Category: Q&A

Question: The RAI User’s Manual guidance for mechanically altered diet mentions “soft solids.” Would that include solids that are naturally soft or solids that we would “soften”? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: The diet needs to be mechanically altered to facilitate eating/swallowing in order to code …

Question: If the resident was in the emergency department (ED) and then admitted to the hospital before readmitting to the nursing home, can I capture IV fluids at the ED visit?   Answer from Jessie McGill, RN, BSN, RAC-MTA, RAC-CTA: IV fluids from pre-admission are captured under K0520A2, while not …

Question: A long-term care resident has a Quarterly assessment due on 6/19 and an Annual assessment due on 6/27. Can I do the Annual assessment early, before the Quarterly deadline? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: Yes, you can absolutely do this. Set the ARD for the …

Question: When a resident returns from an interrupted stay, is an IPA required or any kind of readmission assessment if no change? Answer from Jeff Taylor: IPAs are always optional. In an interrupted stay, no new Medicare MDS is required. You would do the required OBRA Discharge assessment and an …

Question: A resident on a Medicare Part A stay discharged return not anticipated. His last covered day of Medicare was the day before. Can I combine the Part A PPS Discharge with the OBRA discharged return not anticipated? Answer from Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC: Yes, when a …

Question: For section GG documentation, the direct care staff was given the wrong dates. It was supposed to be the ARD and the two days before, but they did the first 3 days of the look-back period. Am I able to use any of the GG documentation they completed? Answer …

Question: Do I code J1400, Prognosis, as yes when a resident is under palliative care and not hospice? There is no physician documentation certifying or stating the physician’s belief that the resident’s terminal illness is that their life expectancy is six months or less.   Answer from Scott Heichel RN, RAC-MT, RAC-CTA, DNS-CT, …

Question: What is considered as the most updated COVID-19 vaccine to code on the MDS? Answer from Jessie McGill RN, BSN, RAC-MTA, RAC-CTA: To determine up to date, we must reference the Staying Up to Date with COVID-19 Vaccines CDC homepage: www.cdc.gov/covid/vaccines/stay-up-to-date.html There are few considerations- such as age and …

Question: For the PHQ-2 to 9 interview, if the resident is at least sometimes understood and the interview is attempted, but the resident did not respond to the first two questions, how is this coded and can we proceed to the Staff Interview of Mood? Answer from Carol Maher, RN, …