1. MINIMUM DATA SET (MDS) 3.0/
RESIDENT ASSESSMENT INSTRUMENT (RAI):
CMS UPDATES, FREQUENT CODING ISSUES
IN TEXAS AND CHANGES COMING IN
2014!
Cheryl Shiffer, RN, BSN, RAC-CT
Center for Policy and Innovation
Texas Department of Aging and Disability
Services (DADS)
RAI Panel, Center for Medicare & Medicaid
Services (CMS)
Fall 2013
1

2. MDS 3.0 OBJECTIVES
• List three or more significant changes that
CMS recently made to the MDS 3.0 RAI
Manual
• Describe three or more MDS 3.0 items that
are frequent coding issues for Texas.
2

3. MDS 3.0 OBJECTIVES
• Apply key clarifications and scenarios to
ensure accurate coding of Section G of the
MDS
I
• Identify at least three changes affecting the
MDS 3.0 process in 2014
3

4. CMS UPDATES
CMS updates listed are based on the MDS
3.0 RAI Manual (RAIM3), v1.11
Effective Date: October 1, 2013
4

5. CMS UPDATES
Along with the new version of the RAIM3 is
a new version of the data specifications
(v1.13.2).
The new specifications removed the “T”
(test) value for PRODN_TEST_CD. Test
records are no longer accepted by the
system.
5

6. CMS UPDATES
New items for the MDS item sets include:
•Items O0400A3A, O0400B3A, and
O0400C3A. Co-treatment minutes
Added for reporting co-treatment minutes
Only for Part A, does not apply to Part B
6

7. CMS UPDATES
• Item O0420. Distinct Calendar Days of
Therapy
Added to record the number of calendar days
The resident received Speech-Language
Pathology and Audiology Services,
Occupational Therapy or Physical Therapy
For at least 15 minutes a day in past 7 days
7

8. CMS UPDATES
• Items K0710A1 through K0710B3
(replaced items K0700A and K0700B)
K0710. Percent Intake by Artificial Route
Added 3 columns for coding:
1. While NOT a Resident
2. While a Resident
3. During Entire 7 Days
8

9. CMS UPDATES
Chapter 1, Section 1.8 - Protecting the
Privacy of the MDS Data – Adds:
• A revised “Privacy Act Statement – Health
Care Records” (RAIM3, pages 1-16 to
1-18)
9

10. CMS UPDATES
Chapter 2, Section 2.6 - Required Omnibus
Budget Reconciliation Act (OBRA)
Assessments for the MDS – Clarifies:
•Setting the Assessment Reference Date (ARD)
for a Discharge assessment is not set
prospectively as with other OBRA assessments.
(RAIM3, page 2-36)
10

11. CMS UPDATES
• The ARD (Item A2300) for a Discharge
assessment is always equal to the discharge
date (Item A2000).
• The ARD may be coded on the assessment
any time during the Discharge assessment
completion period (i.e., discharge date
(A2000) + 14 calendar days).
(RAIM3, page 2-36)
11

12. CMS UPDATES
Chapter 2, Section 2.9 - MDS Medicare
Assessments for SNFs – Clarifies:
•A Change of Therapy (COT) MDS is
required:
When the most recent assessment used for
Part A
Excluding an End of Therapy (EOT) MDS
Has a sufficient level of rehabilitation
therapy to qualify for:
12

13. CMS UPDATES
1. An Ultra High, Very High, High, Medium, or
Low Rehabilitation category (even if the
final classification index maximizes to a
group below Rehabilitation), and
2. The intensity of therapy changes to such a
degree it no longer reflect the Resource
Utilization Group (RUG) IV classification
assigned for a Part A resident based on the
most recent assessment used for
Medicare payment.
(RAIM3, page 2-50)
13

14. CMS UPDATES
Section 2.9 - MDS Medicare Assessments for
SNFs - Coding Tips and Special Populations
adds a Note:
•Acknowledging it may not be practicable to
conduct the resident interview items on or prior
to the ARD for a standalone unscheduled Part A
assessment, and
•Allowing facilities to conduct those resident
interview sections up to two calendar days after
the ARD (A2300).
(RAIM3, page 2-52)
14

15. CMS UPDATES
Section 2.13 - Factors Impacting the SNF
Medicare Assessment Schedule –
clarifies under Resident Takes a Leave of
Absence (LOA) from the SNF:
•An unscheduled Prospective Payment
System (PPS) MDS which meets the
appropriate standards may have an ARD
(A2300) that falls on a LOA day, but…
(RAIM3, page 2-72)
15

16. CMS UPDATES
•Only if the unscheduled PPS MDS is not
combined with a scheduled PPS MDS.
Scheduled PPS MDS must have an ARD
that falls on a Medicare Part A benefit day.
(RAIM3, page 2-72)
16

17. CMS UPDATES
Chapter 3, Section G - Item G0110
Activities of Daily Living (ADL)
Assistance – extensively revises:
•The “Rule of 3”, and
•The ADL Self-Performance Algorithm, and
•Adds several resident scenarios and
rationales for correctly coding those
situations.
(RAIM3, pages G-1 to G-22)
22

18. CMS UPDATES
Chapter 3, Section M - Skin Conditions,
replaces:
•The MDS Item Set screen shots for several
updated items in Section M, and
•References to ‘necrotic tissue’ and instead
refers to it as ‘eschar’.
(RAIM3, Section M, throughout)
22

19. CMS UPDATES
Chapter 3, Section O – Special
Treatments, Procedures and Programs –
clarifies coding the Dates of Therapy:
•When an End of Therapy with Resumption
(EOT-R) is completed, the Therapy Start
Date (items O0400A5, O0400B5, and
O0400C5) on the next PPS assessment is
the same as the initial therapy evaluation
date.
(RAIM3, page O-17)
22

20. CMS UPDATES
Chapter 3, Section Z - Item Z0400 Signatures of Persons Completing the
Assessment – adds under Coding Tips
and Special Populations:
•If a person who completed a portion of the
MDS is not available to sign it, then the
person signing the attestation should:
Verify those portions of the MDS that may
be verified with the medical record
22

21. CMS UPDATES
The date signed should be the date the
record review was verified.
For sections requiring resident interviews,
the person signing the attestation should
interview the resident to ensure the
accuracy of the information.
The date signed should be the date the
interview was validated.
(RAIM3, page Z-7)
22

22. CMS UPDATES
Chapter 5, Section 5.2 - Timeliness
Criteria, clarifies:
•The completion timing for the Omnibus
Budget Reconciliation Act (OBRA)
Admission and Annual assessment is
corrected to match the OBRA instructions
from Chapter 2 of the RAIM3.
(RAIM3, page 5-2)
22

23. CMS UPDATES
Chapter 6, Section 6.6 - RUG-IV 66-Group
Model Calculation Worksheet for SNFs
-Situation 2 clarifies:
•If the Z0100A classification for an SOT (Item
A0310C = 1), not combined with an OBRA
assessment or other PPS assessment, is
not in a Rehabilitation Plus Extensive
Services group or a Rehabilitation group,
then the following adjustment applies:
22

24. CMS UPDATES
The Medicare Non-Therapy RUG-IV group
reported in Item Z0150A should be adjusted
to AAA (the default group).
• Situation 3 clarifies:
If the Z0100A classification for an SOT
OMRA, combined with an OBRA
assessment or other PPS assessment, is in
a Rehabilitation Plus Extensive Services
group or a Rehabilitation group, then no
adjustment is made.(RAIM3, page 6-49).
22

25. OTHER FREQUENT CODING ISSUES
IN TEXAS
From page 2-2 of the RAIM3, “If allowed by
the State, facilities may have some flexibility
in form design …or use a computer
generated printout of the RAI as long as the
state can ensure that the facility’s RAI in the
resident’s record accurately and completely
represents the CMS-approved State’s RAI.”
25

26. OTHER FREQUENT CODING ISSUES
IN TEXAS
The state of Texas allows this flexibility as
long as the printed assessments:
•Are legible/readable, and
•Display all the active items for that type of
assessment in the order they are coded,
and
•Display the answer that the facility selected.
26

27. OTHER FREQUENT CODING ISSUES
IN TEXAS
From page 2-6 of the RAIM3, there are three
options for maintaining 15 months of MDS:
•Electronically with electronic signatures
•Electronically without electronic signatures
(or signatures that do not print or are not
safeguarded)
•Hard copy
27

28. OTHER FREQUENT CODING ISSUES
IN TEXAS
If MDS are maintained electronically with
electronic signatures:
•Facilities must have written policies in place
to ensure proper security measures to
protect the use of an electronic signature by
anyone other than the person to whom the
electronic signature belongs.
28

29. OTHER FREQUENT CODING ISSUES
IN TEXAS
If MDS are maintained electronically without
electronic signatures (or signatures that do
not print or are not safeguarded):
29

30. OTHER FREQUENT CODING ISSUES
IN TEXAS
• Facilities must maintain hard copies of
signed and dated CAA(s) completion
(Items V0200B-C), correction completion
(Items X1100A-E), and assessment
completion (Items Z0400-Z0500) data that
is resident-identifiable in the resident’s
active clinical record.
• No question data is resident-identifiable if
Section A is also printed.
30

31. OTHER FREQUENT CODING ISSUES
IN TEXAS
From page 2-7 of the RAIM3, surveyors are
directed to review the MDS in the form it is
maintained. If electronic, ensure enough
terminals and “read-only” access are
available.
31

32. OTHER FREQUENT CODING ISSUES
IN TEXAS
From the RAIM3, page 2-6, after the 15month period RAI information may be
thinned from the clinical record and stored
in the medical records department,
provided that it is easily retrievable if
requested by clinical staff, State agency
surveyors, CMS, or others.
32

33. OTHER FREQUENT CODING ISSUES
IN TEXAS
From page 2-8 of the RAIM3, Item A2300 Assessment Reference Date (ARD):
•Refers to the last day of the observation (or
“look back”) period ... Since a day begins at
12:00 a.m. and ends at 11:59 p.m., the ARD
must also cover this time period.
33

34. OTHER FREQUENT CODING ISSUES
IN TEXAS
• The facility is required to set the ARD on the
MDS item set itself or in the facility software
within the appropriate timeframe of the
assessment type being completed.
• This concept of setting the ARD is used for
all assessment types (OBRA and Medicare
PPS).
34

35. OTHER FREQUENT CODING ISSUES
IN TEXAS
From page 2-12 of the RAIM3, a Leave of
Absence (LOA): Does not require completion
of either a Discharge assessment or an Entry
record and occurs when a resident has:
35

36. OTHER FREQUENT CODING ISSUES
IN TEXAS
• Temporary home visit of at least one night;
or
• Therapeutic leave of at least one night; or
• Hospital observation stay less than 24 hours
and the hospital does not admit the patient.
36

37. OTHER FREQUENT CODING ISSUES
IN TEXAS
Hospital observation stay less than
24 hours and the hospital does not
admit the patient means:
• From the time the resident left the facility
until the time the resident returned was less
than 24 hours, and
37

38. OTHER FREQUENT CODING ISSUES
IN TEXAS
• The resident remained in observation and
was not admitted, and
• Any hospital observation stay periods while
actually at the hospital are irrelevant.
38

39. OTHER FREQUENT CODING ISSUES IN
TEXAS
From page 2-22 of the RAIM3, a
Significant Change in Status (SCSA)
(A0310A=04) is required to be completed
NLT the 14th calendar day after
determining a significant change
occurred when:
39

40. OTHER FREQUENT CODING ISSUES IN
TEXAS
•The resident will not return to baseline
within 2 weeks.
•There are two or more areas of
improvement or two or more areas of
decline.
40

41. OTHER FREQUENT CODING ISSUES IN
TEXAS
•Scenario: A resident has a change in both
self-performance and staff support in Item
G0110B Transfer. The resident is newly
coded as requiring extensive assistance and
one staff member’s support. Prior coding
was independent and no staff support.
•If the only change, no SCSA is required.
41

42. OTHER FREQUENT CODING ISSUES IN
TEXAS
•Scenario: A resident has a change in both
self-performance and staff support in Item
G0110B Transfer and Item G0110H Eating.
The resident is newly coded as requiring
extensive assistance and one staff member’s
support. Prior coding was independent and
no staff support.
•This is two areas of change and a SCSA is
required.
42

43. OTHER FREQUENT CODING ISSUES IN
TEXAS
An SCSA is also required when a resident
elects or revokes Hospice:
• Unless the resident dies or discharges prior
to midnight on the 14th calendar day
• Staff should make an entry in the clinical
record to reflect why the SCSA was not
started or completed.
43

44. OTHER FREQUENT CODING ISSUES
IN TEXAS
From page 2-36 of the RAIM3, a Discharge
assessment (A0310F=10 or 11):
•ARD must be set for the day of
discharge within 14 days of the
date of discharge
•Must be completed within 14 days of the ARD
•Ensure discharge date in A2000 matches the
ARD in A2300
44

45. OTHER FREQUENT CODING ISSUES
IN TEXAS
From page A-26 of the RAIM3, when a
resident on a Medicare Part A stay is
discharged:
•The Assessment Reference Date (ARD) of a
scheduled Medicare PPS MDS may be
adjusted to the day of discharge only when
the ARD for the scheduled PPS assessment
was set prior to the day of discharge.
45

46. OTHER FREQUENT CODING ISSUES IN
TEXAS
From page I-3 of the RAIM3, Section I
Active Diagnoses - Determining Active
Diagnoses is a Two Step Process:
1.Determine all physician-documented
diagnoses in the last 60 days.
2.Determine whether each diagnosis (except
UTI) was active in the 7 day look-back
period.
46

47. OTHER FREQUENT CODING ISSUES IN
TEXAS
• Active diagnoses have a direct relationship
to the resident’s functional status, cognitive
status, mood or behavior, medical
treatments, nursing monitoring, or risk of
death during the look-back period. (RAIM3,
page I-4)
• Item I8000 – Do not code HIV/AIDS or
related diagnosis (Texas State Law).
• Read The March 2013 The MDS Mentor!
47

48. OTHER FREQUENT CODING ISSUES IN
TEXAS
From page M-7 of the RAIM3, determining if
Pressure Ulcers were “present on admission”:
•If the pressure ulcer was unstageable on admission,
but becomes staged later, it should be considered as
“present on admission” at the stage at which it first
becomes staged.
•If it subsequently worsens to a higher stage, that
higher stage should not be considered “present
on admission.”
48

49. OTHER FREQUENT CODING ISSUES
IN TEXAS
• If a resident who has a pressure ulcer is
hospitalized and returns with that pressure ulcer
at the same stage, the pressure ulcer should not
be coded as “present on admission” because it
was present at the facility prior to the
hospitalization.
• If a current pressure ulcer worsens to a higher
stage during a hospitalization, it is coded at the
higher stage upon reentry and should be coded
as “present on admission.”
49

50. OTHER FREQUENT CODING ISSUES
IN TEXAS
From page O-1 of the RAIM3, Item O0100.
Special Treatments, Procedures and
Programs (STPP)
•Facilities may code items the resident
performed themselves, independently or
after set-up by facility staff.
50

51. OTHER FREQUENT CODING ISSUES
IN TEXAS
Include in column 2. While a resident - the
applicable STPP items that occurred during
the 14 day look-back while the resident was
a resident of the facility.
•Remember: Column 2 includes those items
that occurred while the resident was
physically present in the facility or that
occurred during a Leave of Absence (LOA).
51

52. OTHER FREQUENT CODING ISSUES IN
TEXAS
• Do not code services that were provided
solely in conjunction with a surgical
procedure or diagnostic procedure, such
as IV medications or ventilators.
• Surgical procedures include routine preand post-operative procedures.
52

53. OTHER FREQUENT CODING ISSUES
IN TEXAS
From page O-3 of the RAIM3, Item O0100H IV
medications - DO NOT include IV fluids (Normal
Saline, D5W, etc.)
From page O-4 of the RAIM3, Item O0100M
Isolation - DO NOT include wound infections,
UTIs or encapsulated pneumonia
53

54. OTHER FREQUENT CODING ISSUES
IN TEXAS
From pages O-4 to O-5 of the RAIM3, Item
O0100M Isolation – Code for “single room
isolation” only when all of the following
conditions are met:
•Note: Never code isolation for wound
infections, urinary tract infections or
encapsulated pneumonia.
54

55. OTHER FREQUENT CODING ISSUES
IN TEXAS
• Active infection with highly transmissible,
epidemiologically significant pathogens.
• Precautions are over and above standard
precautions… transmission-based
precautions (contact, droplet or airborne)
55

56. OTHER FREQUENT CODING ISSUES
IN TEXAS
• The resident is in a room alone because of
active infection and cannot have a
roommate.
• The resident must remain in his/her room.
All services available in the facility are
brought to the resident (e.g. rehab,
activities, dining, etc.).
56

57. OTHER FREQUENT CODING ISSUES
IN TEXAS
From Appendix A, page A-19, Item O0400D
Respiratory Therapy: Following the state
Nursing Practice Act, this therapy must be
provided by a respiratory therapist (RT) or
a trained nurse.
•The March 2011 issue of
The MDS Mentor explains all the
requirements for coding Item O0400D.
57

58. OTHER FREQUENT CODING ISSUES
IN TEXAS
Item Z0400 Signatures of Persons
Completing the Assessment or Entry/Death
Reporting:
•Date for completing interview items is on the
ARD or before the ARD (except stand alone
unscheduled PPS)
•Date for gathering information for other MDS
items is usually after the ARD
58

59. OTHER FREQUENT CODING ISSUES
IN TEXAS
Item Z0400 Signatures of Persons
Completing the Assessment or Entry/Death
Reporting:
•From page Z-7 of the RAIM3, “All staff who
completed any part of the MDS must enter
their signatures, titles, sections or portion(s)
of section(s) they completed, and the date
completed.”
•Read the attestation
59

60. OTHER FREQUENT CODING ISSUES
IN TEXAS
From page 5-10 to 5-11 of the RAIM3, a
modification request is used to modify most MDS
items, including the Target Date:
•Entry Date (Item A1600) on an Entry tracking
record (Item A0310F = 1)
•Discharge Date (Item A2000) on a
Discharge/Death in Facility record (Item A0310F =
10, 11, 12),
•Assessment Reference Date (Item A2300) on an
OBRA or PPS assessment.*
60

61. OTHER FREQUENT CODING ISSUES
IN TEXAS
*
: Only correct the ARD when:
•There was a typographical error, and
•The ARD does not reflect the look-back period
used to determine the coding of the MDS.
•Monitoring will occur to determine if an ARD is
changed and clinical data is also changed (at the
same time or in a subsequent modification).
61

62. OTHER FREQUENT CODING ISSUES
IN TEXAS
A Modification Request is also used to
correct:
•Type of Assessment (Item A0310)
•Clinical Items (Items B0100-V0200C),
including Section O items
Note: Item A0310 can only be modified when
the Item Set Code (ISC) of that assessment
does not change.
62

63. ACCURATE CODING OF SECTION G
To code ADLs in Item G0110:
•Read Section G of the RAIM3
•Apply the ADL Algorithm and Rule of 3 on page G7
•Code 4, total dependence: only if there was full
staff performance of an activity with no participation
by resident for any aspect of the ADL activity. The
resident must be unwilling or unable to perform any
part of the activity over the entire 7-day look-back
period.
63

64. ACCURATE CODING OF SECTION G
• Scenario: During the entire 7-day lookback period, the resident required total
assistance (4) of two staff (3) to transfer
during the day and evening shift. On the
night shift, staff coded that the activity did
not occur (8).
• G0110B Transfer would reflect the resident
required total assistance of two staff every
time the activity occurred.
64

65. ACCURATE CODING OF SECTION G
• Scenario: During the entire 7-day look-back
period, the resident required total assistance
(4) three times, extensive assistance (3) two
times and limited assistance (2) six times in
dressing.
• G0110G Dressing would reflect the resident’s
self performance was extensive assistance.
Total dependence occurred three times but not
every time. Staff code extensive.
(RAIM3, page G-4)
65

66. ACCURATE CODING OF SECTION G
• Code 8, activity did not occur: if, over the 7-day
look-back period, the ADL activity (or any part of
the ADL) was not performed by the resident or
staff at all.
Scenario: ADL self performance is coded as 8 if
the ADL was performed only by family or friends,
or those either directly or indirectly paid by family
or friends, during the entire look-back period.
66

67. ACCURATE CODING OF SECTION G
From page G-6 and again on page G-7 of
the RAIM3, Instructions for the Rule of 3:
•When an ADL activity has occurred three
or more times, apply the four steps of the
“Rule of 3” (keeping the ADL coding level
definitions and the exceptions on page G-5
in mind) to determine the code to enter in
Column 1, ADL Self-Performance.
67

68. ACCURATE CODING OF SECTION G
• These steps must be used in sequence.
• Use the first instruction encountered that
meets the coding scenario (e.g., if Step 1
applies, stop and code that level).
• Also, if sub step 3b applies, stop and code
that level. Do not apply 3c.
68

69. ACCURATE CODING OF SECTION G
Instructions for the Rule of 3:
•1. When an activity occurs three or more
times at any one level, code that level.
•2. When an activity occurs three or more
times at multiple levels, code the most
dependent level that occurred three or
more times.
69

70. ACCURATE CODING OF SECTION G
• 3. When an activity occurs three or more
times and at multiple levels, but not
three times at any one level, apply the
following:
a. Convert episodes of full staff
performance to weight-bearing assistance
when applying the third Rule of 3.
70

71. ACCURATE CODING OF SECTION G
 b. When there is a combination of full staff
performance and weight-bearing assistance that
total three 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 three or
more times—code limited assistance (2).
• 4. If none of the above are met, code
supervision.
71

72. ACCURATE CODING OF SECTION G
Definition of facility staff whose assistance is
coded in ADL support provided in Section G:
•Facility employees, agency staff, therapy (PT, OT,
ST) whether they are employees or contract staff
Scenario: CNAs provide full staff support but
Therapy staff only provides extensive assistance
for transfers during the look-back period. Staff
would code extensive assistance on the MDS.
72

73. ACCURATE CODING OF SECTION G
Definition of non-facility staff whose assistance
is NOT coded in ADL support provided in
Section G:
•Family, friends, sitters, visitors, personal care
aides
•EMS/Ambulance, Hospice, Lab, Diagnostic
Imaging (X-Ray, Ultrasound, etc.) personnel
•Nursing students/CNA students*
73

74. CHANGES COMING IN 2014
International Classification of Diseases, Tenth
Revision, Clinical Modification (ICD-10-CM)
•ICD-10-CM will be used by all providers in
every health care setting.
•ICD-10-PCS (Procedure Coding System)
will be used only for hospital claims for
inpatient hospital procedures.
74

75. CHANGES COMING IN 2014
• ICD-10-CM and ICD-10-PCS implement
October 1, 2014.
• Making the transition to ICD-10 is not
optional.
• This transition will affect all covered entities
as defined by the Health Insurance Portability
and Accountability Act of 1996 (HIPAA).
75

76. CHANGES COMING IN 2014
• Covered entities are required to adopt ICD10 codes for services provided on or after
the October 1, 2014, compliance date.
• For inpatient hospital claims, ICD-10
diagnosis and procedure codes are required
for all stays with discharge dates on or after
October 1, 2014.
76

77. CHANGES COMING IN 2014
• Note: The transition to ICD-10 does not
directly affect provider use of the Current
Procedural Terminology (CPT) and
Healthcare Common Procedure Coding
System (HCPCS) codes.
77

78. CHANGES COMING IN 2014
The CMS ICD-10 website is at
http://www.cms.gov/icd10
• Each ICD-10-CM code is 3 to 7 characters.
• The first must be an alpha character (all letters
except U are used).
• The second character is numeric.
• Characters 3-7 are either alpha or numeric (alpha
characters are not case sensitive),
• With a decimal after the third character.
78

79. CHANGES COMING IN 2014
Other changes expected in 2014:
• Updated RAIM3 – traditionally April (May)
and October
• Updated FY2015 SNF PPS Rules? – Too
early to know
79

80. TEXAS MDS RESOURCES
Call Cheryl Shiffer for Clinical Questions:
• 210-619-8010
Call Brian Johnson for Technical Questions:
• 512-438-2396
• Visit the state MDS web site:
http://www.dads.state.tx.us/providers/MDS/
(Check out The MDS Mentor! & Sign up for emails)
80

81. FINAL THOUGHTS
“When All Else Fails, Read The Instructions”
Ralph Waldo Emerson, Poet, 1803-1882
“If you don't have time to do it right, when will you
have time to do it over?”
John Wooden, American Coach, 1910-2010
81