Review Other MDS Changes 9/29/2019

Changes to the MDS for October 2019 Chapter 2 This chapter has been extensively revised for this year’s manual. Due to the scope of the revisions, individual changes have not been recorded and tracked in this Change Table. Users are encouraged to review the chapter in its entirety. Chapter 3, Section C 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. As such, only in the case of PPS assessments, staff may complete the Staff Assessment for Mental Status for an interviewable 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.

Changes to the MDS for October 2019 Section GG 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). 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. 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. GG0110 Prior Device Use GG0110C, Mechanical lift, includes sit-to-stand, stand assist, stair lift, and full-body-style lifts.

Section I Primary Diagnosis #14 eliminated I0020B is now for the primary diagnosis code on each PPD MDS. Indicate the resident’s primary medical condition category that best describes the primary reason for the Medicare Part A stay; then proceed to I0020B and enter the International Classification of Diseases (ICD) code for that condition, including the decimal. 9/29/2019

ACTION PLAN Accurate identification of the Primary Diagnosis ICD-10-CM Official Guidelines for Coding and Reporting FY 2019 Page 107 of 120 Section II. Selection of Principal Diagnosis The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” Since that time the application of the UHDDS definitions has been expanded to include all non-outpatient settings (acute care, short term, long term care and psychiatric hospitals; home health agencies; rehab facilities; nursing homes, etc). The UHDDS definitions also apply to hospice services (all levels of care). In determining principal diagnosis, coding conventions in the ICD-10-CM, the Tabular List and Alphabetic Index take precedence over these official coding guidelines. (See Section I.A., Conventions for the ICD-10-CM)

Section J2100 Recent Surgery Requiring Active SNF Care 1. Ask the resident and his or her family or significant other about any surgical procedures that occurred during the inpatient hospital stay that immediately preceded the resident’s Part A admission. 2. Review the resident’s medical record to determine whether the resident had major surgery during the inpatient hospital stay that immediately preceded the resident’s Part A admission. Medical record sources include medical records received from facilities where the resident received health care during the inpatient hospital stay that immediately preceded the resident’s Part A admission, the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available. Medical record sources include medical records received from facilities where the resident received health care during the inpatient hospital stay that immediately preceded the resident’s Part A admission, the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available. Check the following information sources in the medical record for the last 30 days to identify “active” surgeries: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor’s orders, consults and official diagnostic reports, and other sources as available. 9/29/2019

Section J2100 Identify recent surgeries: The surgeries in this section must have been documented by a physician (nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 30 days and must have occurred during the inpatient stay that immediately preceded the resident’s Part A admission. • Medical record sources for recent surgeries include progress notes, the most recent history and physical, transfer documents, discharge summaries, diagnosis/problem list, and other resources as available. • Although open communication regarding resident information between the physician and other members of the interdisciplinary team is important, it is also essential that resident information communicated verbally be documented in the medical record by the physician to ensure follow-up. • Surgery information, including past history obtained from family members and close contacts, must also be documented in the medical record by the physician to ensure validity and follow-up.

Section J2100 2. Determine whether the surgeries require active care during the SNF stay: Once a recent surgery is identified, it must be determined if the surgery requires active care during the SNF stay. Surgeries requiring active care during the SNF stay are surgeries that have a direct relationship to the resident’s primary SNF diagnosis, as coded in I0020B. • Do not include conditions that have been resolved, do not affect the resident’s current status, or do not drive the resident’s plan of care during the 7-day look-back period, as these would be considered surgeries that do not require active care during the SNF stay. • Check the following information sources in the medical record for the last 30 days to identify “active” surgeries: transfer documents, physician progress notes, recent history and physical, recent discharge summaries, nursing assessments, nursing care plans, medication sheets, doctor’s orders, consults and official diagnostic reports, and other sources as available.

Section J2100 In the rare circumstance of the absence of specific documentation that a surgery requires active SNF care, the following indicators may be used to confirm that the surgery requires active SNF care: The inherent complexity of the services prescribed for a resident is such that they can be performed safely and/or effectively only by or under the general supervision of skilled nursing. For example: — The management of a surgical wound that requires skilled care (e.g., managing potential infection or drainage). — Daily skilled therapy to restore functional loss after surgical procedures. — Administration of medication and monitoring that requires skilled nursing.

Generally, major surgery for item J2100 refers to a procedure that meets the following criteria: 1. the resident was an inpatient in an acute care hospital for at least one day in the 30 days prior to admission to the skilled nursing facility (SNF), and 2. the surgery carried some degree of risk to the resident’s life or the potential for severe disability. Recommended: Get operative reports for accurate description 9/29/2019

Section K Section K : When not a resident Removed for Mechanically Altered Diet and intake via parenteral/enteral Feedings. 9/29/2019

Section O Section O Respite Care removed

Section O Finally, when coding for isolation, the facility should review the resident’s status and determine if the criteria for a Significant Change of Status Assessment (SCSA) is met based on the effect the infection has on the resident’s function and plan of care Regardless of whether the resident meets the criteria for an SCSA, a modification of the resident’s plan of care will likely need to be completed.

documented in the resident’s medical record, and Code only medically necessary therapies that occurred after admission/readmission to the nursing home that were : ordered by a physician (physician’s assistant, nurse practitioner, and/or clinical nurse specialist as allowable under state licensure laws) based on a qualified therapist’s assessment (i.e., one who meets Medicare requirements or, in some instances, under such a person’s direct supervision) and treatment plan, documented in the resident’s medical record, and care planned and periodically evaluated to ensure that the resident receives needed therapies and that current treatment plans are effective. Therapy treatment may occur either inside or outside of the facility. 1. Individual minutes - record the total number of minutes this therapy was administered to the resident individually since the start date of the resident's most recent Medicare Part A stay (A2400B). 9/29/2019

Section O - 34 Item Rationale Health-related Quality of Life Maintaining as much independence as possible in activities of daily living, mobility, and communication is critically important to most people. Functional decline can lead to depression, withdrawal, social isolation, breathing problems, and complications of immobility, such as incontinence and pressure ulcers/injuries, which contribute to diminished quality of life. The qualified therapist, in conjunction with the physician and nursing administration, is responsible for determining the necessity for, and the frequency and duration of, the therapy services provided to residents.

PDPM Modes of Therapy Group Therapy plus Concurrent Therapy will be limited to 25% of total minutes per discipline Group and Concurrent minutes will be counted in full rather than one-quarter and one-half respectively as in RUGs-IV PPS End of Stay Assessment will monitor therapy utilization A non-fatal error warning will appear on the Validation Report if the 25% amount is exceeded 9/29/2019

Modes of Therapy Modes of Therapy A resident may receive therapy via different modes during the same day or even treatment session. These modes are individual, concurrent and group therapy. When developing the plan of care, the therapist and assistant must determine which mode(s) of therapy and the amount of time the resident receives for each mode and code the MDS appropriately. The therapist and assistant should document the reason a specific mode of therapy was chosen as well as anticipated goals for that mode of therapy. For any therapy that does not meet one of the therapy mode definitions below, those minutes may not be counted on the MDS. The therapy mode definitions must always be followed and apply regardless of when the therapy is provided in relationship to all assessment windows (i.e., applies whether or not the resident is in a look-back period for an MDS assessment).

Modes of therapy for Medicare Part A Individual Therapy - The treatment of one resident at a time. The resident is receiving the therapist’s or the assistant’s full attention . Concurrent Therapy - The treatment of 2 residents, who are not performing the same or similar activities, at the same time, regardless of payer source, both of whom must be in line-of-sight of the treating therapist or assistant . Group Therapy - The treatment of 4 residents, regardless of payer source, who are performing the same or similar activities, and are supervised by a therapist or assistant who is not supervising any other individuals. Medicare Part B The treatment of two or more residents who may or may not be performing the same or similar activity, regardless of payer source, at the same time is documented as group treatment

Section X X0570: Optional State Assessment (A0300A/B on existing record to be modified/inactivated)

Section Z The HIPPS code is comprised of the PDPM case mix code, which is calculated from the assessment data. The first four positions of the HIPPS code contain the PDPM classification codes for each PDPM component to be billed for Medicare reimbursement, followed by an indicator of the type of assessment that was completed. See the next to last page of the PDPM Estimator for more information about the HIPPS code for PDPM. 9/29/2019

Z0100 Medicare Part A Billing – HIPPS Code Health Insurance Prospective Payment System code is comprised of the PDPM case mix code, which is calculated from the assessment data. The first four positions of the HIPPS code contain the PDPM classification codes for each PDPM component to be billed for Medicare reimbursement, followed by an indicator of the type of assessment that was completed. Under PDPM, the first position represents the Physical Therapy/Occupational Therapy (PT/OT) Payment Group, the second position represents the Speech Language Pathology (SLP) Payment Group, t the third position represents the Nursing Payment Group, the fourth position represents the Non-therapy Ancillary (NTA) Payment Group, and the fifth position represents the Assessment Indicator (AI) code indicating which type of assessment was completed 9/29/2019