Terry Raser RN RACCT CNE CIC Senior Consultant January 2016 Describe the history and intent of the MDS Focused Survey Identify the findings of the 2014 pilot MDS Focused Survey Discuss the importance of ADL coding Accuracy ID: 760744
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Slide1
ADL Coding Impacts the MDS Focused Survey
Terry
Raser
, RN, RAC-CT, C-NE, CICSenior ConsultantJanuary 2016
Slide2Describe the history and intent of the MDS Focused SurveyIdentify the findings of the 2014 pilot MDS Focused SurveyDiscuss the importance of ADL coding AccuracyIdentify ADL Tasks and DefinitionsApply ADL coding accurately
Objectives
Slide3Purpose of the MDS 3.0 is to serve as the clinical basis for individualized care planning and Delivery of person-centered care.The MDS is used for many different areas of quality reporting2013- OIG report found 47% of claims reviewed had at least one MDS coding error.
History and Intent
Slide42014- MDS Focused Survey pilotFive States- (MD, PA, VA, IL and MN)24 of 25 had deficienciesDeficient AreasADLs 15.4%One in every 7 cases2015- Expanded MDS Focused survey
History and Intent
Slide5ADL CODING
Slide6Coding for my 8 hour shift
Coding on the MDS
2 Ways to Educate ADL Coding
Slide7Coding For My 8 hr. Shift
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Slide8Self PerformanceColumn 1 Coding Definitions
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Slide90- Independent
Resident completed activity with no help or staff oversight any time
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Slide101- Supervision
Oversight, encouragement, or cueing was provided
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Slide112- Limited Assistance
Resident was highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance
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Slide123-Extensive Assistance
Resident performed part of activity, help of following type provided:Weight-bearing supportFull staff performance during part of activity but not all
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Slide134- Total Dependence
Full staff performance of an activity with no participation by resident for any aspect of the task the entire shift.The resident was unwilling or unable to perform any part of the activity.
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Slide148- Activity Did Not Occur
Over the entire shift, the ADL activity was not performed by the resident or staff at all.
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Slide15When to Code (8)Activity Did Not Occur
Transfer- When resident never got out of bedToileting- Only if elimination did not occur during the entire shiftLocomotion- Resident was on bed-rest and did not get out of bed, and there was no locomotion via bed, w/c or other meansEating- Only if the resident received no nourishment by any route the entire shift
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Slide16Residents With Feeding Tube
Code Extensive (3)- resident received tube feeding by staff but feed self orally at least one time during the shiftCode Total Dependence (4)- resident received tube feeding by staff and/or was fed by staff orally every time during the shiftResident did not participate in any aspect of eatingDid not pick up finger foods or drink
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Slide17Staff Support ProvidedColumn 2Coding
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Slide18Code (0) No Setup or Physical Help from Staff
Resident completed activity with no help or oversight
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Slide19Code 1- Setup Help Only
Resident is provided with material or devices necessary to perform the ADL independently. This can include giving or holding out an item that the resident takes from the caregiver.
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Slide20Code 2- One Person Physical Assist
Resident was physically assisted by one staff person
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Slide21Code 3 -Two+ Person Assist
Resident was physically assisted by two or more staff persons
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Slide22Code 8-Activity Did Not Occur
The ADL activity did not occur the entire shift
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Slide23ADL Education
How often is staff educated on ADL coding?
What is your facility policy?
Does the facility provided competencies?
Do you give pre and post ADL scenario testing?
Slide24RNAC ADL Coding of the MDS
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Slide25G0110 Column 1 ADL Self-Performance
Determine which ADLs the resident performed across all shifts during the past 7 days. (ARD + back 6 days)Assess the resident’s self-performance (what the resident actually did).
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Slide26G0110 Column 2ADL Support Provided
Measure the most support provided by staff to complete each ADL activity.Document the most support provided even if it occurred only once.Code Column 1 and Column 2 separately.
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Slide27G0110 Coding Column 1 ADL Self-Performance
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Slide28G0110 Column 1Conduct the Assessment
Review the medical record.Talk with direct care staff from each shift that has cared for the resident.Determine the type and level of facility staff assistance provided for each ADL activity. Staff assistance includes oversight, verbal cueing or encouragement, physical assistance, or full staff performance
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Slide29ADLs Performed by Facility Staff
For completing Section G, "facility staff" pertains to: direct employees and facility-contracted employees (e.g. rehabilitation staff, nursing agency staff.Does not include individuals hired, compensated or not, by individuals outside of the facility's management and administration. families, hospice staff, nursing/CNA students, etc. Not including these individuals allows the facility to retain the primary responsibility for the care of the resident.
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Slide30ADLs Performed by Facility Staff
If family or hospice do all the care for the resident then you code “8” activity did not occur and document it in the clinical record who gave the care.Example: Wife feeds husband all meals. Staff would code “8/8” for all meals feed by wife. Staff should document in clinical record that the wife feeds her husband all meals.
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Slide31G0110 Column 1Guidelines
Assess the resident’s functional status for each ADL.Document the level of assistance the resident required to complete the activity.Consider each episode of the activity that occurred during the look-back period.
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Slide32G0110 ADL Self-PerformanceCoding Guidelines
Determine if each ADL or activity occurred three or more times if it did code the highest code. If not,Apply the Rule of 3 to determine the resident’s level of self-performance. If this doesn’t apply then,Use the ADL Self-Performance Algorithm to facilitate accurate coding.
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Slide33ACTIVITY OCCURRED 3 OR MORE TIMES
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Slide34EXTENSIVE ASSISTANCE ( CODE 3)
Use code 3, Extensive Assistance, if a resident performed part of the activity over the last 7 days and help of the following type(s) was provided 3 or more times:Weight-Bearing support provided 3 or more times ORFull staff performance of activity 3 or more times during part but not all of the last 7 daysFull staff performance 3 times but not every time
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Slide35EXTENSIVE ASSISTANCE EXAMPLE
A resident received weight-bearing assistance 3 times during the 7 day look back period.THIS MEETS THE ADL SELF-PERFORMANCE DEFINITION FOR EXTENSIVE ASSISTANCE SINCE IT SATISFIES ONE OF THE CRITERIA.Weight-Bearing support provided 3 or more times
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Slide36EXTENSIVE ASSISTANCE ( CODE 3)
Two Criteria for Extensive AssistWeight-Bearing support provided 3 or more times ORFull staff performance of activity 3 or more times during part but not all of the last 7 daysThe only time episodes can be combined is when the activity occurs 3 or more times and at multiple levels, but not 3 times at anyone level.
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Slide37TOTAL DEPENDENCE (CODE 4)
Total Dependence applies only if the resident requires full staff performance every time the ADL occurred and the activity itself occurred 3 or more times during the 7 day look back period.If unable to meet this rule, Code 4 (Total Dependence) can not be entered on the MDS!
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Slide38EXTENSIVE ASSISTANCE (CODE 3)
If Total Dependence occurs at least 3 times but not every time during the 7 day look back period it can be counted under the second criteria for Extensive assistanceFull staff performance of activity 3 or more times during part but not all of the last 7 days
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Slide39ADL SELF-PERFORMANCE EXCEPTION CODES
Four ADL Self-Performance coding level definitions that are exceptions to the Rule of 3:Code (0) IndependentCode (4) Total DependentCode (8) Activity Did Not OccurCode (7) Occurred 1-2 times
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Slide40ADL SELF-PERFORMANCE EXCEPTION CODES
They must occur every time to code on the MDS and have at least 3 occurrences :Code (0) IndependentCode (4) Total DependentCode (8) Activity Did Not OccurIf any other code was coded with the above codes during the 7 day look back period you can not use the above codes
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Slide41Code 0 Independent
Must be coded at least 3 timesCode 0 if the resident did not need ANY assistance or oversight to complete the ADL every time.
11-708080807-300000003-110000000
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Slide42Code 4 Total Dependence
Must be coded at least 3 timesCode 4 if the resident is unwilling or unable to perform any part of the ADL for the entire look-back period every time.
11-744444447-344484843-118844844
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Slide43Code 8 Activity Did Not Occur
Code 8 if the resident or staff did not perform the ADL at all during the look-back period ORFamily or non-facility staff provided care regarding the task 100% of the time during the 7 day look back period
11-788888887-388888883-118888888
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Slide44Code 7 Activity OccurredOnly Once or Twice
Determine if ADL occurred three or more times during the look-back period. If not,Code 7 if ADL occurred only once or twice
11-788888887-388848383-118888888
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Slide45INSTRUCTIONS FOR THE RULE OF 3
Rule (1): When an activity occurs three or more times at any one level, code that level.ADL Coding Scenario #1MR. X two times required guided maneuvering of his arms to don his shirt. Four times, he had pain in his shoulders and he required the staff to assist him with his shirt by physically lifting each of his arms. This component of the dressing ADL occurred six times in the 7- day look back period
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Slide46INSTRUCTIONS FOR THE RULE OF 3
ADL Coding Scenario #1Observations indicate the resident required the following assistance:2 times non-weight bearing (limited assist)4 times weight-bearing (extensive assist)Code Extensive Assistance (3), The episodes of care occurred 3 or more times at one level- weight bearing which is consistent with the rule 3.
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Slide47INSTRUCTIONS FOR THE RULE OF 3
Rule (2): When an activity occurs 3 or more times at multiple levels, code the most dependent level that occurred 3 or more times:ADL scenario # 2Mrs. C. required verbal cueing 4 times for hand placement during stand-pivot transfers from her W/C. She required weight-bearing assistance 3 times to help her rise from the W/C and turn back to the bed. She completed this transfer without assistance in 14 other occurrences during the 7 day look back period.
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Slide48INSTRUCTIONS FOR THE RULE OF 3
ADL Coding Scenario # 2Observations indicate the resident required the following assistance:4 times supervision (Supervision)3 times weight-bearing (Extensive)14 times no assistance (Independence)Code Extensive Assistance (3)Code the most dependent that occurred 3 or more times
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Slide49INSTRUCTIONS FOR THE RULE OF 3
Rule (3): When an activity occurs 3 or more times and at multiple levels but not 3 times at any one level.Sub-items under 3rd Rule of 3(a)Convert episodes of full staff performance to weight-bearing assistance(b)When there is a combination of full staff performance and weight-bearing assistance that total 3 or more times, Code Extensive Assistance (3)(c) When there is a combination of full staff performance/weight-bearing assistance and/or non-weight-bearing assistance that total 3 or more times, code Limited Assistance (2)
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Slide50INSTRUCTIONS FOR THE RULE OF 3
Ms. F was in the NH for only one day prior to transferring to another facility. The following assistance for eating ADL was provided:ADL Coding Scenario # 32 times she required weight-bearing assistance to help her lift her fork to her mouth (Extensive)1 time staff fed Ms. F (Total Dependence)Code Extensive Assistance (3)
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Slide51INSTRUCTIONS FOR THE RULE OF 3
ADL Coding Scenario # 3Observations indicate the resident required the following assistance:2 times Extensive1 time Full Staff Performance(Note: In the scenario, the ADL occurred 3 times and at multiple levels, but neither of the levels 3 times)Sub-Item Rule 3:(a)Covert episodes of full staff performance to weight-bearing assistance. (This give 3 times at Extensive)
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Slide52INSTRUCTIONS FOR THE RULE OF 3
ADL Coding Scenario # 4:Mr. N was sent to the hospital on day 2 of his NH stay. The following assistance for dressing was provided:Weight bearing assistance 1 time (Extensive)Non-weight bearing assistance 1 time (Limited)Full staff performance 1 time (Total)Independent 1 time ( Independent)(Note: The ADL occurred 3 times and at multiple levels, but none of the levels occurred 3 times)
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Slide53INSTRUCTIONS FOR THE RULE OF 3
ADL Coding Scenario # 4Weight bearing assistance 1 timeNon-weight bearing assistance 1 timeFull staff performance 1 timeIndependent 1 timeRule (3): When an activity occurs 3 or more times and at multiple levels but not 3 times at any one level.Sub-items under 3rd Rule of 3(c) When there is a combination of full staff performance/weight-bearing assistance and/or non-weight-bearing assistance that total 3 or more times, code Limited Assistance (2)
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Slide54INSTRUCTIONS FOR THE RULE OF 3
ADL Coding Scenario # 5Mr. P- toileting occurred 20 times in the look back period. Mr. P was able to toilet independently 18 times. The other 2 times Mr. P required non-weight bearing assist.Observation indicates:18 times independent2 times non-weight bearing (Limited)Code: Supervision (1)Note: If none of the Rule of 3 are met, code Supervision
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Slide55Item G0110Column 2Coding ADLSupport Provided
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Slide56G0110 (2)ADL Support Provided
Complete the ADL Self-Performance assessment for each ADL first.ADL Support Rule 1- Code Most Support provided even if it only occurred once during the 7 day look back period.ADL Support Rule 2- Coded separately from the ADL Self-Performance assessment (column 1).ADL Support Rule 3- Rule of 3 does not apply to Column 2.
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Slide57ADL Support Provided – Column 2
Slide58ADL Importance $$$$ RUG IV
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Slide59MDS
Coded
Inaccurately
MDS Coded Accurately
3
3
3
3
3
3
3
3
3
3
3
2
0
1
4
4
0
1
59
Slide603
3
3
3
3
3
3
3
3
3
3
2
0
1
0
1
4
4
4
4
4
2
0
0
10
12
MDS Coded Inaccurately
MDS Coded Accurately
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Slide61MDS Coding Payment Difference
4
4
4
4
4
2
0
0
10
12
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Slide62If ADL coding does not look like the residentResident always requires 2 person assist but not codedADL tracker coding: 3/1, 2/1, 8/2, 1 /2Clarification Note:Should identify the task, the accurate Self-Performance type, and the number of times occurred during the (specified) 7 day look-back period, date of the note and the signature and title of the person writing the note.
Need for ADL Clarification Note
Slide63Thank You
Terry
Raser
, RN, RAC-CT, C-NE, CIC
traser@lw-consult.com
610-314-5095
Slide64Ref: S&C: 15-06-NH, Nationwide Expansion of Minimum Data Set (MDS) Focused Survey, October 31, 2014.http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-06.pdfRef: S&C: 15-25-NH, MDS/Staffing Focused Survey Update, February 13, 2015MDS 3.0 RAI Manual v 1.13, October 2015
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