MDS 3.0 U pdates O - PowerPoint Presentation

MDS 3.0 Updates October 2019- Part 1 Haideh Najafi, BSN, RN, MSED,EDSRAI/MDS and OASIS Educational CoordinatorPhone: (517) 335-2086E-mail: NajafiH@michigan.gov 1

ObjectiveIdentify standardized assessment data across the post Acute Care (PAC) settings.Identify Major changes to the Resident Assessment Instrument (RAI) Minimum Data Set (MDS). Describe the new assessment types.Describe the updates to sections A, GG, I, J, and O. Identify different between Resource Utilization Group version IV (RUG-IV) and Patient Driven Payment Model (PDPM).Describe reason for changes from RUG-IV to PDPM.2

Improving Medicare Post-Acute Care Transformation Act (Impact Act) of 2014Bipartisan Bill passed on September 18, 2014 and signed into law on October 6, 2014. 3

Impact Act of 2014 (continued)Impact Act requires standardized patient assessment data across post-acute care (PAC) that include:Nursing Homes (NHs). Home Health Agencies (HHAs).Long Term Care Hospital (LTCH).Inpatient Rehab Facilities (IRF).4

Impact Act of 2014 (continued)5 For more information regarding Impact-Act 2014 please visit the Centers for Medicare and Medicaid Services (CMS) website at:https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-of-2014-Data-Standardization-and-Cross-Setting-Measures.html

Impact Act of 2014 (continued)In response to Impact Act, CMS established the Skilled Nursing Facility Quality Reporting Program (SNF QRP) and its’ quality requirements starting in Fiscal Year (FY) 2016 SNF Prospective Payment System (PPS). Per statute SNFs that do not submit the required Quality Measure (QM) data may receive a two-percentage-point reduction to their Annual Payment Update (APU) for the applicable payment year.For more information regarding the SNF QRP please refer to the following CMS website at:https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Skilled-Nursing-Facility-Quality-Reporting-Program/SNF-Quality-Reporting-Program-Overview.html6

Impact Act of 2014 (continued)Impact Act requires standardized patient assessment data across PAC that will enable:Quality Care and improve outcomes. Data element uniformity.Comparison of quality and data across PAC settings.Improved, person-centered, goals-driven discharge planning.Exchangeability of data.Coordinated care.7

Impact Act RequirementsData Must be InteroperableQuality Measures:Functional Status. Skin Integrity.Medication Reconciliation.Incidence of Major Falls.Transfer of Health Information.Medicare Spending per Beneficiary.Discharge to Community.Potentially Preventable Hospital Readmissions. 8

Impact Act Requirements (continued)Data Must be InteroperableStandardized Data Submission: Admission and Discharge.Functional status.Cognitive function and mental status.Special services, treatments, and interventions.Medical conditions and co-morbidities.Impairments.Other categories required by the Secretary. 9

Standardized Data GoalsGoals 10Fosters seamless care transitions. Data & Information that can follow the patient. Evaluation of longitudinal Outcomes for patients that traverse setting. Assessment of quality across setting. Improved outcomes, and efficiency. Reduction in provider burden.

Standardized Data: Guiding principleData Uniformity 11Reusable. Informative. Increase validity/ Reliability. Facilitates patient care coordination. Data that can communicate in the same language across settings. Follow the individual. Interoperability Guiding principle Data that can be transferable forward and backward to facilitate care coordination.

IMPACT Act- InteroperableIMPACT Act requires that post-acute care assessment data element be interoperable to:“allow for the exchange of data among PAC providers and other providers and the use by such providers of such data that has been exchanged, including by using common standards and definitions, in order to provide access to longitudinal information for such providers to facilitate coordinated care and improved Medicare beneficiary outcomes.” 12

Interoperable Assessment ContentCare Coordination between multiple providers/ proxy/ family members.Transitions of care referrals.Admission/Discharge information notification. Population Health Management Administration.Changing relationship between patient and caregivers.Getting providers engaged.Advanced directives.13

PAC Assessment- Administrative ContentPatient Name.Date of Birth.Race/Ethnicity. Marital status.Admission/Discharge dates.Admit from/Discharged to locations.Reason for admission.Provider National Provider Identifier (NPI), CMS Certification Number (CCN), Medicaid Provider number.14

PAC Assessment Content- (continued)Standardized Patient Assessment Data Elements (SPADEs) across instrument: Function.Cognitive function.Special services, treatments & interventions.Medical conditions and co-morbidities. Impairments.Other categories. 15

PAC Assessment - Clinical ContentDiagnosis/medical conditions.Mental/Cognitive Status.Communication. Functional Status.Bladder and Bowel continence.Falls.Pressure ulcers and other skin conditions.Surgery.Nutritional and swallowing status. 16

PAC Assessment -Clinical Content (continued)Medication information.Special treatments, procedures & programs. Height and Weight.Patient preferences and goals of treatment.Pain.Vaccinations.Therapy-PT, OT, SLT.Living arrangements/support availability.Care planning. 17

General Changes18

General ChangesAcronyms have been spelled out the first time they are used with the acronym to follow. URLs have been updated. Typographical and grammatical errors have been fixed. Page numbers that are used as reference, replaced with Section/Chapter reference. Standardized acronym for Quality Improvement Evaluation System Assessment Submission and Processing system, as “QIES ASAP System.” “Pressure ulcer” revised to “pressure ulcer/injury” where appropriate. Removed “mental retardation in federal regulation” when referring to “intellectual disability.” 19

General Changes (continued)Guidance added throughout the manual in relation to the two new item sets have been added. The term, “Medicare,” revised to Prospective Payment System, “PPS,” where appropriate. All references to the following have been removed throughout the entire RAI Manual:PPS 14-Day, 30-Day, 60-Day, and 90-day AssessmentsOther Medicare Required Assessment (OMRA) (Start of therapy , End of therapy, Start and End of Therapy, and Change of Therapy) Assessments. Swing Bed (SB) Clinical Change Assessment (CCA). 20

General Changes (continued)New Chapter 6:6.3 Patient Driven Payment Model6.3 PDPM Calculation WorksheetsChanged Chapters: 2, and 5 Sections: A, C, D, GG, I, J, K, O, V, X, & Z Unchanged Section B, E, F, G, H, L, M, N, P, & Q 21

Changes by Chapter22 Chapter 6NewPatient Driven Payment Model (PDPM)PDPM Calculation Worksheets Chapter 2 Assessment for the Resident Assessment Instruction (RAI) Chapter 5 Submission and Correction Of the MDS Assessment

Changes by Sections23 Section A - Identification InformationSection K – Swallowing /Nutritional StatusSection C - Cognitive Patterns Section O – Special Treatment, Procedures, and Programs Section D - Mood Section V – Care Area Assessment (CAA) Summary Section GG - Functional Abilities and Goals Section X – Correction Request Section I - Active Diagnoses Section Z – Assessment Administration Section J - Health Condition

No Changes24 Section B-Hearing, Speech, and VisionSection L - Oral /Dental StatusSection E - Behavior Section M - Skin Condition Except add Injury to all PU Section F - Preferences for Customary Routine and Activities Section N - Medications Section G - Functional Status Section P - Restraints and Alarm Section H - Bladder and Bowel Section Q - Participation in Assessment and Goal setting

New Assessment Types/Item SetsThere are two new assessment types. Both are optional: Interim Payment Assessment (IPA ). Optional State Assessment (OSA).25

Chapter 2Assessments for RAI26

Change of Ownership (CHOW)There are two type of change in ownership transaction:The more common situation when the new owner assume all assets and liabilities of the prior owner. The second CHOW is when the new owner does not assume the assets and liabilities of the previous owner.27

Change in Ownership (continued)The following clarification was added to CHOW when the new owner assumes the assets and liabilities of the prior owner: The new owner Retains the current CMS Certification Number (CCN) number. 28

Change in Ownership (continued)The example was updated to reflect the IPA:“ If the resident is in a Part A stay, and the 5 - Day PPS assessment was combined with the OBRA Admission assessment, the next PPS assessment could be an Interim Payment Assessment (IPA), if the provider so chooses to complete one, and would also be submitted under the existing provider number.”29

Section A Identification Information30

A0100- Facility Provider Numbers 31

A0100B- CMS Certification Number (CCN)The following instruction was added on the manual:A0100B (Facility CCN) if: A0410=3 (Federal required submission), then A0100B (facility CCN) must not be blank.32

A0100C- State Provider NumberA0100C: State Provider Number (optional): The term “State Survey agency” was added to the A0100C (State Provider number).This number is assigned by the State survey agency and provided to the intermediary. When known, enter the State Provider Number in A0100C.33

New Assessment Types/Item SetsThere are two new assessment types, and Both are optional: Interim Payment Assessment (IPA ): This is the set of items active on an IPA and used for PPS payment purpose.34

New Assessment Types/Item Sets (continued)Optional State Assessment (OSA): This is the set of items that may be required by a State Medicaid agency to calculate the Resource Utilization Group (RUG) III or RUG IV Health Insurance Prospective Payment System (HIPPS) code. This is not a federally required assessment.It is required at the discretion of the State Agency for payment purposes, Item A0300A =1-Yes.35

A0300- Optional State Assessment (OSA) New ItemThis item allows for collection of data required for State payment reimbursement.OSA is a standalone assessment. 36

A0300 (continued)Code in order to identify if this is an Optional State Payment assessment.Code “0. No”, if:This assessment is not required for state payment, Then,Proceed to A0310-Type of assessment.Code “1. Yes”, if:This assessment required for state payment purposes. Proceed to item A0300B-Assessment Type. These responses are used to calculate the case mix group Health Insurance Prospective Payment System (HIPPS) code for state payment purpose. 37

A0300 (continued)A0300B- Enter the number to the reason for completing this state assessment. Start of therapy (SOT).End of Therapy (EOT).SOT & EOT.Change of therapy (COT).Other payment assessment.38

A0300 (continued)For any question related to Medicaid requirement, please contact:Michael Daeschlein Manager of Long-term Care Policy Section at Bureau of Medicaid Policy and Health Systems Innovation Michigan Department of Health and Human Services at (517) 335-5322 orDaeschleinM@Michigan.gov 39

A0310- Type of Assessment40 Old

A0310- Type of Assessment (continued) 41New

A0310- Type of Assessment (continued)42 Identify the assessment that needed for resident. Enter the reason(s) for completing this assessment. If assessment is being completed for both Omnibus Budget Reconciliation Act (OBRA) and PPS, all requirements for both assessments must be met. Complete Significant Change in Status Assessment (SCSA) every time a resident elect or revoke the hospice benefit regardless if a recent MDS was completed and the only change is election or revocation of the hospice benefit.

A0310A- Federal OBRA Reason for assessment43

Prospective Payment System Definition44 PPS is a method of reimbursement which Medicare payment is made based on the classification system of that service.

A0310B- PPS assessment45

Scheduled PPS AssessmentIt is the first PPS-Required assessment to be completed when the resident is first admitted for a SNF Part A stay.The first day of Medicare Part A coverage for current stay is considered day 1 for PPS assessment scheduling purpose. It is the first PPS-required assessment when the resident re-admitted to the facility for a SNF Part A stay following:A discharge assessment-return not anticipated; orReturn more than 30 days after a discharge return anticipated.46

Scheduled PPS Assessment (continued)The PPS-required standard assessment is the 5-Day assessment that has a predetermined time period for setting ARD. ARD must set on days 1-8 in order to be compliance with the SNF PPS PDPM Requirement. 47

5-day Assessment (continued)The ARD must be set on the MDS form or in the facility software before this window has passed. It must be completed within 14 days after the ARD.Must be submitted electronically and accepted into QIES ASAP system within 14 days after completing.5-Day assessment is authorized payment for entire PPS stay except when an Interim Payment Assessment (IPA) is completed.If combined with the OBRA Admission assessment, the assessment must be completed by the end of day 14 of admission.48

5-day Assessment (continued)A 5-day assessment is not required at the time when a resident return to a part-A-covered day following an interrupted stay, regardless of the reason for the interruption such as: Facility discharge.Resident no longer skilled.Payer change.Etc.49

5-day Assessment (continued)If a resident changes payers from Medicare Advantage to Medicare Part A the SNF: Must complete a 5 - Day assessment with the ARD set for one of the days 1 through 8 of the Medicare Part A stay, With the resident’s first day covered by Medicare Part A serving as Day 1, unless it is a case of an interrupted stay.50

A0310B-PPS AssessmentA0310B, PPS Assessment:Code 01. 5-Day Scheduled Assessment. Code 08. IPA-Interim Payment Assessment.Code 99. None of the above.51

Unscheduled AssessmentUnscheduled PPS Assessment:There are situations when a SNF may complete an assessment after the 5-day assessment. This assessment is unscheduled assessment and called “Interim Payment Assessment (IPA).”When facility determined that based on facility’s requirement appropriate to complete IPA, then this assessment may be completed to capture changes in the resident’s status and condition.52

A310B- Interim Payment Assessment (IPA) OptionalARD may be set for any day of the SNF PPS stay, beyond the ARD of the 5-day.The ARD for an IPA may not precede of the 5-Day assessment. Must be completed within 14 days after the ARD.Authorizes payment for remainder of the PPS stay, beginning on the ARD.Must be submitted electronically and accepted into the QIES ASAP system within14 days after completion.May not be combine with other assessments.53

A0310E-Is this Assessment the First Assessment Since the Most Recent Admission / Entry or Reentry?Code A0310E“0. No” if:This assessment is not the first of these assessments since the most recent admission/entry or reentry. Entry Tracking.Death in Facility tracking records.54

A0310 E (continued)Code A0310E “0. No” for:A standalone Part A PPS Discharge assessment: A0310A=99A0310B=99A0310F=99A0310H=1An Interim Payment Assessment (IPA): A0310A=99 A0310B=08 (IPA) A0310F=99 A0310H= 0 55

A0310 E (continued)Code “1. Yes” if: This assessment is the first of these assessments since the most recent admission/entry or reentry.On the first OBRA, Scheduled PPS, or OBRA Discharge assessment that it is completed and submitted once a facility obtains CMS certification.Note: The first submitted assessment may not be an OBRA Admission assessment.56

A0310 F- Entry/discharge reporting57

A0310 G-Type of DischargeCode “1” if the discharge was planned.Code “2” if the discharge was unplanned.58

Part A PPS Discharge AssessmentPart A PPS Discharge Assessment is completed when:A resident’s Medicare Part A stay ends; But The resident remains in the facility. Part A Discharge assessment may be combined with an OBRA Discharge if the part A stay ends:On the same day; or The day before the resident’s Discharge Date. 59

PPS Discharge Assessment (continued)For the Part A PPS Discharge assessment, the ARD is not set prospectively as with other assessments. The ARD for a standalone Part A PPS Discharge assessment is always equal to the End Date of the Most Recent Medicare Stay. The ARD may be coded on the assessment any time during the assessment completion period. If the resident’s Medicare Part A stay ends and the resident is physically discharged from the facility, an OBRA Discharge assessment is required. 60

A0310 G1-Is this a SNF Part A Interrupted Stay? New ItemCode “0. No” if: The resident was discharged from SNF care, ButDid not resume SNF care at the same SNF within the interrupted window.Code “1. Yes” if:The resident was discharged from SNF care; ButDid resume SNF care at the same SNF within the interrupted window. 61

Interrupted Stay -NewInterrupted Stay is a Medicare Part A SNF stay that in which: The resident is discharged from SNF care andSubsequently resumes SNF care in the same SNF for Medicare Part A-covered stay during the interruption window.62

Interrupted Window - NewInterrupted Window is: A 3- day period starting with the calendar day of discharge from SNF care; and Including the 2 days immediately following calendar days, ending at 11:59 p.m. on the third calendar day.63

Interrupted Stay policy-NewInterrupted Stay Policy applies to residents who either: Leave the SNF, then return to the same SNF within the interruption window; orDischarged from part A-covered services and remain in the SNF, but then resume a Part A-covered stay within the interruption window.64

Interruption stay policy (continued) NewResumption SNF Care: If a resident in Medicare Part A SNF stay is discharged from Part A, the subsequent stay is considered a continuation of the previous Medicare Part A covered stay, if both of the following conditions are met by 11:59 p.m. at the end of the third calendar day after their Part A-covered stay ended: The resident must resume Part A services (i.e., Part A Covered stay), or Return to the same SNF to resume Part A services.65

Summary Interrupted Stay PolicyInterruption Window A 3 - day period: Starting with the calendar day of D/C from SNF care (i.e., Part A - covered stay) and including the 2 immediately following calendar days, Ending at 11:59 p.m. on the third calendar day.66Interrupted Stay Medicare Part A SNF stay in which a resident: Is discharged (D/C) from SNF care (i.e., the resident is D/C from a Medicare Part A - covered stay), and Subsequently resumes SNF care in the same SNF for a Medicare Part A - covered stay during the interruption window. Resumption of SNF Care Resident must resume SNF care (i.e., Part A-covered stay) in the same SNF or Return to the same SNF (if physically D/C) to resume SNF care, by 11:59 p.m. of the end of the third calendar day after their Part A - covered stay ended.

PPS Discharge AssessmentIf the resident’s Medicare Part A stay ends and the resident subsequently returns to a skilled level of care and Medicare Part A benefits do not resume within 3 days, the PPS schedule starts again with a 5-Day assessment. If the Medicare Part A stay does resume within the 3-day interruption window, then this is an interrupted stay. 67

Interrupted StayIf the resident leaves the facility for an interrupted stay:No Part A PPS Discharge Assessment is required when the resident leaves the building at the outset of the interrupted stay. However, an OBRA Discharge record is required if the discharge criteria are met. If the resident returns to the facility within the 3-Day interruption window:An Entry tracking form is required; However, no new 5-Day assessment is required. 68

Examples of interrupted stay where the resident leaves the SNF and returns to the same SNF to resume Part A-Covered stay69 Resident leaves against medical advice and returns to the same SNF to resume Part A-covered services within the interruption window.Resident transfers to Acute care setting for evaluation/treatment due to a change in condition and then returning to the same SNF to resume Part A-covered services within the interruption window.Resident transfers to Psychiatric facility for evaluation/treatment and then returning to the same SNF to resume Part A-covered services within the interruption window. Resident transfers to Outpatient facility for a procedure/treatment and then returning to the same SNF to resume Part A-covered services within the interruption window. Resident transfers to Assisted living facility or private residence with home health services and then returning to the same SNF to resume Part A-covered services within the interruption window.

Examples of interrupted stay where the resident remain in the SNF but stops being covered under the Part A PPS benefit and resumes Part A again within the interruption window70 Resident elects the hospice and then revokes the hospice benefit and resumes Part A within the interruption window.Resident refuses to participate in rehabilitation, then decides to engage in planned rehabilitation resuming Part A coverage within the interruption window.Resident changes payer source from Medicare Part A to an alternate payer source then wishes to resume Part A again within the interruption window.

Discharge from Part A, remains in the facility and resume Part A in SNF within 3 - day interrupted windowIf a resident is discharged from Part A, remains in the SNF, and resumes a Part A-covered stay in the SNF within the 3-day interruption window, this is an interrupted stay. In this case, on resumption of care the following assessments are Not required:Discharge assessment. Entry Tracking Record.5-Day PPS assessment.71

Discharge from Part A, remains in the facility and resume Part A within 3 –day interrupted window (continued)Subsequent stay is considered a continuation of the previous Medicare Part A covered stay. This is considered an Interrupted Stay because both of the following criteria were met: Discharge from Part A. Resumption of Part A within in the 3-day interruption window. 72

Leave the SNF and resume Part A in the same SNF within the 3-day Interruption windowIf a resident leaves the SNF and returns to resume Part A-covered services in the same SNF within the interruption window, this is an interrupted stay. Although this situation does not end the resident’s Part A PPS stay, but the resident left the SNF, and therefore the following assessment would be required:OBRA Discharge assessment is required.On return Entry tracking & OBRA Admission is required if the resident discharged return not anticipated.The following assessment would not be required:5-Day PPS assessment.OBRA admission assessment if the resident was discharged return anticipated.73

Leave the SNF and resume Part A in the same SNF within the 3-day Interruption window (continued)Subsequent stay is considered a continuation of the previous Medicare Part A covered stay. This is considered an Interrupted Stay because both criteria were met:Discharge from Part A; and Returned to the same facility to resume Part A within the 3 - day interruption window.When an interrupted stay occurs, a 5-Day PPS assessment is not required upon reentry or resumption of SNF care in the same SNF, because an interrupted stay does not end the resident’s Part A PPS stay. 74

Interruption stay did not occurIf a resident is discharged from Part A, remains in the SNF and does not resume Part A-covered services within the 3-day interruption window, an interrupted stay did not occur, in this situation:A Part A PPS Discharge is required. If the resident qualifies and there is a resumption of Part A services within the 30-day window allowed by Medicare, a 5-Day assessment would be required. The OBRA schedule would continue from the resident’s original date of admission. 75

Interruption stay did not occur (continued)Subsequent stay, if there is one, is considered a new Part A stay. This is not considered an Interrupted Stay because both of the following criteria were not met: Discharge from Part A.Did not resume Part A services within in the 3 - day interruption window. 76

Interrupted Stay did not occur (continued)If a resident discharge from Part A, Leaves the SNF and does not return to resume Part A-covered services in the same SNF within the 3-day interruption window, an interrupted stay did not occur, in this situation, both of the following assessments are required:Part A PPS Discharge assessment. OBRA Discharge assessments are required.77

Interrupted Stay did not occur (continued)If this resident returns to the same SNF, this would be considered a new Part A stay and the following are required: An Entry Tracking record.5-Day would be required on resumption if within 30-day window allowed by Medicare. An OBRA Admission would be required if the resident was discharged return not anticipated.If the resident was discharged return anticipated, no new OBRA Admission would be required. 78

Interrupted Stay did not occur (continued)Subsequent stay, if there is one, it is considered a new Part A stay. This is not considered an interrupted stay because both of the following criteria were not met:Discharged from Part A.Did not return to the facility to resume Part A within in the 3 - day interruption window. 79

A0310 H- Is this a SNF Part A PPS Discharge Assessment?Code 0, No: If this is not a Part A PPS Discharge assessment. Code 1, Yes: If this is a Part A PPS Discharge assessment.80

A0310 H (continued)The Part A PPS Discharge assessment is required under the SNF QRP when:The resident’s Medicare Part A stay ends, ButThe resident remains in the facility.If the End Date of the Most Recent Medicare Stay occurs on the day of or one day before the Discharge Date, the OBRA Discharge assessment and Part A PPS Discharge assessment are both required and may be combined. When the OBRA and Part A PPS Discharge assessments are combined, the ARD must be equal to the Discharge Date. 81

Changes on Combining PPS and OBRA AssessmentPPS and OBRA Assessment Combination have been revised for combination of the 5-Day with the following assessments: 82OBRA Admission Assessment OBRA Quarterly Assessment Annual Assessment Significant Change in Status Assessment (SCSA) Part A PPS Discharge Assessment OBRA Discharge Assessment Significant Correction to Prior Quarterly (SCQA) Significant Correction to Prior Comprehensive (SCPA)

PPS Assessment: Tracking & Discharge83

Entry, OBRA Discharge, Reentry Algorithm and Schedule Tables84

Factors Impacting SNF PPS Assessment Scheduling 85

Resident expires before or on the Eighth Day of SNF StayIf the beneficiary dies in the SNF or while on a leave of absence before or on the eighth day of the covered SNF stay:Prepare a 5-Day assessment as completely as possible. Submit the assessment as required. If there is not a PPS assessment in the QIES ASAP system, must bill the default rate for any Medicare days. Complete a Death in Facility Tracking Record.86

Resident transfers or is Discharged before or on the Eighth Day of SNF stayIf the beneficiary is discharged from the SNF or the Medicare Part A stay ends before or on the eighth day of the covered SNF stay:Prepare a 5-Day assessment as completely as possible. Submit the assessment as required.If there is not a PPS assessment in the QIES ASAP system:Bill the default rate for any Medicare days.87

Resident transfers or is Discharged before or on the Eighth Day of SNF stay (continued)When the Medicare Part A stay ends on or before the eighth day of the covered SNF stay, and the beneficiary remains in the facility: A Part A PPS Discharge assessment is required.When the beneficiary is discharged from the SNF:Complete an OBRA Discharge assessment.If the Medicare Part A stay ends on or before the eighth day of the covered SNF stay and the beneficiary is physically discharged from the facility the day of or the day after the Part A stay ends:The Part A PPS and OBRA Discharge assessments required and may be combined.88

Resident admitted to Acute Care facility and returnResident is admitted to an Acute Care Facility and later return to SNF to resume Part A:A new 5-Day assessment is required, unless it is an interrupted stay. If it is a case of an interrupted stay, then:No PPS assessment is required upon reentry.Entry Tracking form is required.An IPA may be completed, if appropriate.89

Resident sent to the Acute Care facility Not admitted and did not return over midnightIf a resident is out of the facility over a midnight, but for less than 24 hours, and is not admitted to an acute care facility:A new 5 - day PPS assessment is not required. An IPA may be completed, if appropriate.There is a Payment implications: The day preceding the midnight on which the resident was absent from the nursing home is not a covered Part A day, known as “midnight rule.”90

Leave of Absence (LOA) Resident Takes a LOA from the SNF:If a resident is out of the facility for a LOA, there may be payment implications. For example: If a resident leaves a SNF at 6 p.m. on Wednesday, which is Day 27 of the resident’s stay, and returns to the SNF on Thursday (Day 28) at 9 a.m., then: Wednesday becomes a non - billable day; and Thursday becomes Day 27 of the resident’s stay.91

Discharge from Part A and from facility & return to Part A skilled ServicesWhen a beneficiary is discharged from Medicare Part A and is physically discharged from the facility but returns to resume SNF Part A skilled services after the interruption window has closed, must complete:The OBRA Discharge. Part A PPS Discharge.The OBRA & PPS Discharge assessments may be combined.92

Discharge from Part A and from facility & return to Part A skilled Services (continued)If the resident return to the facility, it is considered a new Part A stay and must complete the following: New 5-Day.Entry Tracking Record. OBRA admission if the resident was discharge return not anticipated.No OBRA admission is required if the resident was discharged return anticipated.93

Discharge from Part A and from facility & return to Part A skilled Services (continued)However if this is an interrupted stay then : An Entry Tracking Record is required on reentry.OBRA Discharge assessment is required.If the resident was discharged return not anticipated, a new OBRA Admission assessment is required. 5-Day is not required.If the resident was discharged return anticipated, no OBRA assessment is required. Assess the beneficiary to determine if there was a SCSA. 94

Discharge from Part A but is not physically discharged from SNFWhen resident Discharged from Part A Skilled Services but Is Not Physically Discharged from the Skilled Nursing Facility and remain in a Medicare and/or Medicaid certified bed with another payer source:Continue with the OBRA schedule from the beneficiary’s original date of admission (item A1900); andComplete a Part A PPS Discharge assessment.95

Discharge from Part A but physically was not discharge from SNF (continued)If Part A benefits resume, there is no reason to change the OBRA schedule; PPS schedule would start again with a 5-Day assessment.MDS item A0310B = 01 (5-Day), unless it is a case of an interrupted stay, No Part A PPS Discharge is completed, nor is a 5-Day required when Part A resumes.96

Late Assessment If fail to set the ARD within the defined ARD window for a 5-Day assessment, and the resident is still on Part A:Must complete a late assessment. The ARD can be no earlier than the day the error was identified. Bill the default rate for the number of days that the assessment is out of compliance.Then bill the HIPPS code established by the late assessment for the remainder Period of Time that the assessment would have controlled payment of the SNF stay, unless the SNF chooses to complete an IPA. 97

Miss PPS AssessmentIf the SNF fails to set the ARD of a 5-Day assessment prior to the end of the last day of the ARD window, and the resident was already discharged from Medicare Part A when this error is discovered, the provider cannot complete an assessment for SNF PPS purposes, and the days cannot be billed to Part A. 98

ARD outside the Medicare Part A BenefitDo not use a date outside the SNF Part A Medicare Benefit as the ARD for a PPS assessment. For example, the resident returns to the SNF on December 11 following a hospital stay, requires and receives SNF skilled services and has 3 days left in his or her SNF benefit period. In this case set the ARD for the PPS assessment on December 11, 12, or 13 in order to be able to bill for the HIPPS code associated with the assessment. 99

A0410- Unit Certification or Licensure Designation100 Coding Instruction for Code 1 was clarified as follow: “…if the MDS record is for a resident on a unit that is neither Medicare nor Medicaid certified, and neither CMS nor the state has authority to collect MDS information for residents on this unit, the facility may not submit MDS records to QIES ASAP.”

A0600A- Social Security Number101 Enter the Social Security Number (SSN) in A0600A.If no SSN is available for the resident the item may be left blank. Note: A valid SSN should be submitted in A0600A whenever it is available so that resident matching can be performed as accurately as possible.

A0600B- Medicare Number102 OldNew

A0600B- Medicare NumberEnter Medicare number in A0600B exactly as it appears on the resident’s documents.For PPS assessments (A0310B = 01 or 08 ), the Medicare number (A0600B) must be present.A0600B must be a Medicare number. 103

A0700- Medicaid NumberEnter one number or letter per box beginning in the leftmost box. Enter “+” in the leftmost box if it is Pending.Enter “N” if not a Medicaid recipient.104

A0800- GenderCoding Instruction was updated to include: Resident gender on the MDS must match what is in the Social Security system.105

A1500- Preadmission Screening and Resident Review (PASRR)106 OldNew

A1510- Level II PASRR107 OldNew

A2400- Medicare stay108

A2400- Medicare stay (continued)This item identifies:When the resident is receiving services under the scheduled PPS; and When a resident’s Medicare Part A begins and ends.Most recent Medicare stay is a Medicare Part A covered stay that has started on or after the most recent admission/ entry or reentry to the nursing home.109

A2400- Medicare stay (continued)Medicare covered stay billable to Medicare Part A.It does not include Medicare Advantage HMO plan. Medicare Stay for new admission is day 1 (one) of Medicare Part A stay.Medicare stay for readmission is day 1 (one) of Medicare Part A coverage after readmission following a discharge.110

A2400- Medicare stay (continued)Added the following Coding Tips for A2400:When a resident on Medicare Part A has an interrupted stay (i.e., is discharged from SNF care and subsequently readmitted to the same SNF within the interruption window after the discharge), this is a continuation of the Medicare Part A stay, not a new Medicare Part A stay. Items A2400A - A2400C are not active when the OBRA discharge assessment indicates the resident has had an interrupted stay (A0310G1=1).111

Section CCognitive Patterns112

C0100- Should Brief Interview for Mental Status be conducted?The following tips was added to C0100:Because a PDPM cognitive level is utilized in the speech language pathology (SLP) payment component of PDPM, assessment of resident cognition with the BIMS or Staff Assessment for Mental Status is a requirement for all PPS assessments. 113

C0100 (continued)As such, only in the case of PPS assessments, staff may complete the Staff Assessment for Mental Status for an interview-able resident when the resident is unexpectedly discharged from a Part A stay prior to the completion of the BIMS. In this case: The assessor should enter 0, No in C0100 (Should Brief Interview for Mental Status Be Conducted?); and Proceed to the Staff Assessment for Mental Status.114

Section DMood115

D0350 & D0650 - Safety Notification PHQ9 & PHQ9-OV © D0350- Follow-up to D0200I and D0650- follow-up to D0500I were removed. 116RemovedRemoved

Section GGFunctional Abilities and Goals117

Section GG and Time of Assessment Functions Time of the Assess: 118 GG0100-Prior Functioning: Everyday Activities Admission GG0110-Prior Device Use Admission GG0130-Self- Care Admission and Discharge GG0170- Mobility Admission and Discharge

Section GG and QRPSNF QRP added four new quality measures (QMs):Meet the requirements of the IMPACT Act addressing the domain of functional status and cognitive function and change in function and cognitive function. Use data elements currently collected in MDS section GG and add/modify data elements.Include standardized data elements used across PAC settings.Adapted functional Outcome measures previously endorsed by the National Quality Forum (NQF) for IRFs.Data collection for this measures began October 1, 2018.119

GG100Prior Functioning everyday activities 120

GG0100- Prior Functioning: Everyday Activities 121

GG0100- Coding InstructionsCode 8, Unknown 122Code 3, IndependentCode 2, Need Some Help Code 1, Dependent Code 9, Not Applicable If the resident completed the activities by himself or herself, with or without an assistive device, with no assistance from a helper. If the resident needed partial assistance from another person to complete the activities. If the helper completed the activities for the resident, or the assistance of two or more helpers was required for the resident to complete the activity. If the resident’s usual ability prior to the current illness, exacerbation or injury is unknown. If the activity was not applicable to the resident prior to the current illness, exacerbation, or injury.

GG0100 (continued)123 Old

GG0100 (continued)124 New

GG0100A- Self Care125

GG0100B- Indoor Mobility (Ambulation) 126

GG0100C- Stairs127

GG0100D- Functional Cognition128

GG110Prior Device Use 129

GG0110-Prior device Use 130 Old

GG0110-Prior device Use (continued) 131 New

GG0110D-WalkerWalker refers to all types of walkers such as:Pickup walkers. Hemi-walkers.Rolling walkers.Platform walkers.Four-wheel walker.Rollator walker.Knee walker.Walkers for mobilizing while seated in walker. 132

GG0110 C-Mechanical LiftAny device a resident or caregiver requires for lifting or supporting the resident’s bodyweight. Mechanical lift, includes, but not limited to: Stair Lift.Hoyer Lift.Bathtub lift.133

General guidelineGG0130, GG0170, & Interim Performance 134

GG0130- Self-Care GG0170- Mobility GG0130 (Self-Care) identified the resident’s ability to perform the listed self-care activities and discharge goal(s). GG0170 (Mobility) identifies the resident’s ability to perform the listed mobility activities and discharge goal(s).135

GG0130- Self-Care and GG0170-Mobility (continued)Step #1 for assessment clarified. Assess the resident’s self-care and Mobility performance during the three days assessment period based on:Direct observation, Incorporating resident self-reports,Reports from qualified clinicians, care staff, or family documented in the resident’s medical record. 136

GG0130, GG0170 & Interim (continued)Step #1 for assessment clarified (continued): For Section GG, the admission assessment period is the first three days of the Part A stay starting with the date in A2400B. On admission, these items are completed only when A0310B = 01. Added statement: For the Interim Payment Assessment (A0310B=08), the assessment period for Section GG is the last 3 days (i.e., the ARD and two days prior). 137

GG0130, GG0170, &Interim (continued)Steps #5 clarified: The admission functional assessment, when possible, should be conducted prior to the resident benefitting from treatment interventions in order to reflect the resident’s true admission baseline functional status. Do not held treatment in order to conduct the functional assessment.138

GG0130, GG0170, & Interim (continued)Allowed the resident to perform activities as independently as possible as long as they are safe. If helper assistance is required score according to amount of assistance provided.If two or more helpers are required to assist the resident in completing the activity code “01, Dependent.”139

GG0130 &GG0170Performance Coding: “Contact guard” added to definition of code 04, Supervision or touching assistance in the Resident Assessment Instrument (RAI) Manual.140

Six - Point ScaleCode 03 141Code 06Code 05 Code 04 Code 02 Independent. Setup or Clean-up assistance. Supervision or touching assistance. Partial/moderate assistance. Substantial/maximal assistance. Code 01 Dependent.

Code 09, Not ApplicableCodes for Activity Was Not Attempted Code 88, Not attempted due to medical conditions or safety concerns.142Code 07,Resident refused Code 10, Not attempted due to environmental limitation Resident refused to complete the activity Not attempted and the resident did not perform this activity prior to the current illness, exacerbation or injury For example, lack of equipment, weather constraints Activity was not attempted due to medical condition and safety concerns.

GG0130-Self-care 143

Interim Payment Assessment-Optional144

GG0170-Mobility 145

Part A PPS AdmissionAdmission: The 5-Day PPS assessment is the first Medicare required assessment to be completed when the resident is admitted for a SNF Part A. 146

3-Day Admission Assessment period (Part A)Admission Assessment Period for functional assessment is First 3 days of the Part A stay: Starting with the date of the Most Recent Medicare Stay and following 2 days. Ending at 11:59 p.m. on day 3.147

3-Day Admission Assessment period (continued)The 5-Day PPS assessment code the resident’s functional status based on a clinical assessment of the resident’s performance that occurs soon after the resident’s admission. The admission function scores are to reflect the resident’s admission baseline status and are to be based on an assessment. The assessment should occur, when possible, prior to the resident benefitting from treatment interventions in order to determine the resident’s true admission baseline status. 148

GG0130-Self-care (3-day assessment period) Admission -Start of Medicare Part A Stay 149

GG0130-Self care (3- day assessment period) Interim Performance (Interim Payment Assessment-Optional) 150

GG0170-Mobility (3-day assessment period) Admission (Start of Medicare Part A Stay) 151

GG0170-Mobility (3-day assessment period) Admission (Start of Medicare Part A Stay ) (continued) 152

GG0170 -Mobility (3-day assessment period) Interim Performance (Interim Payment Assessment-Optional) 153

Part A PPS DischargeThe Part A PPS Discharge assessment is required to be completed when the resident’s Medicare Part A Stay ends either as:A standalone assessment when the resident’s Medicare Part A stay ends, but the resident remains in the facility. Or May be combined with an OBRA Discharge if the Medicare Part A stay ends on the day of, or one day before the resident’s Discharge Date (A2000). 154

3-Day Discharge AssessmentDischarge (End of SNF PPS Stay): Code the resident’s discharge functional status based on a clinical assessment of the resident’s performance that occurs as close to the time of the resident’s discharge from Medicare Part A as possible. This functional assessment must be completed within the last three calendar days of the resident’s Medicare Part A stay, which includes the day of discharge from Medicare Part A and the two days prior to the day of discharge from Medicare Part A.155

3-Day Discharge Assessment periodDischarge Assessment Period: Last 3 days of the Part A stay: Starting with the end of the Most Recent Medicare Stay; andThe 2 calendar days prior.156

GG0130-Self care (3-Day assessment period)Discharge (End of Medicare Part A Stay) 157

GG0170-Self care (3-Day assessment period)Discharge (End of Medicare Part A Stay) 158

GG0170-Self care (3-Day assessment period)Discharge (End of Medicare Part A Stay) 159

Section GGInterim Payment Assessment (IPA) Item setNew assessment 160

Interim Performance (Optional)The Interim Payment Assessment (IPA) is an optional assessment that may be completed by providers in order to report a change in the resident’s Patient Driven Payment Model (PDPM) classification. For Section GG on the IPA, providers will use the same 6-point scale and activity not attempted codes to complete the column “Interim Performance,” which will capture the interim functional performance of the resident.161

Interim Performance (continued)The ARD for the IPA is determined by the provider, and the assessment period is the last 3 days (i.e., the ARD and the 2 calendar days prior). It is important to note that the IPA changes payment beginning on the ARD and continues until the end of the Medicare Part A stay or until another IPA is completed. The IPA does not affect the variable per diem schedule. 162

GG0130 -Interim Performance-New163

GG0130-Interim Performance-New164

GG0170 - Interim Performance-New165

Discharge Goals For SNF QRP completion of at least (a minimum of) one discharge goal is required for the self-care or mobility items for each resident.Code the resident’s discharge goal(s) at the Start of the PPS stay by using: The 6-point scale. OrActivity not attempted codes (07, 09, 10 or 88).Use of “Activity not attempted” is permitted for the discharge goal(s).The use of dash is permitted for any remaining self-care or mobility goals that were not coded. Use of dash does not affect the Annual Payment Update determination.Licensed, qualified clinicians can establish a resident’s Discharge Goal(s) at the time of admission. 166

Discharge Goals (continued) The goal(s) is chosen based on: The resident’s prior medical condition.Prior self-care and mobility status.Admission assessment self-care and mobility status.Discussions with the resident and family.Professional judgment.The profession’s standard of practice.Expected treatments. Resident’s motivation to improve. Anticipated length of stay. The resident’s discharge plan. 167

Discharge Goals (continued) If the admission performance of an activity was coded 88 during the admission assessment, a Discharge Goal may be entered using the 6-point scale if the resident is expected to be able to perform the activity by discharge. Discharge Goal could be coded:Higher than 5-Day Assessment Admission Performance.The Same as 5-Day PPS Assessment Admission performance code.Lower than 5-Day Assessment Admission performance code.168

Discharge Goals (continued) Admission Performance and Discharge Goals are coded on every Admission Assessment regardless of length of stay and planned or unplanned discharge.If the resident has an incomplete stay: Complete admission performance and Discharge goals.Discharge self-care and mobility performance items are not required.169

Incomplete/Unplanned DischargeUnplanned discharge indicated by type of D/C that has a Discharge Date that is on the same day or the day after the End Date of Most recent Medicare Stay; OR Discharge to an acute care, psychiatric, or long-term care hospital on an MDS Discharge that has a Discharge Date that is on the same day or the day after the End Date of Most Recent Medicare Stay; OR The resident’s death as indicated on an MDS tracking record that has a Discharge Date that is on the same day or the day after the End Date of Most Recent Medicare Stay; OR Medicare Part A Stay is less than 3 days as indicated by End Date of Most Recent Medicare Stay minus Start Date of Most Recent Medicare Stay < 3 days. 170

GG0130- Performance Coding“Decision Tree” – This tool was added to guide coding the resident’s performance on the assessment instrument. Use this decision tree to code the resident’s performance on the assessment instrument.If helper assistance is required because the resident’s performance is unsafe or of poor quality, score the assessment according to the amount of assistance provided. Only use the “activity not attempted codes” if the activity did not occur; that is, the resident did not perform the activity and a helper did not perform that activity for the resident.”171

Start Decision Tree here172 Does the patient /resident complete the activity- with or without assistive devices-by him/herself and with no assistance (physical, verbal/nonverbal curing, setup/clean-up? YesDoes the patient /resident need only setup/clean-up assistance from one helper Does the patient /resident need only verbal/nonverbal cueing or steadying/ touching/ contact guard assistance from one helper? Does the patient /resident need physical assistance –for example lifting or trunk support-from one helper providing less than half of the effort? Does the patient /resident need physical assistance- for example lifting or trunk support- from one helper with the helper providing more than half of the effort? Does the helper provide all the effort to complete the activity OR is the assistance of 2 or more helpers required to complete activity? 06- Independent No Yes 05- Setup/clean-up Assistance No No No No Yes 04-supervision/ touching assistance 03- Partial/moderate assistance Yes Yes Yes 02- Substantial/ maximal assistance 01- Dependent

GG0130-Self-care (3-day assessment period) Admission/Interim/ Discharge(Start/Interim/End of Medicare Part A stay) 173

GG0130. Self - Care Admission Performance (3-Day Assessment Period)174

GG0130A- Eating175

GG0130- Eating (GG0130A)The following statement was added to address coding of eating when a resident receives tube feedings or parenteral nutrition: “Eating involves bringing food and liquids to the mouth and swallowing food. The administration of tube feedings and parenteral nutrition is not considered when coding this activity. The following is guidance for some situations in which a resident receives tube feedings or parenteral nutrition…” References to “parenteral nutrition” were added throughout Coding Tips for this item. 176

GG0130A- Eating (continued)Code GG0130A “88-Not attempted due to medical condition or safety concerns” if because of new condition the resident:Does not eat or drink by mouth andRelies only on nutrition and liquids through tub feedings or Total Parental nutrition (TPN).177

GG0130A- Eating (continued)Code “09, Not applicable- not attempted and the resident did not perform this activity prior to the current illness” if:The resident does not eat or drink by mouth at the time of assessment; and The resident did not eat or drink prior to the current illness, injury, or exacerbation.178

GG0130B- Oral Hygiene179

GG0130C- Toileting Hygiene180

GG0130C- Toileting Hygiene (continued)Toileting hygiene includes managing: Undergarments.Clothing.Incontinence products.Performing perineal cleansing before and after voiding or having a bowel movement.If the resident has an indwelling urinary catheter and has bowel movements, code the Toileting hygiene item based on the amount of assistance needed by the resident when moving his or her bowels. 181

GG0130C- Toileting Hygiene (continued)Toileting hygiene can take place before and after use of: Toilet.Commode.Bedpan. Urinal.If the resident completes a bowel toileting program in bed, code Toileting hygiene based on the resident’s need for assistance in managing clothing and perineal cleansing. 182

GG0130E- Shower/Bathe Self183

GG0130E- Shower /Bathe self (continued)Shower/bathe self includes the ability to wash, rinse, and dry: Face. Upper body.Lower body.Perineal area.Feet. Do not include washing, rinsing, and drying the resident’s back or hair.Shower/bathe self does not include transferring in/out of a tub/ shower. 184

GG0130E- Shower /Bathe self (continued)Assessment of Shower/bathe self can take place in a shower or bath or at a sink. If the resident cannot bathe his or her entire body because of a medical condition, then code Shower/bathe self based on the amount of assistance needed to complete the activity. Code “05, Setup or clean-up assistance” if:The resident bathes himself/herself and a helper sets up materials for bathing/showering.185

GG0130F- Upper Body Dressing186

GG0130F (continued)Example of the Upper Body Dressing Items 187Bra Undershirt Nightgown (Not Hospital gown) Hand/arm prosthetic /orthotic T-shirt Button-down shirt Dresses Upper body support device Pullover shirt Sweatshirt Pajama top Neck support Stump sock/shrinker Abdominal Binder Thoracic-Lumbar-Sacrum Orthosis (TLSO) Back brace Upper body dressing cannot be assessed based solely on donning/doffing a hospital gown.

GG0130G- Lower Body Dressing188

GG0130G (continued)Example of the Lower Body Dressing Items 189Lower-limb prosthesis Stump sock/shrinker Underwear Slacks Knee brace Incontinence brief Shorts Capri Pants Elastic bandage Shirts Pajama bottoms

GG0130H- Putting on/taking off Footwear190

GG0130H (continued)Example of Footwear Dressing Items 191Orthopedic walking boots Socks Boots Elastic bandage Shoes Running shoes Compression stocking Foot orthotic Ankle foot orthosis (AFO)

Resident with bilateral AmputeeFor residents with bilateral lower extremity amputations with or without use of prostheses, the activity of putting on/taking off footwear may not occur. For example, the socks and shoes may be attached to the prosthesis associated with the upper or lower leg. Code “88, Not attempted due to medical condition or safety concerns” if:The resident performed the activity of putting on/ taking off footwear immediately prior to the current illness, exacerbation, or injury. 192

Resident with bilateral Amputee (continued)Code “09, Not applicable - Not attempted and the resident did not perform this activity prior to the current illness, exacerbation, or injury” if The resident did not perform the activity of putting on/taking off footwear immediately prior to the current illness, exacerbation, or injury, because the resident had bilateral lower-extremity amputations and the activity of putting on/taking off footwear was not performed during the assessment period.193

Resident with single Amputee For residents with a single lower extremity amputation with or without use of a prosthesis, the activity of putting on/taking off footwear could apply to the intact limb or both the limb with the prosthesis and the intact limb.If the resident performed the activity of putting on/taking off footwear for the intact limb only, then code based upon the amount of assistance needed to complete the activity. If the resident performed the activity of putting on/taking off footwear for both the intact limb and the prosthetic limb, then code based upon the amount of assistance needed to complete the activity. 194

GG0130F, GG0130G & GG0130H Code 05, “Setup or clean-up assistance” for upper body dressing, lower body dressing, and putting on/taking off footwear, if:The resident dresses himself/herself and a helper retrieves or puts away the resident’s clothing. When coding upper body dressing and lower body dressing, helper assistance with buttons and/or fasteners is considered touching assistance.195

GG0130F, GG0130G & GG0130H (continued) If donning and doffing an elastic bandage, elastic stockings, or an orthosis or prosthesis occurs while the resident is dressing/undressing, then count the elastic bandage/elastic stocking/ orthotic/ prosthesis as a piece of clothing when determining the amount of assistance the resident needs when coding the dressing item. 196

GG0170-Mobility (3-day assessment period) Admission/Interim/ Discharge(Start/Interim/End of Medicare Part A stay) 197