ADL CODING IMPACTS THE MDS FOCUSED SURVEY TERRY

ADL CODING IMPACTS THE MDS FOCUSED SURVEY TERRY RASER, RN, RAC-CT, C-NE, CIC SENIOR CONSULTANT JANUARY 2016

Objectives Describe the history and intent of the MDS Focused Survey p Identify the findings of the 2014 pilot MDS Focused Survey p Discuss the importance of ADL coding Accuracy p Identify ADL Tasks and Definitions p Apply ADL coding accurately p

History and Intent p Purpose of the MDS 3. 0 is to serve as the clinical basis for n n individualized care planning and Delivery of person-centered care. The MDS is used for many different areas of quality reporting p 2013 - OIG report found 47% of claims reviewed had at least one MDS coding error. p

History and Intent p 2014 - MDS Focused Survey pilot n n n Five States- (MD, PA, VA, IL and MN) 24 of 25 had deficiencies Deficient Areas ADLs 15. 4% p One in every 7 cases p p 2015 - Expanded MDS Focused survey

ADL CODING

2 Ways to Educate ADL Coding for my 8 hour shift Coding on the MDS

Coding For My 8 hr. Shift 7

Self Performance Column 1 Coding Definitions 8

0 - Independent p Resident completed activity with no help or staff oversight any time 9

1 - Supervision p Oversight, encouragement, or cueing was provided 10

2 - Limited Assistance p Resident was highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 11

3 -Extensive Assistance p Resident performed part of activity, help of following type provided: n Weight-bearing support n Full staff performance during part of activity but not all 12

4 - Total Dependence p Full staff performance of an activity with no participation by resident for any aspect of the task the entire shift. p The resident was unwilling or unable to perform any part of the activity. 13

8 - Activity Did Not Occur p Over the entire shift, the ADL activity was not performed by the resident or staff at all. 14

When to Code (8) Activity Did Not Occur Transfer- When resident never got out of bed p Toileting- Only if elimination did not occur during the entire shift p Locomotion- Resident was on bed-rest and did not get out of bed, and there was no locomotion via bed, w/c or other means p Eating- Only if the resident received no nourishment by any route the entire shift p 15

Residents With Feeding Tube p Code Extensive (3)n n p resident received tube feeding by staff but feed self orally at least one time during the shift Code Total Dependence (4)n n resident received tube feeding by staff and/or was fed by staff orally every time during the shift Resident did not participate in any aspect of eating Did not pick up finger foods or drink 16

Staff Support Provided Column 2 Coding 17

Code (0) No Setup or Physical Help from Staff p Resident completed activity with no help or oversight 18

Code 1 - Setup Help Only p Resident is provided with material or devices necessary to perform the ADL independently. p This can include giving or holding out an item that the resident takes from the caregiver. 19

Code 2 - One Person Physical Assist p Resident was physically assisted by one staff person 20

Code 3 -Two+ Person Assist p Resident was physically assisted by two or more staff persons 21

Code 8 -Activity Did Not Occur p The ADL activity did not occur the entire shift 22

ADL Education How often is staff educated on ADL coding? p What is your facility policy? p Does the facility provided competencies? p Do you give pre and post ADL scenario testing? p

RNAC ADL Coding of the MDS 24

G 0110 Column 1 ADL Self-Performance p Determine which ADLs the resident performed across all shifts during the past 7 days. (ARD + back 6 days) p Assess the resident’s self-performance (what the resident actually did). 25

G 0110 Column 2 ADL Support Provided p Measure the most support provided by staff to complete each ADL activity. p Document the most support provided even if it occurred only once. p Code Column 1 and Column 2 separately. 26

G 0110 Coding Column 1 ADL Self-Performance 27

G 0110 Column 1 Conduct the Assessment Review the medical record. p Talk with direct care staff from each shift that has cared for the resident. p n n Determine the type and level of facility staff assistance provided for each ADL activity. Staff assistance includes oversight, p verbal cueing or encouragement, p physical assistance, or p full staff performance p 28

ADLs Performed by Facility Staff p For completing Section G, "facility staff" pertains to: n p Does not include n n p direct employees and facility-contracted employees (e. g. rehabilitation staff, nursing agency staff. individuals hired, compensated or not, by individuals outside of the facility's management and administration. families, hospice staff, nursing/CNA students, etc. Not including these individuals allows the facility to retain the primary responsibility for the care of the resident. 29

ADLs Performed by Facility Staff p If family or hospice do all the care for the resident then you code “ 8” activity did not occur and document it in the clinical record who gave the care. n Example: Wife feeds husband all meals. Staff would code “ 8/8” for all meals feed by wife. Staff should document in clinical record that the wife feeds her husband all meals. 30

G 0110 Column 1 Guidelines Assess the resident’s functional status for each ADL. n Document the level of assistance the resident required to complete the activity. p Consider each episode of the activity that occurred during the look-back period. p 31

G 0110 ADL Self-Performance Coding Guidelines 1. Determine if each ADL or activity occurred three or more times n n 2. Apply the Rule of 3 to determine the resident’s level of self-performance. n 3. if it did code the highest code. If not, If this doesn’t apply then, Use the ADL Self-Performance Algorithm to facilitate accurate coding. 32

ACTIVITY OCCURRED 3 OR MORE TIMES 33

EXTENSIVE ASSISTANCE ( CODE 3) p Use code 3, Extensive Assistance, if a resident performed part of the activity over the last 7 days and help of the following type(s) was provided 3 or more times: n n Weight-Bearing support provided 3 or more times OR Full staff performance of activity 3 or more times during part but not all of the last 7 days p Full staff performance 3 times but not every time 34

EXTENSIVE ASSISTANCE EXAMPLE p A resident received weight-bearing assistance 3 times during the 7 day look back period. n THIS MEETS THE ADL SELF-PERFORMANCE DEFINITION FOR EXTENSIVE ASSISTANCE SINCE IT SATISFIES ONE OF THE CRITERIA. p Weight-Bearing support provided 3 or more times 35

EXTENSIVE ASSISTANCE ( CODE 3) p Two Criteria for Extensive Assist n n p Weight-Bearing support provided 3 or more times OR Full staff performance of activity 3 or more times during part but not all of the last 7 days The only time episodes can be combined is when the activity occurs 3 or more times and at multiple levels, but not 3 times at anyone level. 36

TOTAL DEPENDENCE (CODE 4) p Total Dependence applies only if the resident requires full staff performance every time the ADL occurred and the activity itself occurred 3 or more times during the 7 day look back period. n If unable to meet this rule, Code 4 (Total Dependence) can not be entered on the MDS! 37

EXTENSIVE ASSISTANCE (CODE 3) p If Total Dependence occurs at least 3 times but not every time during the 7 day look back period it can be counted under the second criteria for Extensive assistance n Full staff performance of activity 3 or more times during part but not all of the last 7 days 38

ADL SELF-PERFORMANCE EXCEPTION CODES p Four ADL Self-Performance coding level definitions that are exceptions to the Rule of 3: n n Code (0) (4) (8) (7) Independent Total Dependent Activity Did Not Occurred 1 -2 times 39

ADL SELF-PERFORMANCE EXCEPTION CODES p They must occur every time to code on the MDS and have at least 3 occurrences : n n n p Code (0) Independent Code (4) Total Dependent Code (8) Activity Did Not Occur If any other code was coded with the above codes during the 7 day look back period you can not use the above codes 40

Code 0 Independent p Must be coded at least 3 times p Code 0 if the resident did not need ANY assistance or oversight to complete the ADL every time. 11 -7 0 8 0 8 0 7 -3 0 0 0 0 3 -11 0 0 0 0 41

Code 4 Total Dependence p Must be coded at least 3 times p Code 4 if the resident is unwilling or unable to perform any part of the ADL for the entire look-back period every time. 11 -7 4 4 4 4 7 -3 4 4 4 8 4 3 -11 8 8 4 4 42

Code 8 Activity Did Not Occur p p Code 8 if the resident or staff did not perform the ADL at all during the look-back period OR Family or non-facility staff provided care regarding the task 100% of the time during the 7 day look back period 11 -7 8 8 8 8 7 -3 8 8 8 8 3 -11 8 8 8 8 43

Code 7 Activity Occurred Only Once or Twice Determine if ADL occurred three or more times during the look-back period. If not, p Code 7 if ADL occurred only once or twice p 11 -7 8 8 8 8 7 -3 8 8 8 4 8 3 -11 8 8 8 8 44

INSTRUCTIONS FOR THE RULE OF 3 Rule (1): When an activity occurs three or more times at any one level, code that level. p ADL Coding Scenario #1 p MR. X two times required guided maneuvering of his arms to don his shirt. Four times, he had pain in his shoulders and he required the staff to assist him with his shirt by physically lifting each of his arms. This component of the dressing ADL occurred six times in the 7 - day look back period p 45

INSTRUCTIONS FOR THE RULE OF 3 p ADL Coding Scenario #1 n Observations indicate the resident required the following assistance: 2 times non-weight bearing (limited assist) p 4 times weight-bearing (extensive assist) p n n Code Extensive Assistance (3), The episodes of care occurred 3 or more times at one level- weight bearing which is consistent with the rule 3. 46

INSTRUCTIONS FOR THE RULE OF 3 p p p Rule (2): When an activity occurs 3 or more times at multiple levels, code the most dependent level that occurred 3 or more times: ADL scenario # 2 Mrs. C. required verbal cueing 4 times for hand placement during stand-pivot transfers from her W/C. She required weight-bearing assistance 3 times to help her rise from the W/C and turn back to the bed. She completed this transfer without assistance in 14 other occurrences during the 7 day look back period. 47

INSTRUCTIONS FOR THE RULE OF 3 p ADL Coding Scenario # 2 n Observations indicate the resident required the following assistance: 4 times supervision (Supervision) p 3 times weight-bearing (Extensive) p 14 times no assistance (Independence) p n n Code Extensive Assistance (3) Code the most dependent that occurred 3 or more times 48

INSTRUCTIONS FOR THE RULE OF 3 p p Rule (3): When an activity occurs 3 or more times and at multiple levels but not 3 times at any one level. Sub-items under 3 rd Rule of 3 n (a)Convert episodes of full staff performance to weight-bearing assistance n (b)When there is a combination of full staff performance and weight-bearing assistance that total 3 or more times, Code Extensive Assistance (3) n (c) When there is a combination of full staff performance/weight-bearing assistance and/or nonweight-bearing assistance that total 3 or more times, code Limited Assistance (2) 49

INSTRUCTIONS FOR THE RULE OF 3 Ms. F was in the NH for only one day prior to transferring to another facility. The following assistance for eating ADL was provided: p ADL Coding Scenario # 3 p n n n 2 times she required weight-bearing assistance to help her lift her fork to her mouth (Extensive) 1 time staff fed Ms. F (Total Dependence) Code Extensive Assistance (3) 50

INSTRUCTIONS FOR THE RULE OF 3 p ADL Coding Scenario # 3 Observations indicate the resident required the following assistance: n 2 times Extensive n 1 time Full Staff Performance (Note: In the scenario, the ADL occurred 3 times and at multiple levels, but neither of the levels 3 times) Sub-Item Rule 3: (a)Covert episodes of full staff performance to weightbearing assistance. (This give 3 times at Extensive) n 51

INSTRUCTIONS FOR THE RULE OF 3 p ADL Coding Scenario # 4: n Mr. N was sent to the hospital on day 2 of his NH stay. The following assistance for dressing was provided: Weight bearing assistance 1 time (Extensive) p Non-weight bearing assistance 1 time (Limited) p Full staff performance 1 time (Total) p Independent 1 time ( Independent) p n (Note: The ADL occurred 3 times and at multiple levels, but none of the levels occurred 3 times) 52

INSTRUCTIONS FOR THE RULE OF 3 p ADL Coding Scenario # 4 Weight bearing assistance 1 time p Non-weight bearing assistance 1 time p Full staff performance 1 time p Independent 1 time p p Rule (3): When an activity occurs 3 or more times and at multiple levels but not 3 times at any one level. n Sub-items under 3 rd Rule of 3 n (c) When there is a combination of full staff performance/weight-bearing assistance and/or nonweight-bearing assistance that total 3 or more times, code Limited Assistance (2) 53

INSTRUCTIONS FOR THE RULE OF 3 p p p ADL Coding Scenario # 5 Mr. P- toileting occurred 20 times in the look back period. Mr. P was able to toilet independently 18 times. The other 2 times Mr. P required non-weight bearing assist. Observation indicates: n n p p 18 times independent 2 times non-weight bearing (Limited) Code: Supervision (1) Note: If none of the Rule of 3 are met, code Supervision 54

Item G 0110 Column 2 Coding ADL Support Provided 55

G 0110 (2)ADL Support Provided Complete the ADL Self-Performance assessment for each ADL first. p ADL Support Rule 1 - Code Most Support provided even if it only occurred once during the 7 day look back period. p ADL Support Rule 2 - Coded separately from the ADL Self-Performance assessment (column 1). p ADL Support Rule 3 - Rule of 3 does not apply to Column 2. p 56

ADL Support Provided – Column 2

ADL Importance $$$$ RUG IV 58

MDS Coded Inaccurately MDS Coded Accurately 3 3 3 3 0 1 3 2 3 3 4 4 59

MDS Coded Inaccurately MDS Coded Accurately 3 3 3 3 0 1 3 2 3 3 4 4 2 0 4 4 4 0 10 12 60

MDS Coding Payment Difference 4 4 4 2 0 0 10 12 61

Need for ADL Clarification Note If ADL coding does not look like the resident p Resident always requires 2 person assist but not coded p ADL tracker coding: 3/1, 2/1, 8/2, 1 /2 p Clarification Note: p n Should identify the task, the accurate Self. Performance type, and the number of times occurred during the (specified) 7 day look-back period, date of the note and the signature and title of the person writing the note.

Thank You Terry Raser, RN, RAC-CT, C-NE, CIC traser@lw-consult. com 610 -314 -5095

Resources p Ref: S&C: 15 -06 -NH, Nationwide Expansion of Minimum Data Set (MDS) Focused Survey, October 31, 2014. n http: //www. cms. gov/Medicare/Provider-Enrollment-and. Certification/Survey. Certification. Gen. Info/Downloads/Surveyand-Cert-Letter-15 -06. pdf Ref: S&C: 15 -25 -NH, MDS/Staffing Focused Survey Update, February 13, 2015 p MDS 3. 0 RAI Manual v 1. 13, October 2015 p