Question: How do you code walking if the resident only walks with therapy staff?

MDS 3.0 and the RAI Process / NAC / Q&A

Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, and Jessie McGill, RN, BSN, RAC-MTA, RAC-CTA: If the resident only walked with therapy, then the assessment for usual performance is based on the resident’s usual performance with therapy. The only coding tip that restricts using the walking performance during therapy …

Question: With the new definition of fall with major injury, would a bump on the head or a laceration be a head injury? With the new definition of fall with major injury, would a bump on the head or a laceration be a head injury?

MDS 3.0 and the RAI Process / NAC / Q&A

Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, and Jessie McGill, RN, BSN, RAC-MTA, RAC-CTA: Your team will need to assess each individual injury from a fall, using clinical standards of practice and clinical judgement. Your team’s assessment of the injury, its effect on the resident (e.g., neuro checks, …

Question: I am confused by the new section GG guidance for when the activity “is being/will be” routinely performed. What does “will” mean?

MDS 3.0 and the RAI Process / NAC / Q&A

Answer from Jennifer LaBay, RN, RAC-MT, RAC-MTA, QCP, CRC, and Jessie McGill, RN, BSN, RAC-MTA, RAC-CTA: The term “will” in this coding tip is likely referring to the resident’s goals or preferences. The example in this instruction states “walking might be assessed for a resident who did/does/will use a wheelchair …

Q&A: We had a resident on a Medicare Part A stay admit and discharge back to the hospital that same evening after a few hours. We could not assess much information during that brief amount of time. What are all the required MDS assessments that need to be completed on this resident? I know an entry tracker and an OBRA discharge, but do we need to also complete a 5-Day PPS?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: We had a resident on a Medicare Part A stay admit and discharge back to the hospital that same evening after a few hours. We could not assess much information during that brief amount of time. What are all the required MDS assessments that need to be completed on …

Q&A: The new definition of a fall includes an overwhelming external force, but the definition of fracture related to a fall states, “Do not include fractures caused by trauma related to car crashes or pedestrian versus car accidents or impact of another person or object against the resident.” Does this instruction contradict the new definition of a fall?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: The new definition of a fall includes an overwhelming external force, but the definition of fracture related to a fall states, “Do not include fractures caused by trauma related to car crashes or pedestrian versus car accidents or impact of another person or object against the resident.” Does this instruction …

Q&A: Can Isolation be coded for methicillin-resistant staphylococcus aureus (MRSA) on a wound?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: Can Isolation be coded for methicillin-resistant staphylococcus aureus (MRSA) on a wound? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: No, the RAI User’s Manual specifically states that isolation cannot be coded for a wound infection. See page O-8 (bold text added for emphasis): Code only when the …

Q&A: If an open area is found on day four after admission, is that still present on admission (7-day look-back period)? The definition of “present on admission” is “as close to admission as possible.”

MDS 3.0 and the RAI Process / NAC / Q&A

Question: If an open area is found on day four after admission, is that still present on admission (7-day look-back period)? The definition of “present on admission” is “as close to admission as possible.” Answer from Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, QCP, ICC, IPCO: I do not think this would …

Q&A: A long-term resident went out to the hospital and returned on a skilled stay using his Managed Care plan. He has both a 5-Day and Annual scheduled for the same day, but at separate times. Do both of these get coded as “the first assessment” in A0310E?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: A long-term resident went out to the hospital and returned on a skilled stay using his Managed Care plan. He has both a 5-Day and Annual scheduled for the same day, but at separate times. Do both of these get coded as “the first assessment” in A0310E? Answer from …

Q&A: For section GG, the nurse aides use a mechanical lift transfer with two-person assist for transfers four times, but physical therapy transfers with one person and maximal assist once. Part of the dependent definition is “helper does all the effort” – but this was not true for all transfers—would this be dependent or maximal assistance?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: For section GG, the nurse aides use a mechanical lift transfer with two-person assist for transfers four times, but physical therapy transfers with one person and maximal assist once. Part of the dependent definition is “helper does all the effort” – but this was not true for all transfers—would …

Q&A: I miscalculated the ARD window for a 5-Day and scheduled the 5-Day/PPS Discharge on day 9 of the Medicare stay. What do I need to do?

MDS 3.0 and the RAI Process / NAC / Q&A

Question: I miscalculated the ARD window for a 5-Day and scheduled the 5-Day/PPS Discharge on day 9 of the Medicare stay. What do I need to do? Answer from Jeff Taylor:Leave everything as it is and bill one day default for the late assessment. Since the 5-Day is one day …