T

he federal MDS changes just keep coming. Perhaps this year will be known as the year of the MDS changes. Providers have been bounced from new interpretations, to new regulations, to new indicators. The Center for Medicare and Medicaid Services (CMS) has finally released a draft of the new revised Resident Assessment Instrument (RAI) manual. They are actively soliciting comments. Here is your chance to let them know how you feel about the current draft. It is due for release this October, so make those comments promptly. The website is http://www.cms.hhs.gov/medicaid/mds20/man-form.asp.
       Continuing on the news front, in August there was a meeting in Baltimore for all the RAI coordinators and other interested healthcare professionals. This meeting served to introduce the new RAI manual and changes. These alterations include not only the new Q&As but also the new alterations to the newest Q&As that came out in May of this year. This manual will incorporate these answers seamlessly. In the future, the manual will be updated quarterly. Once again, we will have one source document to go to for answers about definitions of data in the MDS. It has been a long time since that happened! If you are just interested in contacting CMS at their new website, it is http://www.cms.hhs.gov/.
       We have received several questions about scheduling. The Medicare Part A assessments, hereafter to be referred to as the PPS assessments, are often difficult to schedule. The reason is not because the directions are difficult to understand. It is because we are dealing with people, and they never fit into boxes very well. It often feels like the rules for PPS assessments don't bend or give, making scheduling and maximization of Part A benefits seem like Mount Impossible. Also, the refusal of most financial intermediaries to clearly define what qualifies as a skilling service or RUG makes the challenge even harder. Several software companies have built-in RUG assessors that claim to be able to tell if a resident meets Medicare Part A skilling. Beware of these tools. Skilling often depends on your financial intermediary. Making an effort to develop a relationship with someone in their office will pay you back handsomely!
       Let's take a look at a couple of those questions.
       Question: "I have a Part A resident who was discontinued from therapies and discharged on the 31st day of her stay. Do I still need to do a 30-day PPS assessment?" (registered nurse, Illinois)
       Answer: No, you do not need to complete a 30-day PPS assessment. The assessment you completed for the 14-day PPS will pay through days 14 to 30. You will not be paid for the day of discharge, so there is no need to complete the 30-day assessment.
       Question: "We had a resident who was discharged home on day 23 of his Part A stay. He decompensated at home and was readmitted within 16 days. Can I still skill this resident without another three-day stay? He has three stage 3 ulcers, is oxygen dependent, and has a feeding tube. He was unable to maintain himself at home related to difficulty finding home healthcare. Can I readmit him Part A? If so, where do I start with his Part A assessments?" (registered nurse, Massachusetts)
       Answer: Yes, you may readmit him Part A, because the resident was not out over the 30-day limit. However, be aware of some areas of concern. First, this resident requires a skilling service, which you have already ascertained. You must start with a 5-day assessment. If you discharged this resident "return not anticipated," then you must also decide when to do an initial assessment. This may be completed with the 5-day or the 14-day PPS assessment. In counting the remaining days for Part A reimbursement, remember to include the previous 17 days used at your facility. That means he has only 87 days left in this spell of illness.
       Another hint regarding scheduling is to get help. Scheduling is critical for PPS assessments. Miss one and you may end up not getting paid. That is why it is so important to enlist help. Many facilities appoint the MDS coordinator responsible for tracking PPS assessments. This is probably a really good idea. Still, to have just one person monitoring and accountable for such an important function is asking for trouble. If this onerous task has been placed firmly on your back, don't be shy about asking others for their input. The best persons are the admissions coordinator, the business manager, and the computer guru if you have one. Build checks and balances into any system of scheduling you create. It is better to be corrected before an error costs thousands of dollars than to unknowingly make an error and be refused payment.
       Most software systems have a scheduling function built in. We have yet to meet the MDS coordinator who likes or trusts one. (If you have one that works, we would love to hear from you. You can e-mail us at MabelMDS@aol.com.)Several of the ones we have seen cannot address timing situations that are unique to residents. That takes a human being. Besides PPS assessments, you must also meet OBRA guidelines. These vary by state. So, if you have software developed in Texas, and you are in Pennsylvania, you may have some built-in problems.
       Our last gem of advice is to read, read, and re-read the SNF manual. This is available on line at http://cms.hhs.gov/manuals/12_snf/SN00.asp. Most corporate facilities are provided this by their corporate management staff. If you are not part of a corporate structure, you will have to do your own hunting and searching. The CMS website is a great place to start. You should be able to quote chapter and verse of this manual. If in doubt, always refer to the SNF manual in conjunction with the RAI manual. These two books, or manuals, are your MDS bibles. Keep them close.
       All in all, not only has this been an exciting year, it has been an exciting 10 or 11 years. The MDS has changed the face of long-term care forever. We can never go back. Most of the nurses we know do not want to go back. Our industry has garnered a hard-won recognition and a newfound pride in ourselves and the care we provide. Our care is the most basic. All other care is built on the basics we have learned to excel in performing. We do it day after day, week after week, and year after year. There are few accolades. No one gets ecstatic over the prevention of open areas and unplanned weight loss. However, others are now beginning to see what we have done. We have a quantifiable database from which to extract quality measures. We can look back and discover why our indicators for open areas and unplanned weight loss, for example, are low. Other healthcare providers are recognizing what a gigantic leap forward we have made. As an MDS coordinator, you should take pride in the knowledge that you have helped to build this database. Your honest and accurate responses have made a difference in the lives of your current residents and the lives of future residents, patients, and other healthcare providers. While it has not been easy, it has been worth it.
       Keep up the good work!

The publisher, HMP Communications, and the authors disclaim responsibility for any injury to persons or property resulting from any ideas or products referred to in this article.