, bumping/scooting on their buttocks). If so, code based on the type and amount of assistance required to complete the activity.  


If, at the time of assessment, a resident is unable to complete the stair activities because of a physician-prescribed bedrest, code the stair activity using the appropriate “activity not attempted” code.  


While a resident may take a break between ascending or descending the 4 steps or 12 steps, once they start the activity, they must be able to ascend (or descend) all the steps, by any safe means, without taking more than a brief rest break to consider the stair activity completed.
If, at the time of the assessment, a resident is unable to complete the activity because of a physician-prescribed restriction (for instance, no stair climbing for two weeks) but could perform this activity prior to the current illness, exacerbation, or injury, code 88 (not attempted due to medical condition or safety concern).

Section K (Swallowing/Nutritional Status)

In the draft RAI User’s Manual v1.19.1, CMS (page K-10 in chapter 3) revised the definition of “feeding tube” for K0520 (Nutritional Approaches), removing the word “medications” as one of the options that the tube may be designed to deliver. The following excerpts explain:

Draft v1.19.1 Revised Definition of Feeding TubeCurrent v1.18.11 Definition of Feeding Tube
Presence of any type of tube that can deliver food/nutritional substances/fluids directly into the gastrointestinal system. Examples include, but are not limited to, nasogastric tubes, gastrostomy tubes, jejunostomy tubes, percutaneous endoscopic gastrostomy (PEG) tubes.Presence of any type of tube that can deliver food/nutritional substances/fluids/medications directly into the gastrointestinal system. Examples include, but are not limited to, nasogastric tubes, gastrostomy tubes, jejunostomy tubes, percutaneous endoscopic gastrostomy (PEG) tubes.

By taking this step, CMS has aligned the feeding tube definition with the existing coding tip for K0520B (Feeding Tube), which states, “Only feeding tubes that are used to deliver nutritive substances and/or hydration during the assessment period are coded in K0520B [page K-12].” In addition, the coding instructions for K0520B are now completely consistent with the nutrition- and/or hydration-only coding requirements for K0520A (Parenteral/IV Feeding).

Section N (Medications)

In the finalized v1.19.1 MDS item sets, CMS added the new subitem N0415K (Anticonvulsants) to N0415 (High-Risk Drug Classes: Use and Indication). N0415K will include column 1 (Is Taking) and column 2 (Indication Noted) like all the other high-risk drug classes captured in N0415. The draft RAI User’s Manual v1.19.1 (page N-8 in chapter 3) provides the following coding instructions for N0415K1 and N0415K2:

N0415K1 (Anticonvulsant/Is Taking)  

Check if an anticonvulsant medication was taken by the resident at any time during the 7-day observation period (or since admission/entry or re-entry if less than 7 days).
N0415K2 (Anticonvulsant/Indication Noted)  

Check if there is an indication noted for all anticonvulsant medications taken by the resident any time during the observation period (or since admission/entry or re-entry if less than 7 days).

In addition, CMS added N0415K to the list of medications to be reviewed in the Review of Indicators for two Care Area Assessments (CAAs)—the Mood State CAA and the Dental Care CAA—in Appendix C of the draft RAI User’s Manual v1.19.1 (pages C-34 and C-63 of the appendix, respectively).

Finally, CMS incorporated the existing definition of “indication” for coding N0415 into the glossary and common acronyms list in Appendix A of the draft RAI User’s Manual v1.19.1. The definition that will be on page A-11 in Appendix A, as well as on page N-6 in chapter 3, is as follows:

Indication  
The identified, documented clinical rationale for administering a medication that is based upon a physician’s (or prescriber’s) assessment of the resident’s condition and therapeutic goals.

Section O (Special Treatments, Procedures, and Programs)

Important updates in this section of the draft RAI User’s Manual v1.19.1 include the following:

* Clarified the coding instructions for item O0110O1 (IV Access). CMS added a sentence to the draft RAI User’s Manual v1.19.1 (page O-9 in chapter 3) that states, “An arteriovenous (AV) fistula does not meet the definition of IV Access for O0110O1.”

* Revised three coding examples for O0300 (Pneumococcal Vaccine). The following changes (pages O-17 – O-18 in chapter 3) make examples 1, 3, and 4 consistent with the most recent pneumococcal vaccine recommendations from the Advisory Committee on Immunization Practices (ACIP):

Draft v1.19.1 Revised Coding Examples for O0300Current v1.18.11 Coding Examples for O0300
1. Resident L, who is 72 years old, received the PCV13 pneumococcal vaccine at their physician’s office last year. They had previously been vaccinated with PPSV23 at age 66.  

Coding: O0300A would be coded 1 (yes); skip to O0350 (Resident’s COVID-19 Vaccination Is Up to Date).  

Rationale: Resident L, who is over 65 years old, has received the recommended PCV13 and PPSV23 vaccines. Because it is not at least 5 years after the last pneumococcal vaccine, PCV20 is not considered by the physician at this time.  

2. Resident A, who has congestive heart failure, received PPSV23 vaccine at age 62 when they were hospitalized for a broken hip. They are now 78 years old and were admitted to the nursing home one week ago for rehabilitation. They were offered and given PCV13 on admission.  

Coding: O0300A would be coded 1 (yes); skip to O0350 (Resident’s COVID-19 Vaccination Is Up to Date).  

Rationale: Resident A received PPSV23 before age 65 years because they have a chronic heart disease and received PCV13 at the facility because they are age 65 years or older. They should receive another dose of PPSV23 at least 1 year after PCV13 and 5 years after the last PPSV23 dose (i.e., Resident A should receive 1 dose of PPSV23 at age 79 years, but is currently up to date because they must wait at least 1 year since they received PCV13). The resident is not eligible to receive a PCV20 dose until at least 5 years after the last pneumococcal vaccine; therefore, the physician advises the resident to receive the PPSV23 when eligible instead of waiting to receive the PCV20.  

3. Resident T, who has a long history of smoking cigarettes, received the PPSV23 pneumococcal vaccine at age 62 when they were living in a congregate care community. They are now 64 years old and are being admitted to the nursing home for chemotherapy and respite care. They have not been offered any additional pneumococcal vaccines.  

Coding: O0300A would be coded 0 (no); and O0300B would be coded 3 (not offered).  

Rationale: Resident T is not up to date with their pneumococcal vaccination and has not been offered another vaccination to bring them up to date per current vaccination recommendations. Resident T received 1 dose of PPSV23 vaccine prior to 65 years of age because they are a smoker. Because Resident T is now immunocompromised, they should receive 1 dose of PCV15 or PCV20 at least 1 year after the most recent PPSV23 vaccination regardless of risk condition. Their vaccines would then be complete.
1. Resident L, who is 72 years old, received the PCV13 pneumococcal vaccine at their physician’s office last year. They had previously been vaccinated with PPSV23 at age 66.

Coding: O0300A would be coded 1 (yes); skip to O0400 (Therapies).  

Rationale: Resident L, who is over 65 years old, has received the recommended PCV13 and PPSV23 vaccines.  

2. Resident A, who has congestive heart failure, received PPSV23 vaccine at age 62 when they were hospitalized for a broken hip. They are now 78 years old and were admitted to the nursing home one week ago for rehabilitation. They were offered and given PCV13 on admission.  

Coding: O0300A would be coded 1 (yes); skip to O0400 (Therapies).  

Rationale: Resident A received PPSV23 before age 65 years because they have a chronic heart disease and received PCV13 at the facility because they are age 65 years or older. They should receive another dose of PPSV23 at least 1 year after PCV13 and 5 years after the last PPSV23 dose (i.e., Resident A should receive 1 dose of PPSV23 at age 79 years, but is currently up to date because they must wait at least 1 year since they received PCV13).  

3. Resident T, who has a long history of smoking cigarettes, received the pneumococcal vaccine at age 62 when they were living in a congregate care community. They are now 64 years old and are being admitted to the nursing home for chemotherapy and respite care. They have not been offered any additional pneumococcal vaccines.  

Coding: O0300A would be coded 0 (no); and O0300B would be coded 3 (not offered).  

Rationale: Resident T received 1 dose of PPSV23 vaccine prior to 65 years of age because they are a smoker. Because Resident T is now immunocompromised, they should receive PCV13 for this indication. They will also need 1 dose of PPSV23 8 weeks after PCV13 and at least 5 years after their last dose of PPSV23 (i.e., Resident T is eligible to receive PCV13 now and 1 dose of PPSV23 at age 67).

* Added coding instructions for new finalized item O0350 (Resident’s COVID-19 Vaccination Is Up to Date). These coding instructions include the item rationale, the steps for assessment, the coding instructions, and a coding tip as shown in the following excerpt (pages O-19 – O-20 in chapter 3):

Item Rationale  

Health-related Quality of Life  

The intent of this item is to report if a person is up to date with their COVID-19 vaccine status.

Age is the strongest risk factor for severe coronavirus disease 2019 (COVID-19) outcomes. In 2020, persons aged 65 years or older accounted for 81 percent of U.S. COVID-19-related deaths.

Severe illness caused by COVID-19 means that the person with COVID-19 may require hospitalization, intensive care, or ventilator support for breathing, or may even die.  
Planning for Care  

A strong infection prevention and control program is vital to protect both residents and healthcare personnel.

Remaining up to date with all recommended COVID-19 vaccine doses is critical to protect both staff and residents from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection.

COVID-19 vaccines currently approved or authorized by the U.S. Food & Drug Administration are effective in reducing the risk of serious outcomes of COVID-19, including severe disease, hospitalization, and death.

Efforts to increase the number of people in the United States who are up to date with their COVID-19 vaccines remain an important strategy for preventing illnesses, hospitalizations, and deaths from COVID-19.

A vaccine, like any other medicine, could possibly cause serious problems, such as severe allergic reactions. Serious problems from the COVID-19 vaccine are very rare. More information about potential side effects of the COVID-19 vaccine, precautions, and contraindications can be found on the CDC webpage “Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States” at https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html#contraindications.  
Steps for Assessment  
1. Vaccination status may be determined based on information from any available source.  

Review the resident’s medical record or documentation of COVID-19 vaccination and/or interview the resident, family or other caregivers or healthcare providers to determine whether the resident is up to date with their COVID-19 vaccine.   2. If the resident is not up to date, and the facility has the vaccine available, ask the resident if they would like to receive the COVID-19 vaccine.  

Coding Instructions  

Code 0 (no) resident is not up to date if the resident does not meet the CDC’s definition of up to date.  

This includes residents who have not received one or more recommended COVID-19 vaccine doses for any reason including medical, religious, or other qualified exemptions.

This includes residents for whom vaccination status cannot be determined.   Code 1 (yes) resident is up to date if the resident meets the CDC’s definition of up to date.     A dash is a valid response, indicating the item was not assessed. CMS expects dash use to be a rare occurrence.
Coding Tip  
Current COVID-19 vaccine recommendations are available on the Centers for Disease Control and Prevention’s (CDC’s) webpage “Stay Up to Date with COVID-19 Vaccines” at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html.

CMS also included the following definition of “up to date” in both the new O0350 coding instructions (page O-20 in chapter 3) and in the Appendix A glossary (page A-25):

UP TO DATE for COVID-19 Vaccine  

For the definition of “up to date,” providers should refer to the CDC webpage “Stay Up to Date with COVID-19 Vaccines” at https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html.

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