MDS Essentials: Sections GG and K.

MDS Essentials: Sections GG and K

Faculty Disclosures I have no financial relationships to disclose
I have no conflicts of interests to disclose I will not promote any commercial products or services All Planning Committee members, content reviewers, authors, and presenters have been evaluated for conflicts of interest and there are not any to disclose.

Educational Activity Completion and CE Disclosure
Requirements for Successful Completion 1.25 contact hours will be awarded for this continuing nursing education activity. Criteria for successful completion includes attendance for at least 80% of the entire event. Partial credit may not be awarded. Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services. American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. *AAPACN d/b/a American Association of Nurse Assessment Coordination (AANAC)

Content RAI User’s Manual Chapter 3 Section GG and K Intent Rationale
Basic coding instructions The content for todays training comes from the RAI users manual, chapter 3. The MDS essentials course provides an introduction to section GG and K and for that reason much of the content does comes directly from the RAI users manual. Understanding how to use the RAI manual is key for anyone who is new to MDS coding – we will be reviewing the intent, rationale and basic coding instructions. We will also be covering some coding tips and examples as we work our way through these items. So lets get started with section GG

Section GG SECTION GG: FUNCTIONAL ABILITIES AND GOALS
Intent: This section includes items about functional abilities and goals. It includes items focused on prior function, admission performance, discharge goals, and discharge performance. Functional status is assessed based on the need for assistance when performing self-care and mobility activities If you have some experience or history with the MDS, you may know that section GG was new to the MDS as of Oct 1st The items in this section were introduced to allow for the collection of data for the quality reporting program measures from the IMPACT Act. IMPACT stands for Improving Medicare Post-acute transformation act and was passed by congress in This act requires the submission of standardized data from Post acute care settings, which includes the section GG information that is collected from the MDS for skilled nursing facilities. Section GG began with data collection for the SNF QRP measure, Admission and discharge functional assessment and a care plan that addresses function. This measure utilizes Section GG data and requires that at least one goal is set in column 2 of self-care or mobility. In oct 2018, section GG significantly grew to provide data for four new Section GG SNF QRP Measures, THOSE ARE: Change in self care score, change in mobility score, Discharge self care score and discharge mobility score. The reason this is important, is because there is a penalty if you do not submit the information required to calculate the program measures. For these and the other MDS based SNF QRP measures, the data is collected when the MDS is submitted to the QIES ASAP data base. If the SNF fails to submit at least 80% of the data required to calculate these measures, the SNF may receive an 2 percent reduction to their Medicare Annual Payment Update for the specified payment year. Also, Since the IMPACT Act applies to Original Medicare only, the section GG items also apply to Original Medicare only.

Section GG and Function
Section GG focuses on 3 areas: Resident’s prior function (GG0100, GG0110) Resident’s self-care (GG0130) Resident’s mobility (GG0170) Section GG assesses: Resident’s admission performance; Resident’s discharge goals; and Resident’s performance at the time of discharge

Section GG Assessment Types
Since Section GG only applies to traditional Medicare part A, it is only completed on the 5-day MDS and on the Part A PPS Discharge Assessment. 

Prior function and device use Admission Performance Discharge Goals

Prior function and device use Admission Performance Discharge Goals Section GG Discharge Performance

Section GG GG0100 Prior Functioning Everyday Activities
Key point this slide: Prior to current illness, exacerbation, or injury

Coding scale just for GG0100
Coding GG0100 Coding scale just for GG0100 Review scale: Coding tip: If no information about the resident’s ability is available after attempts to interview the resident or his or her family and after reviewing the resident’s medical record, code as 8, Unknown. If no information about the resident’s ability is available code as 8, unknown

Coding GG0100 Task Descriptions
Review item descriptions carefully to fully understand what tasks are to be coded

GG0100 Example for prior functioning for self-care (GG0100A)
Mr. T was admitted to an acute care facility after sustaining a stroke and subsequently admitted to the SNF for rehabilitation. Prior to the stroke, Mr. T was independent in eating and using the toilet; however, Mr. T required assistance for bathing and putting on and taking off his shoes and socks. The assistance needed was due to severe arthritic lumbar pain upon bending, which limited his ability to access his feet How would you code GG0100A, prior functioning for self-care? Answer and rationale on next slide

GG0100 Example for prior functioning for self-care (GG0100A)
Mr. T was admitted to an acute care facility after sustaining a stroke and subsequently admitted to the SNF for rehabilitation. Prior to the stroke, Mr. T was independent in eating and using the toilet; however, Mr. T required assistance for bathing and putting on and taking off his shoes and socks. The assistance needed was due to severe arthritic lumbar pain upon bending, which limited his ability to access his feet Coding: GG0100A would be coded 2, Needed Some Help Rationale: Mr. T needed partial assistance from a helper to complete the activities of bathing and dressing. While Mr. T did not need help for all self-care activities, he did need some help. Code 2 is used to indicate that Mr. T needed some help for self-care Review example

Same information sources as GG0100
Coding based on an assessment of the resident’s function PRIOR to the current illness, exacerbation, or injury Same information sources as GG0100

GG0110 Any – mechanical, sit-to-stand, stand assist, full body lifts
All types

Section GG- Admission Performance
1 1 1 2 1 8 There is a strong correlation between section GG and Section A, item A2400. When you are collecting the self performance and mobility data for admission performance on the 5 day MDS, the data collection period is the first 3 days of the Medicare stay. The start of the Medicare stay is coded at A2400B and this will equal day 1 of the 3 day assessment period for admission performance. Only required for traditional Medicare SNF Part A stays

Admission: The 5-Day PPS assessment (A0310B = 01) is the first Medicare-required assessment to be completed when the resident is admitted for a SNF Part A stay Code the resident’s functional status based on a clinical assessment of the resident’s performance that occurs soon after the resident’s admission Must be completed within the first three days (3 calendar days) of the Medicare Part A stay, starting with the date in A2400B, Start of Most Recent Medicare Stay Functional status should reflect the admission baseline status and are to be based on an assessment Should reflect the resident’s status prior to any benefit from interventions Review slide and add: 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. Even if treatment started on the day of admission, a baseline functional status assessment can still be conducted. Treatment should not be withheld in order to conduct the functional assessment.

Section GG- Discharge Performance
Discharge: The Part A PPS Discharge assessment is required to be completed when the resident’s Medicare Part A Stay ends Documented in A2400C, End of Most Recent Medicare Stay Standalone assessment when the resident’s Medicare Part A stay ends, but the resident remains in the facility 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) 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 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 Review slide

Section GG- Admission and Discharge Performance
Admission Performance (column 1) and Discharge Performance (column 3) have the same coding instructions If the activity for self care or mobility was not attempted during the first 3 days of the Medicare stay, you will use of the activity was not attempted reasons- which we will also be covering in more detail shortly

Section GG- Discharge Goals
Column 2. Discharge Goal We will come back to this… The discharge goals are only completed on the 5-day MDS. However, since the coding instructions are the same for Columns 1 and 3 for the admission performance and discharge performance,, we are going to skip column 2 for just a moment

Steps for Assessment GG0130 and GG0170 Admission and Discharge Performance
Assess the resident’s self-care and mobility performance based on direct observation, as well as the resident’s self-reports and reports from qualified clinicians, care staff, or family documented in the resident’s medical record during the 3-day assessment period. CMS anticipates that an interdisciplinary team of qualified clinicians is involved in assessing the resident during the 3-day assessment period. Qualified clinician: Healthcare professionals practicing within their scope of practice and consistent with Federal, State, and local law and regulations Resident should be allowed to perform activities as independently as possible, as long as they are safe Review slide; Also note CMS Definition of qualified clinician QUALIFIED CLINICIAN Healthcare professionals practicing within their scope of practice and consistent with Federal, State, and local law and regulations

For section GG a “helper” is defined as facility staff who are 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 such as hospice staff, nursing/certified nursing assistant students, etc. Helper is NOT family members or “sitters” hired by the family If a helper’s assistance is required because a resident’s performance is unsafe or of poor quality, only consider staff assistance when scoring according to the amount of assistance provided

Activities may be completed with or without assistive device(s) and not impact coding Admission functional assessment, when possible, should be conducted prior to the person benefitting from treatment interventions in order to determine a true baseline functional status on admission Refer to facility, Federal and State policies and procedure to determine which staff members may complete an assessment

Definition: Usual Performance
A resident’s functional status can be impacted by the environment or situations encountered at the facility Observing the resident’s interactions with others in different locations and circumstances is important for a comprehensive understanding of the resident’s functional status If the resident’s functional status varies, record the resident’s usual ability to perform each activity Do not record the resident’s best performance Do not record the resident’s worst performance Record the resident’s usual performance

If there’s fluctuation in the performance of activities during the three-day assessment: the performance wouldn’t be the worst, and it wouldn’t be the best, but it would be what’s “usual” for that individual When we code section G self performance we have to try to figure out the rule of three, the exceptions and use the algorithm. But for section GG, we just have to identify what the residents USUSAL performance … no RULE of three! And again, self performance for section GG wouldn’t be the worst, and it wouldn’t be the best, but it would be what’s “usual”

Coding Instructions GG0130 & GG0170
To code resident’s usual performance and discharge goal(s), use the “six-point scale” OR use 1 of the 4 “activity was not attempted” codes Code Description 06. Independent: Resident completes the activity by him/herself with no assistance from a helper 05. Setup or clean-up assistance: helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity but NOT during the activity 04. Supervision or touching assistance: helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity. Help may be provided throughout or intermittently

code Description 03. Partial/moderate assistance: If helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort 02. Substantial/maximal assistance: If helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort 01. Dependent: If the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two (2) or more helpers is required for the resident to complete the activity More than half or less than half – what if effort seems be half? Use your clinical judgment

If activity was not attempted, code reason 07. Resident refused 09. Not applicable – Not attempted and resident did not perform prior to current illness, exacerbation, or injury 10. Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints) 88. Not attempted due to medical condition or safety concerns CMS stated that allowing staff to use the “activity was not attempted reasons” will reduce the number of dashes used in GG

Section GG0130: Self-Care Functional Abilities
GG0130A. Eating The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Includes modified food consistency GG0130B. Oral hygiene The ability to use suitable items to clean teeth. Dentures (if applicable): The ability to insert and remove dentures into and from the mouth, and manage denture soaking and rinsing with use of equipment GG0130C. Toileting hygiene The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment Review slide Add to Toileting hygiene: 3 tasks to assess: 1) perineal hygiene; 2) adjust clothes before; 3) adjust clothes after voiding or having a bowel movement

GG0130: Self-Care Functional Abilities
GG0130E. Shower/ bathe self The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower GG0130F. Upper body dressing The ability to dress and undress above the waist; including fasteners, if applicable. (Includes orthotic/prosthesis) GG0130G. Lower body dressing The ability to dress and undress below the waist, including fasteners; does not include footwear. (Includes orthotic/prosthesis) GG0130H. Putting on/taking off footwear The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. (Includes orthotic/prosthesis) Coding Tips GG0310E. Shower/bathe self: Read entire description in order to code accurately Assessment can take place in a shower or bath, at a sink, or at the bedside (i.e., sponge bath) GG0130F. Upper body dressing: Includes bra, undershirt, button-down shirt, pullover shirt, dresses, sweatshirt, sweater, nightgown (NOT hospital gown), and pajama top Other examples: thoracic-lumbar-sacrum orthosis (TLSO), abdominal binder, back brace, stump sock/shrinker, neck support, hand or arm prosthetic/orthotic Helper assistance with buttons and/or fasteners is considered touching assistance GG0310G. Lower body dressing: Includes underwear, incontinence brief, slacks, short, capri pants, pajama bottoms, and skirts Other examples: knee brace, elastic bandage, stump sock/shrinker, lower-limb prosthesis GG0130G. Putting on/taking off footwear Includes socks, shoes, boots, and running shoes Other examples: ankle-foot orthosis (AFO), elastic bandages, foot orthotics, orthopedic walking shoes, compression stocking (on and off over foot) Amputees may not have footwear as shoe attached (pg. GG-23)

Section GG0170: Mobility Functional Abilities
GG0170A. Roll left and right The ability to roll from lying on back to left and right side, and return to lying on back on the bed GG0170B. Sit to lying The ability to move from sitting on side of bed to lying flat on the bed GG0170C. Lying to sitting on side of bed The ability to move from lying on the back to sitting on the side of the bed with feet flat on the floor, and with no back support GG0170D. Sit to stand The ability to come to a standing position from sitting in a chair, or wheelchair, or on the side of the bed GG0170E. Chair/bed-to-chair transfer The ability to transfer to and from a bed to a chair (or wheelchair) GG0170F. Toilet transfer The ability to safely get on and off a toilet or commode

GG0170G. Car transfer The ability to transfer in and out of a car or van on the passenger side. Does not include the ability to open/close door or fasten seat belt GG0170I. Walk 10 feet Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space. If admission or discharge performance coded 07, 09, 10, or Skip to GG0170M, 1 step (curb) GG0170J. Walk 50 feet w/ 2 turns Once standing, the ability to walk at least 50 feet and make two 90-degree turns GG0170K. Walk 150 feet Once standing, the ability to walk at least 150 feet in a corridor or similar space GG0170L. Walk 10 ft on uneven surfaces The ability to walk 10 feet on uneven or sloping surfaces (indoor or outdoor), such as turf or gravel Review slide Add coding tips: Walking items do not need to occur in one session Mobility items do not consider parallel bars

1 step (curb) The ability to go up and down a curb and/or up and down one step. If admission or discharge performance coded 07, 09, 10, or Skip to GG0170P, Picking up object GG0170N. 4 steps The ability to go up and down 4 steps with or without a rail. If admission or discharge performance coded 07, 09, 10, or Skip to GG0170P, Picking up object GG0170O. 12 steps The ability to go up and down 12 steps with or without a rail GG0170P. Picking up object The ability to bend/stoop from a standing position to pick up a small object, such as a spoon, from the floor. Could also occur if the resident is upright in a wheelchair

Skip pattern used for the question “Does the resident use a wheelchair and/or scooter?” If no, skip: GG0170R. Wheel 50 feet with two turns GG0170S. Wheel 150 feet GG0170R. Wheel 50 feet with two turns Once seated in wheelchair/scooter, the ability to wheel at least 50 feet and make two turns GG0170S. Wheel 150 feet Once seated in wheelchair/scooter, the ability to wheel at least 150 feet in a corridor or similar space Indicate the type of wheelchair or scooter used Follow-up question to each Manual Motorized

Coding Tips – Admission/Discharge Performance
If two or more helpers are required to assist the resident to complete the activity, code 01, Dependent Code based on the resident’s performance. Do not record the staff’s assessment of the resident’s potential capability to perform the activity If a resident does not perform oral hygiene during therapy, determine the resident’s abilities based on performance on the nursing care unit To clarify your own understanding of the resident’s performance, ask probing questions to staff about the resident

Examples of Probing with Staff
Oral hygiene: Example of a probing conversation between a nurse and a CNA to determine a resident’s oral hygiene routine Nurse: “Does Mrs. K help with brushing her teeth?” Certified nursing assistant: “She can help clean her teeth.” Nurse: “How much help does she need to brush her teeth?” Certified nursing assistant: “She usually gets tired after starting to brush her upper teeth. I have to brush most of her teeth” Code = Substantial/maximal assistance (more than half of the effort)

Examples – please also check RAI Manual
Eating: Ms. S has multiple sclerosis, affecting her endurance and strength. Ms. S prefers to feed herself as much as she is capable. During all meals, after eating three-fourths of the meal by herself, Ms. S usually becomes extremely fatigued and requests assistance from the CNA to feed her the remainder of the meal Lets look at just one more example Lets review one example: Eating: Ms. S has multiple sclerosis, affecting her endurance and strength. Ms. S prefers to feed herself as much as she is capable. During all meals, after eating three-fourths of the meal by herself, Ms. S usually becomes extremely fatigued and requests assistance from the CNA to feed her the remainder of the meal. Consider how you would code this example

Examples – please also check RAI Manual
Eating: Ms. S has multiple sclerosis, affecting her endurance and strength. Ms. S prefers to feed herself as much as she is capable. During all meals, after eating three-fourths of the meal by herself, Ms. S usually becomes extremely fatigued and requests assistance from the CNA to feed her the remainder of the meal Coding: GG0130A. Eating would be coded 03, Partial/moderate assistance Rationale: The CNA provides less than half the effort for the resident to complete the activity of eating for all meal Coding: GG0130A. Eating would be coded 03, Partial/moderate assistance. Rationale: The CNA provides less than half the effort for the resident to complete the activity of eating for all meal

GG0130 Examples of Probing with Staff
Oral hygiene: Example of a probing conversation between a nurse and a CNA to determine a resident’s oral hygiene score Nurse: “Does Mrs. K help with brushing her teeth?” Certified nursing assistant: “She can help clean her teeth” Nurse: “How much help does she need to brush her teeth?” Certified nursing assistant: “She usually gets tired after starting to brush her upper teeth. I have to brush most of her teeth” The RAI also provides Examples of how Probing Staff can help clarify coding Here is am example of probing to better understand oral hygiene Nurse: “Does Mrs. K help with brushing her teeth?” Certified nursing assistant: “She can help clean her teeth.” Nurse: “How much help does she need to brush her teeth?” Certified nursing assistant: “She usually gets tired after starting to brush her upper teeth. I have to brush most of her teeth.” You would Code 2 substantial/maximal assist ( the helper did more than ½ the effort) Code 02 = Substantial/maximal assistance (more than half of the effort)

Examples – More help in RAI Manual
Eating: Mr. R is unable to eat by mouth since he had a stroke one week ago. He receives nutrition through a gastrostomy tube (G-tube), which is administered by nurses The RAI also has examples of when to use the activity did not occur reasons. Lets review an example for eating: Mr. R is unable to eat by mouth due to his medical condition. He receives nutrition through a gastrostomy tube (G-tube), which is administered by nurses.

Examples – More help in RAI Manual
Eating: Mr. R is unable to eat by mouth since he had a stroke one week ago. He receives nutrition through a gastrostomy tube (G-tube), which is administered by nurses Coding: GG0130A. Eating would be coded 88, Not attempted due to medical condition or safety concerns Rationale: The resident does not eat or drink by mouth at this time due to his recent-onset stroke. Assistance with G-tube feedings is not considered when coding this item Coding: GG0130A. Eating would be coded 88, Not attempted due to medical condition or safety concerns. Rationale: The resident does not eat by mouth at this time. Assistance with G-tube feedings is not considered when coding the item Eating.

Section GG- Discharge Goals
Column 2. Discharge Goal Now for Discharge goals…

Discharge Goals for GG0130/GG0170
Utilizing the Safety and Quality of Performance Scale 06 = Independence 05 = Setup or Clean Up 04 = Supervision / Touching 03 = Partial/Moderate 02 = Substantial/maximal 01 = Dependent For SNF QRP compliance, a minimum of one discharge goal must be coded Facilities may choose to complete more than one goal Code using six-point scale or use one of the “activity not attempted” codes The use of a dash “-” is permissible for any goals that were not coded Dashes in column 3, Discharge Goals, will not count against the SNF QRP compliance, as long as at least one goal was established Activity did not occur reasons: 07 = Resident refused 09 = Not applicable 10 = Not attempted due to environmental limitations 88 = Not attempted due to medical concern or safety concerns

GG0130 – GG0170 Discharge Goal: Coding Tips for Column 2
Licensed qualified clinicians can establish a resident’s discharge goal(s) at the time of admission based on the resident’s prior medical condition, admission assessments, discussions with the resident and family, professional judgment, profession’s practice standards, expected treatments, resident motivation, anticipated length of stay, and the residents discharge plans Goals should be established as part of the resident care plan Lets discuss how the goal or goals are established for the resident. The RAI directs us that Licensed clinicians can establish a resident’s discharge goal or goals at the time of admission based on the 5-day PPS assessment, discussions with the resident and family, professional judgment, and the professional’s standard of practice. These Goals should be established as part of the resident’s care plan

Discharge Goals for GG0130/GG0170
IDT determines the resident is expected to make gains in function by discharge Expected to Improve IDT determines the resident is not expected to progress to a higher level of functioning during the Medicare Part A stay Not Expected to Improve IDT determines decline in function is anticipated and unavoidable Expected to Decline While many residents will have a clear expectation to improve in function and the goal or goals will be set based o the expected gains. There may be times when the resident is not expected to improve and a goal may be to maintain functional status and prevent declines. However, There may also be times when there is an expected decline that is unavoidable and a decline in function may be represented in the goals.

Column 2. Discharge Goal: Coding Tips
Example: GG0170K-Walk 150 Feet Mr. Jones was admitted to the SNF after a fall with a humeral fracture. He used a walker prior to his fall and that is his baseline activity Section GG0170K column 1 Admission Performance is 03: Partial/Moderate assist His goal for his skilled stay is to regain ability to walk independently with the walker again. Therapy and nursing agree this is a realistic goal for Mr. Jones 3 Section GG0170K column 1 Admission Performance might be a 03: Partial/Moderate assist, but his goal for his skilled stay is to get back to his prior level using his walker independently, so column 2 Discharge Goal, would be coded as a 06 because he hopes to be become independent again

Column 2. Discharge Goal: Coding Tips
Example: GG0170K-Walk 150 Feet Mr. Jones was admitted to the SNF after a fall with a humeral fracture. He used a walker prior to his fall and that is his baseline activity Section GG0170K column 1 Admission Performance is 03: Partial/Moderate assist His goal for his skilled stay is to regain ability to walk independently with the walker again. Therapy and nursing agree this is a realistic goal for Mr. Jones Column 2 Discharge Goal, would be coded as a 06 because he hopes to be become independent again 3 6 Section GG0170K column 1 Admission Performance might be a 03: Partial/Moderate assist, but his goal for his skilled stay is to get back to his prior level using his walker independently, so column 2 Discharge Goal, would be coded as a 06 because he hopes to be become independent again

Little break… I think we deserve a little break after section GG.. So lets just take a couple seconds to let all that sink in…

Little break… Because we need to get energized to cover Section K!!

Section K SECTION K: SWALLOWING/NUTRITIONAL STATUS
Intent: The items in this section are intended to assess the many conditions that could affect the resident’s ability to maintain adequate nutrition and hydration. This section covers swallowing disorders, height and weight, weight loss, and nutritional approaches. The assessor should collaborate with the dietitian and dietary staff to ensure that items in this section have been assessed and calculated accurately Alright.. So here we go. SECTION K is SWALLOWING and NUTRITIONAL STATUS The intent of this section is to assess the many conditions that could affect the resident’s ability to maintain adequate nutrition and hydration. In this section we will cover swallowing disorders, height and weight, weight loss, and nutritional approaches.

K0100 The first item in section K swallowing disorders documented at K0100. The rationale for this item is that the ability to swallow safely can be affected by disease processes and functional decline. Swallowing problems can also result in choking and aspiration, which can increase the risk of malnutrition, dehydration and aspiration pneumonia. Rationale The ability to swallow safely can be affected by many disease processes and functional decline Alterations in the ability to swallow can result in choking and aspiration, which can increase the resident’s risk for malnutrition, dehydration, and aspiration pneumonia

K0100 Steps for Assessment Ask the resident if he or she has had any difficulty swallowing during 7-day look-back period Observe resident during meals and at other times when eating, drinking, or swallowing Interview staff on all shifts Review the medical record, including nursing, physician, dietician, and speech language pathologist notes Check all that apply (even if occurred only once in look-back period) The steps for assessment are to ask the resident about difficulty with swallowing during the 7-day lookback period and observe the resident during meals and when eating or swallowing. Also talk to the staff on all shifts and review the medical record. You will check all that apply- K0100A documents the loss of liquids/solids from mouth when eating or drinking, this is coded When the resident has food or liquid in his or her mouth, the food or liquid dribbles down chin or falls out of the mouth. • K0100B, is coded if the resident is Holding food in mouth or cheeks for prolonged periods of time, this is sometimes labeled pocketing or food is left in mouth because resident failed to empty mouth completely. • K0100C is coded if the resident is noted to be coughing or choking during meals or when swallowing medications. The resident may cough or gag, turn red, have more labored breathing, or have difficulty speaking when eating, drinking, or taking medications. The resident may frequently complain of food or medications “going down the wrong way.” • K0100D is coded if the resident expresses any complaints of difficulty or pain with swallowing. Resident may also refuse food because it is painful or difficult to swallow. A key coding tip here is that you Do not code a swallowing problem when interventions have been successful in treating the problem. For example, if the resident is currently on thickened liquids due to coughing or choking on regular liquids, but the resident has not experienced any coughing or choking during the look back period because of the intervention of thickened liquids– you would NOT code it on this assessment.

K0200 K0200 records the resident height and weight. The rationale to collecting this information is that a diminished nutritional or hydration status can lead to debility and adversely affect health, safety and quality of life. Rationale Diminished nutritional and hydration status can lead to debility that can adversely affect health and safety as well as quality of life

K0200 Steps for Assessment: Height
Base height on the most recent height since admission/entry or reentry Measure height consistently over time in accordance with facility policy and procedure For subsequent assessment, check the medical record. If the last height recorded was more than one year ago, measure and record the resident’s height again When documenting the residents height, this is the most recent height, rounded to the nearest whole inch, since admission or reentry to the facility and on subsequent assessment use the most recent height within a year. If the last recorded height is more than a year ago, measure the residents height again. Be sure to check this during the assessment period, so the new height measured is within the lookback period. You will need to follow your facility policy and procedure for measuring height consistently over time Record height to the nearest whole inch Use mathematical rounding to nearest whole inch

K0200 Steps for Assessment: Weight
Base weight on most recent measure in the last 30 days Measure weight consistently over time in accordance with facility policy and procedure For subsequent assessments, check the medical record and enter the weight taken within 30 days of the ARD for this assessment If the last recorded weight was taken more than 30 days prior to the ARD, weigh the resident again If the resident weight was taken more than once during the preceding month, record the most recent weight The residents weight, recorded at K0200B, is based on the most recent weight in the last 30 days. Again follow your facility policy and procedure to consistently measure wt over time– this would include which scale is used, are shoes on or off, or if a wheelchair scale is used, are foot pedals left on or off, as well as time of the day and other considerations to ensure the accuracy and consistency of the measurement Another consideration is that often times residents are weighed only monthly, while a resident may have a wt each calendar month, if a wt is taken the first week of June and the last week of July, there may be 6 weeks between actual wts, not 30 days If the last recorded weight is more than 30 days prior to the ARD, weigh the resident again. Complete this during the look back period, so the resident has a current wt to use on this MDS. However if the resident has more than 1 wt during the prior 30 days, use the wt that is most recent.

K0200 Record the residents weight to the nearest whole pound
Use mathematical rounding If a resident cannot be weighed, for example because of extreme pain, immobility, or risk of pathological fractures, use the standard no-information code (-) and document rationale on the resident’s medical record Weight is recorded by using mathematical rounding to the nearest whole pound. There are times when a resident cannot be weighed, this may be due to a resident in extreme pain or with a high risk of pathological fractures. If the weight cannot be obtained in the 30 days prior to the ARD, code a dash to indicate there is no information and document the reason in the medical record.

K0300 Rationale Weight loss can result in debility and adversely affect health, safety and quality of life For persons with morbid obesity, controlled and careful weight loss can improve mobility and health status For persons with a large volume (fluid) overload, controlled and careful diuresis can improve health status K0300 documents wt loss of either 5% in the last month or 10% in the last 6 months. The rationale for this item is that wt loss can cause debility and adversely affect health, safety and quality of life, however for resident with morbid obesity, controlled wt loss can improve mobility and health status And Residents with fluid overload can also benefit from controlled wt loss through careful diuresis.

K0300 This item compares the resident’s weight in the current observation period with his or her weight at two snapshots in time At a point closest to 30-days preceding the current weight At a point closest to 180-days preceding the current weight Steps for assessment Identify weight from current observation period and from 30 days prior to current weight If current weight is less than weight 30 days ago, calculate percentage of weight loss We determining if a resident had a wt loss you are comparing the residents current weight at two snapshots in time. First you identify the residents wt at a point closest to 30 days preceding the current wt. Keep in mind that the current wt used may have a different date than the ARD, so you are first identifying the current wt in the 30 days preceding the ARD and then comparing that current wt to the wt that is closest to 30 days preceding the current wt. Next you identify the residents wt at a point closest to 180 days preceding the current wt. If the residents current wt has decreased from the wt 30 or 180 days ago, this indicates that there has been a wt loss and you proceed with the calculations to determine if there has been a 5% or 10% wt loss.

K0300 30-day weight loss calculation
Multiply the 30 days ago by 0.95 to identify 5% threshold If current weight is equal to or less than threshold, the resident has lost more than 5% body weight To calculate for a 5% wt loss in 30 days, you multiple the weight that was identified at the snapshot in time 30 days preceding the current by 0.95, this gives you the 5% wt loss threshold. If the current weight is equal to or less than the threshold, the resident HAS had a 5% or more wt loss. Lets work through an example: 

165 lbs. x 0.95 = 156.75 lbs. (5% threshold)
K0300 30-day weight loss calculation Multiply the 30 days ago by 0.95 to identify 5% threshold If current weight is equal to or less than threshold, the resident has lost more than 5% body weight Example Weight 30 days ago = 165 lbs. 165 lbs. x 0.95 = lbs. (5% threshold) The resident weight 30 days ago was 165 lbs, you multiple 165 by .95 to establish a threshold of lbs.

K0300 30-day weight loss calculation Multiply the 30 days ago by 0.95 to identify 5% threshold If current weight is equal to or less than threshold, the resident has lost more than 5% body weight Example Weight 30 days ago = 165 lbs. 165 lbs. x 0.95 = lbs. (5% threshold) Weight 30 days from current weight = 155 lbs. 155 lbs. < lbs. Resident has experienced a 5% weight loss The resident current wt on this MDS is 155lbs. Since this is less than the threshold, the resident has had a 5% or more wt loss in the last 30 days.

K0300 180-day weight loss calculation
Multiply weight 180 days ago by 0.90 to identify 10% threshold If current weight is equal to or less than threshold, the resident has lost more than 10% body weight The calculation for wt loss of 10% in the last 180 days is very similar. You multiply the weight 180 days ago by .90 to identify the 10% wt loss threshold. If the current weight is equal to or less than the threshold, the resident has had a 10% or more wt loss Lets work through an example 

K0300 180-day weight loss calculation Multiply weight 180 days ago by 0.90 to identify 10% threshold If current weight is equal to or less than threshold, the resident has lost more than 10% body weight Example Weight 180 days ago = 165 lbs. 165 lbs. x 0.90 = lbs. (10% threshold) The residents weight 180 days ago was 165 lbs, you multiple 165 x .90 to identify the wt loss threshold of lbs

K0300 180-day weight loss calculation Multiply weight 180 days ago by 0.90 to identify 10% threshold If current weight is equal to or less than threshold, the resident has lost more than 10% body weight Example Weight 180 days ago = 165 lbs. 165 lbs. x 0.90 = lbs. (10% threshold) Current Weight= 152 lbs. 152 lbs. > lbs. Resident has not experienced a 10% weight loss The residents current weight is 152 lbs. Since this wt is above the threshold, the resident has NOT experienced a 10% wt loss.

K0300 Coding instructions Code based on if resident had weight loss in either the last 30 days or the last 6 months Determine if resident was on a physician-prescribed weight-loss regimen When coding K0300, you not only have to identify if the resident had either the 5% or 10% wt loss, but also identify if the resident is on a physician prescribed wt loss regime. The RAI defines this as a wt reduction plan ORDERD by the physician with the CARE PLANNED Goal of wt reduction. It clarified that this planned wt loss may be due to calorie restriction diet and exercise or planned diuresis. The key is that the wt loss is intentional, this also indicates that this is known and care planned and not determined after wt loss has been identified.

K0310 Rationale Weight gain can result in debility and adversely affect health, safety and quality of life This item compares the resident’s weight in the current observation period with his or her weight at two snapshots in time At a point closest to 30-days preceding the current weight At a point closest to 180-days preceding the current weight The next item identifies a wt gain of 5% or 10% during the same snap shots in time. The rationale for this item is that wt gain can also result in debility and adversely affect health, safety and quality of life. You are again looking at the current wt recorded on this MDS and at a point closest to 30 days and 180 days preceding the current wt If the current wt is greater than either preceding wt, you will continue with the calculations to determine if there has been a 5% or 10% wt gain.

K0310 30-day weight gain calculation
Multiply weight 30 days ago by 1.05 to identify 5% threshold If current weight is equal to or more than threshold, the resident has gained more than 5% body weight The calculations are very similar to what we did with the wt loss. For the 30 day wt gain calculation, we multiply the weight 30 days ago by 1.05 to identify the threshold of a 5% wt gain. If the current weight is equal to or MORE than the threshold, the resident has gained 5% or more body wt 

K0310 30-day weight gain calculation Multiply weight 30 days ago by 1.05 to identify 5% threshold If current weight is equal to or more than threshold, the resident has gained more than 5% body weight Example Weight 30 days ago = 165 lbs. 165 lbs. x 1.05 = lbs. (5% threshold) The weight 30 days ago is 165 lbs, this is multiplied by 1.05 and a 5% wt gain threshold is established at lbs. 

K0310 30-day weight gain calculation Multiply weight 30 days ago by 1.05 to identify 5% threshold If current weight is equal to or more than threshold, the resident has gained more than 5% body weight Example Weight 30 days ago = 165 lbs. 165 lbs. x 1.05 = lbs. (5% threshold) Current Weight = 170 lbs. 170 lbs. < lbs. Resident has not experienced a 5% weight gain . The current weight on this MDS is 170 lbs. Since this wt is less than the threshold, the resident has NOT experienced a 5% wt gain in the last 30 days

K0310 180-day weight gain calculation
Multiply weight 180 days ago by 1.10 to identify 10% threshold If current weight is equal to or more than threshold, the resident has gained more than 10% body weight Lets review the 10% wt gain calculation Multiple the weight 180 days ago by 1.10 to establish the 10% wt gain threshold. If the current weight is equal to or greater than the threshold, the resident has experienced a 10% or more gain in body wt.

K0310 180-day weight gain calculation Multiply weight 180 days ago by 1.10 to identify 10% threshold If current weight is equal to or more than threshold, the resident has gained more than 10% body weight Example Weight 180 days ago = 165 lbs. 165 lbs. x 1.10 = lbs. (10% threshold) So if the residents weight 180 days ago was 165, this is multiplied by 1.10 and a 10% threshold is determined to be

K0310 180-day weight gain calculation Multiply weight 180 days ago by 1.10 to identify 10% threshold If current weight is equal to or more than threshold, the resident has gained more than 10% body weight Example Weight 180 days ago = 165 lbs. 165 lbs. x 1.10 = lbs. (10% threshold) Current weight = 183 lbs. 183 lbs. > lbs. Resident has experienced a 10% weight gain The residents current weight on this MDS is 183 lbs, since this is greater than the threshold, the resident has experienced a 10% wt gain in the last 180 days

K0310 Coding instructions Code based on if resident had weight gain in either the last 30 days or the last 6 months Determine if resident was on a physician-prescribed weight-gain regimen Just like when we coded wt loss, we must determine if the resident is on a physician prescribed wt gain regimen. You will code No if there has not been a wt gain or code YES if the resident had a wt gain for either 5% in 30 days OR 10% in 180 days, when coding YES, you must also indicated if the resident is on a physician prescribed wt gain regime.

K0510 The next item documents nutritional approaches during the last 7 days, including parental or IV feeding, tube feeding, mechanically altered diet or therapeutic diet Effective October 1, 2018, CMS does not require completion of Column 1 “while not a resident” for items K0510C “Mechanically altered diet” and K0510D “Therapeutic diet”, ; however, some States continue to require its completion. It is important to know your State’s requirements for completing these items. If your State does not require the completion of Column 1 for items K0510C and K0510D, use the standard “no information” code (a dash, “-”). Rationale Nutritional approaches that vary from the normal or rely on alternative methods can diminish an individual’s sense of dignity and self-work as well as diminish pleasure from eating

K0510 While the look back period is only the last 7 days, we are also going to document if the resident received these items while NOT a resident or while a resident. While not a resident is coded if the item was received BEFORE admission or entry into the facility AND within the last 7 days. 

K0510 While a resident documents if the item was received after admission or reentry to the facility AND within the last 7 days

K0510A. Parenteral/IV Feeding
Coding tips Parenteral/IV feedings may be included when there is supporting documentation that reflects the need for additional fluid intake specifically addressing a nutritional or hydration need Must be noted in the resident medical record according to state and internal facility policy Does not include: IV medications IV fluids used to: Reconstitute or dilute medications, routine part of operative or diagnostic procedure, administered solely as flushes, in conjunction with chemotherapy or dialysis Enteral feeding formulas There are some important coding tips that must be considered when coding K0510. First is that - IV fluids or total parenteral nutrition (TPN), must be administered for nutritional or hydration needs of the resident. They may be administered continuously or intermittently IV fluids in this section DOES NOT include IV medications, IV meds are coded in section O. You also do not include IV fluids used to reconstitute or dilute a medication, or if used as part of a operative or diagnostic procedures, if they are administered solely as flushes or in conjunction with chemo or dialysis. You also do not enteral feeding formulas under IV feedings.

K0510B. Feeding Tube Definitions
The RAI also provides definitions for the different nutritional approaches. While I am not going to read each definition here are some key points and coding tips : Feeding tubes include any type of tube that can deliver food, nutritional substances, fluid or medications directly into the GI system. 

When coding Mechanically altered diet, do not include the feeding formula used via tube feeding. This item does included mechanically altered diets such as soft solids, pureed foods, ground meats and thickened liquids 

A therapeutic diet is a diet that is ordered as an intervention as part of the treatment for a disease or clinical condition. This would include diets low in sodium, a diabetic diet or diet related to an allergy, such as a gluten free or peanut free diet. Also a nutritional supplement given as part of the treatment for a disease or condition does not constitute a therapeutic diet, but may be PART of a therapeutic diet. So supplements are only coded as therapeutic diet if they are administered as PART of a therapeutic diet. If a resident is receiving enteral feeding formula that is specifically altered to manage a health condition, such a enteral formulas specific to diabetics, the enteral formula would be coded both a feeding tube and therapeutic diet. The Key to coding K0510 is to identify all nutritional approaches the resident has received during the 7-day look back period and if the look-back period extends beyond the most recent entry or reentry into the facility, code the MDS if the resident received while not a resident or while a resident. Keep in mind that the resident may have received the intervention both while not and while a resident.

K0710 Ko710 documents the percent of intake by artificial route. The rationale for this item is that residents receiving nutrition from parental or IV feedings or from feeding tubes can have a diminished sense of dignity and self-worth and a diminished pleasure from eating When coding this item, you will be determining the total calories the resident received through parenteral or tube feeding and the total calories the resident received through oral and artificial routes. For fluids, you will determine the total fluids received by IV or tube feeding during the 7 day look back period. This item records the information in three columns, 1st While not a resident, which is prior to entry/reentry to the facility and within the last 7 days, the 2nd column is while a resident, which is after entry/reentry to the facility AND within the last 7 days and the 3rd Column documents the entire 7 days (both while and while not a resident) Effective Oct 1, CMS does not require completion of Column 1. While Not a Resident for items K0710A and K0710B; however, some States continue to require its completion. It is important to know your State’s requirements for completing these items. • If your State does not require the completion of Column 1 for this item, use the standard “no information” code (a dash, “-”) Rationale Nutritional approaches that vary from the normal, such as parental/IV or feeding tubes, can diminish an individual’s sense of dignity and self-worth as well as diminish pleasure from eating

Tube Cal/Total Cal x 100 = % of intake by tube
K0710A. Oral Tube Sun 500 2,000 Mon 250 2,250 Tues Wed 350 Thurs Fri Sat Total 2,450 15,000 Steps for Assessment: Review intake records to determine actual intake through parenteral or tube feeding routes Calculate proportion of total calories received through these routes To understand the coding instructions and steps for assessment, it may be easiest to work through an example. For K0710A, we are documenting the proportion of total calories the resident received through parenteral or tube feeding. to calculate this, we must have the total caloric intake from both oral and tube feeding. This resident was in the facility for the entire 7 days, so the column for while not a resident will be left blank or disabled by your software. Documentation shows the resident had an oral intake of 2,450 calories during the entire 7 day look back. Our documentation also shows 15,000 calories came from the tube feeding. To determine the proportion of calories that came from the tube feeding, we ADD the oral and tube calories together to establish the resident had a total of 17,450 calories in the look back period. Next divide the calories only from the tube by the total. 15,000 tube calories divided by total 17,450, and this equals Multiply by 100 to make into a percentage % of the total calories are from the tube feeding. We would code K0710 while a resident as 3, to indicate 51% or more of the total calories were received via tube feedings. And since this resident was in the facility for the entire look back period, column 1, while not a resident would be left blank, and since column 2, while a resident and column 3, the entire 7 day look back period both reference the same 7 day period, both column 2 and 3 are coded as 3 for 51% or more. Tube Cal/Total Cal x 100 = % of intake by tube 2, ,000 = 17,450 (total calories) 15,000 / 17,450 = x 100 = 85.9%

Total fluids by IV or tube feeding / 7 days
K0710B. IV Fluid Sun 1,250 Mon 775 Tues 925 Wed 1,200 Thurs Fri 500 Sat 450 Total 6,300 Steps for Assessment Add total amount of fluids received each day by IV and/or tube feedings only Divide total by 7 to calculate average fluid intake per day K0710B documents the average number of fluids and will be coded as either 500cc per day or less or 501cc per day or more. For this item we must identify how many cc of fluid the resident received via tube feeding or IV each day during the look back period. Keep in mind, we are still documenting while not a resident, while a resident and for the entire 7 day period. If the resident was in the facility for the entire 7 days, we would only document our findings in columns 2 and 3, while a resident and for the entire 7 days. Lets review this example. The resident received a total of 6,300 cc of IV fluid in the look back period, you divide the total by 7 days and the resident received an average of 900cc per day. And the MDS would be coded as 2, 501cc per day or more. Total fluids by IV or tube feeding / 7 days 6300 / 7 = 900 cc/day average

K0710B. 1900 cc/4 days in hospital = 475 cc/day average
Lets take a look at a much more complex example, when the resident was in the hospital for 4 of the days and in the facility for 3 of the days. Lets start with just looking at the days in the hospital, which would be coded under WHILE NOT A RESIDENT in column 1. The resident received a total of 1,900cc of fluid over 4 days. To calculate the average, divide 1900 by 4 days, this equals 475 cc/day on average. K0710B, column 1 is coded as 1, the resident received 500cc/day or less. 1 While in the hospital While in the Facility Mon 400 cc Fri 510 cc Tues 520 cc Sat Wed 500 cc Sun 490 cc Thurs 480 cc Total 1,900 cc 1520 1900 cc/4 days in hospital = 475 cc/day average

1,520 cc/ 3 days in the facility =
K0710B. 2 Next lets look at column 2, while a resident. The resident received a total of 1,520 cc during the 3 days in the lookback period after returning from the hospital. 1520cc is divided by the 3 days in the facility and this equals an average of 507.cc per day K0710B column 2 is coded as 2, the resident received 501 cc or more per day while a resident While in the hospital While in the Facility Mon 400 cc Fri 510 cc Tues 520 cc Sat Wed 500 cc Sun 490 cc Thurs 480 cc Total 1,900 cc 1,520 cc 1,520 cc/ 3 days in the facility = 507 cc/day average

K0710C. 1,900 + 1,520 = 3,420 cc 3,420 / 7 days = 489 cc / day average
The last step is to calculate the average fluid during the entire 7 day period. The resident received 1900 cc while not a resident and 1,520 while a resident, add those numbers together to identify the total cc received by the resident. This equals 3,420 cc. This number is divided by 7 days and equals 489cc per day. Keep in mind that even if the resident did not receive fluid from IV or tube feeding every day in the look back period, this total is still divided by 7, as you are calculating the average over 7 days. This resident will be coded as cc per day or less in column 3 for the entire 7-day period. While in hospital While in facility Mon 400 cc Fri 510 cc Tues 520 cc Sat Wed 500 cc Sun 490 cc Thurs 480 cc Total 1,900 cc 1,520 cc 1, ,520 = 3,420 cc 3,420 / 7 days = 489 cc / day average

Please continue with MDS Coding Essentials: Sections L, M, N, and P
Thank You Please continue with MDS Coding Essentials: Sections L, M, N, and P

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MDS Essentials: Sections GG and K.

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